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Recurrent Pleural Effusions in an Immunocompromised Patient: Looks Infectious, Acts Infectious, but not Really an Infection
Disorders of the Pleura SESSION TITLE: Student/Resident Case Report Poster - Disorders of the Pleura SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM
Recurrent Pleural Effusions in an Immunocompromised Patient: Looks Infectious, Acts Infectious, but not Really an Infection Yogeeta Naidu MD* Nabeel Alqsous MD Nikhil Mehta MBBS; and Jason Lyons MD Unity Health System, Rochester, NY INTRODUCTION: Chronic Lymphocytic leukemia (CLL) is the most common of the adult leukemias accounting for approximately 30% of all leukemias. Involvement of the pulmonary parenchyma and pleura is rare, expressed as pulmonary infiltrates and pleural effusion. We present a case of 81-year-old female who presented with recurrent trans-exudative pleural effusions due to pleural invasion from CLL.
DISCUSSION: Pleural effusions are a relatively rare complication of chronic lymphocytic leukemia. It can be the result of primary pleural involvement, central lymphatic blockage, infection or changes induced by previous irradiation or chemotherapy. CLL Pleural effusions may be hemorrhagic and contain numerous lymphocytes identical to those in the blood and bone marrow. In our case, pleural biopsy enabled us to demonstrate direct pleural involvement by CLL B-cells. The most effective immunotherapy is R-CHOP (Rituximab, Cyclophosphamide, Doxorubicin, Vincristine, and Prednisolone). CONCLUSIONS: This case report serves to increase awareness and improve the index of suspicion about the pulmonary complications of CLL. Physicians should maintain a high level of suspicion for transformation in CLL and investigate to exclude it, as they require aggressive management. Reference #1: Michael G. Alex, et al. Pleural effusions in hematological malignancies. Chest 2004; 125:1546-1555 DISCLOSURE: The following authors have nothing to disclose: Yogeeta Naidu, Nabeel Alqsous, Nikhil Mehta, Jason Lyons No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.672
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
journal.publications.chestnet.org
583A
DISORDERS OF THE PLEURA
CASE PRESENTATION: An 81 year old female presented with one week history of chills associated with night sweats, and shortness of breath. She had been admitted to the hospital one month prior to presentation with similar complaints. During that admission, she was found to have bilateral pleural effusions and was treated for presumed pneumonia. Her medical history is significant for hypertension, gout, hypothyroidism, and CLL for 20 years on rituximab therapy. Upon admission, the patient was noted to be hypoxic, auscultation revealed decreased breath sounds bilaterally. Significant lab values were chronically elevated white blood count (22,000 /cumm) secondary to CLL. CT scan of the chest identified large bilateral pleural effusions, pleural thickening and a right middle lobe consolidation concerning for pneumonia. She was treated with intravenous Vancomycin and Piperacillin-Tazobactam for presumed pneumonia in an immunocompromised patient. Patient underwent thoracentesis and pleural biopsy was obtained. Pleural fluid was trans-exudative according to Light’s criteria; gram’s stain and culture were negative for microorganisms. To evaluate for possible cardiac etiology, an echocardiogram was done, which showed normal ejection fraction of 65% and no wall motion abnormality. The pleural biopsy flow cytometry revealed monoclonal B cell population with immunostaining positive for CD20 and CD5, confirming CLL invasion of the pleura. Serum Procalcitonin was 0.21ng/ml, indicating low suspicion for bacterial infection and antibiotics were discontinued. Patient was discharged home and advised to follow up with her oncologist.
Recurrent Pleural Effusions in an Immunocompromised Patient: Looks Infectious, Acts Infectious, but not Really an Infection Yogeeta Naidu MD* Nabeel Alqsous MD Nikhil Mehta MBBS; and Jason Lyons MD Unity Health System, Rochester, NY INTRODUCTION: Chronic Lymphocytic leukemia (CLL) is the most common of the adult leukemias accounting for approximately 30% of all leukemias. Involvement of the pulmonary parenchyma and pleura is rare, expressed as pulmonary infiltrates and pleural effusion. We present a case of 81-year-old female who presented with recurrent trans-exudative pleural effusions due to pleural invasion from CLL.
DISCUSSION: Pleural effusions are a relatively rare complication of chronic lymphocytic leukemia. It can be the result of primary pleural involvement, central lymphatic blockage, infection or changes induced by previous irradiation or chemotherapy. CLL Pleural effusions may be hemorrhagic and contain numerous lymphocytes identical to those in the blood and bone marrow. In our case, pleural biopsy enabled us to demonstrate direct pleural involvement by CLL B-cells. The most effective immunotherapy is R-CHOP (Rituximab, Cyclophosphamide, Doxorubicin, Vincristine, and Prednisolone). CONCLUSIONS: This case report serves to increase awareness and improve the index of suspicion about the pulmonary complications of CLL. Physicians should maintain a high level of suspicion for transformation in CLL and investigate to exclude it, as they require aggressive management. Reference #1: Michael G. Alex, et al. Pleural effusions in hematological malignancies. Chest 2004; 125:1546-1555 DISCLOSURE: The following authors have nothing to disclose: Yogeeta Naidu, Nabeel Alqsous, Nikhil Mehta, Jason Lyons No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.672
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
journal.publications.chestnet.org
583A
DISORDERS OF THE PLEURA
CASE PRESENTATION: An 81 year old female presented with one week history of chills associated with night sweats, and shortness of breath. She had been admitted to the hospital one month prior to presentation with similar complaints. During that admission, she was found to have bilateral pleural effusions and was treated for presumed pneumonia. Her medical history is significant for hypertension, gout, hypothyroidism, and CLL for 20 years on rituximab therapy. Upon admission, the patient was noted to be hypoxic, auscultation revealed decreased breath sounds bilaterally. Significant lab values were chronically elevated white blood count (22,000 /cumm) secondary to CLL. CT scan of the chest identified large bilateral pleural effusions, pleural thickening and a right middle lobe consolidation concerning for pneumonia. She was treated with intravenous Vancomycin and Piperacillin-Tazobactam for presumed pneumonia in an immunocompromised patient. Patient underwent thoracentesis and pleural biopsy was obtained. Pleural fluid was trans-exudative according to Light’s criteria; gram’s stain and culture were negative for microorganisms. To evaluate for possible cardiac etiology, an echocardiogram was done, which showed normal ejection fraction of 65% and no wall motion abnormality. The pleural biopsy flow cytometry revealed monoclonal B cell population with immunostaining positive for CD20 and CD5, confirming CLL invasion of the pleura. Serum Procalcitonin was 0.21ng/ml, indicating low suspicion for bacterial infection and antibiotics were discontinued. Patient was discharged home and advised to follow up with her oncologist.