RESUMO
Introduction: Chronic lymphocytic leukemia (CLL) is a lymphoproliferative disorder with clonal proliferation of functionally incompetent mature B lymphocytes, defined by an absolute lymphocyte count>5 9 109/ml malignant cells in the blood. The disorder is more common in men. In most of the cases, it is asymptomatic and diagnosed during routine blood investigations while getting evaluated for some other disease. However, patients need treatment once they are symptomatic with painless enlarged, bulky lymphnodes, anemia or thrombocytopenia. Case report: We report a case of 67 year female, with Type-2DMand HTN, who presented with difficulty in breathing to the emergency during the first wave of Covid -19 pandemic. Chest X-ray revealed left mid zone opacity suggestive of a lung mass. CT Thorax done showed multiple mildly enlarged mediastinal lymph nodes, with lobulated heterogeneously enhancing mass in the prevascular compartment of anterior mediastinum compressing left upper lobar bronchus. USG guided core needle biopsy of left upper lobe mass was done and pleural fluid was analysed, which was suggestive of a lymphoproliferative neoplasm. Then CBC was advised which demonstrated lymphocytosis. Flow cytometry and IHC confirmed the diagnosis mature B-cell neoplasm Chronic Lymphocytic Leukemia (CLL). Discussion(s): Pulmonary manifestation of CLL include, hilar and mediastinal lymphadenopathy. Lung masses are a rare presentation. Richter's transformation is a unique complication of CLL. However, patients with CLL also have an increased risk of secondary malignancy most commonly Kaposi sarcoma, malignant melanoma and carcinoma lung. Our case is unique,as there were no features of Richter transformation that is weight loss, fever, night sweats, muscle wasting and increased hepatosplenomegaly or lymphadenopathy. She was evaluated for respiratory distress and diagnosed on Lung mass biopsy as atypical lymphoid cell infiltration and not as lung carcinoma or transformation to high grade lymphoma. Conclusion(s): Clinicians should be aware that though chronic lymphocytic leukemia is diagnosed incidentally on routine blood investigations, atypical presentation must be kept in mind. A simple CBC and a peripheral smear examination gives a clue to the diagnosis at the earliest.
RESUMO
Individuals with inflammatory rheumatic diseases such as lupus are considered at risk for severe COVID-19 infection due to their immunocompromised state and the use of immunosuppressive treatment. Its impact on lupus is yet to be determined. Herein, we report a case of COVID-19 pneumonia in a 40-year-old female with a history of hypothyroidism and mild pulmonary hypertension who presented with a 4-day history of fever and breathlessness. COVID-19 infection was confirmed by real-time polymerase chain reaction (RT-PCR). On examination, she had a malar rash, short hair, and crepitations on the right side infrascapular and infraaxillary areas. Investigations revealed to have anemia, thrombocytopenia, transaminitis, high ferritin, and low fibrinogen, which were suggestive of cytokine release syndrome. Her antinuclear antibody (ANA) by indirect immunofluorescence on Hep-2 cells was 4+ homogeneous in 1:100 titer dilution and extractable nuclear antigen panel showed antibodies positive for histone, nucleosome, Ro, and smith antigens. The patient was diagnosed with systemic lupus erythematosus (SLE) with severe COVID-19 pneumonia with cytokine release syndrome and managed conservatively without specific antivirals or steroids. Her clinical condition and laboratory parameters improved afterward. On the 12 th day, her RT-PCR for COVID-19 was negative and the patient was discharged. This would probably a reference case which showed conservative management can be helpful at times where no definite antiviral therapy has been approved with judicious use of immunosuppressants. Close monitoring of clinical conditions and laboratory parameters are recommended for such autoimmune disorders with COVID-19 infection.