Manage a case of CLL

62 year old man comes to your office with complaints of fatigue, and bleeding from the gums whenever he brushes. The fatigue has been going on for the past 8 months. He denies any unusual sexual exposure or drug usage.

Examination reveals a relatively well looking man with normal nutritional status. Vitals reveal a Blood pressure of 168/90 and a pulse of 88. Lungs reveal bibasilar crackles that do not disappear on coughing.

labs reveal Hb 9.7g/dL, WBC 32,000/cumm 95% lymphocytes, Platelets of 402,000/cumm . Chest Xray is normal. Peak flow is 430LPM

Which of the following is NOT a reasonable advice for this patient?

1. Start Atenolol

2. Reassure him that most patients with his condition have a good, long life

3. Do a bone marrow analysis

4. Chlorambucil is the drug of choice

5. CT of the chest is needed to diagnose his pathology

Answer is 5. This patient most likely has CLL.

Manage a case of CLL.

Explanation

This is the commonest leukemia in the US. It is typically found on routine blood screening.

Prognosis is good, especially if Platelet count is >100 and Hb >10gm & <3 areas (of lymphatic tissue) involved.

Treatment is with Chlorambucil (Leukeran) and Prednisone (Prednisone is especially helpful in those with auto-immune cytopenias which are a common feature associated with CLL). We know that Steroids reduce Lymphocytes and Eosinophils.

In this particular case, the patient will need evaluation of different lymphatic sites to prognosticate him but diagnosis does not require CT of the chest. It will be confirmed with bone marrow biopsy/aspiration.

ALL is yet another story:

Prognosis is poor. Almost all cases occur in children under the age of 10.

Symptoms are of pancytopenia - anemia (fatigue, SOB), thrombocytopenia (bleeding, poor healing) and Leucopoenia (many infections). fatigue, bleeding.

Diagnosis is by marrow analysis.

Treatment includes Chemotherapy ASAP and Stem cell/Bone marrow transplant.

Marrow transplant is today facilitated by the enormous database of the marrow registry. http://www.marrow.org/NMDP/registry.html