University of South Dakota Sanford School of Medicine Sioux Falls, SD
Muhammad Arsalan Arshad, MD, Smitha Narayana Gowda, MD, Hafez Mohammad Abdullah, MD, Rakshya Sharma, MD, Mohamed A. Abdallah, MD; University of South Dakota Sanford School of Medicine, Sioux Falls, SD
Introduction: B-cell chronic lymphocytic leukemia (CLL) is the most common form of leukemia in the United States. It has a variable presentation with most patients having asymptomatic lymphocytosis. CLL can present with extramedullary involvement. Most commonly this is in the form of skin or central nervous system involvement, though rarely it can present with gastrointestinal involvement.
Methods: We are highlighting a case of a 70-year-old male who presented with complaints of diarrhea for the last 4 months. He was having 4-5 bowel movement a day ranging from semi-solid to watery stools. He denied any history of fevers, abdominal pain, vomiting, weight loss, night sweats, skin rashes, travel history, or exposure to anyone with similar symptoms. On physical examination, his abdomen was soft, non-tender, and without apparent hepatomegaly or splenomegaly. The rest of the system examinations were unremarkable. The initial laboratory evaluation was unremarkable. After failing conservative treatment, a colonoscopy was performed which showed diffuse mucosal nodularities (Image 1 and 2). Histopathology of the biopsied tissue revealed multiple aggregates for small mature lymphocytes in the submucosa (Image 3). Immunohistochemical staining revealed a diagnosis of chronic lymphocytic leukemia/small lymphocytic lymphoma. CT scan revealed extensive bilateral axillary, hilar, abdominal, and pelvic lymphadenopathy. He subsequently underwent bone marrow biopsy histopathology and flow cytometric immunophenotyping which were consistent with CLL. Oncology started him on chemotherapy and he went into remission from his CLL. On 3- and 6-month follow-ups, the patient was asymptomatic. Discussion: A review of the literature revealed a total of n=4 prior reported cases where the initial presentation of CLL/SLL was diarrhea. In the existing case reports with similar presentation a mean age of presentation was n=74 years, ages ranging from 65-81 years. They had fecal urgency, abdominal pain, and weight loss as associated symptoms. Only one patient had history of CLL for which he had undergone treatment and was thought to be in remission. Imaging with CT with contrast in all cases revealed abdominal and pelvic lymphadenopathy. Histopathology of the colonic biopsy in all cases revealed lymphocytic infiltration. This patient was treated successfully with chemotherapy and his diarrhea improved. This is a differential to keep in mind in patients with chronic diarrhea, once the more common causes have been ruled out.
Image 3: Hematoxylin and eosin stain showing lymphoid aggregate with normal colon mucosa
Disclosures: Muhammad Arsalan Arshad indicated no relevant financial relationships. Smitha Narayana Gowda indicated no relevant financial relationships. Hafez Mohammad Abdullah indicated no relevant financial relationships. Rakshya Sharma indicated no relevant financial relationships. Mohamed Abdallah indicated no relevant financial relationships.