Urinary bladder infiltration with chronic B-lymphocytic leukemia:Two cases with unusual presentation

Chronic lymphocytic leukemia (CLL) is the most common type of leukemia in the western world. About 70% of cases are diagnosed incidentally on a routine full blood count [1]. Patients with CLL may present with lymphadenopathy, splenomegaly, hepatomegaly, constitutional symptoms or symptoms of bone marrow failure or immunosuppression. Infiltration of solid organs has been reported but is rare and usually asymptomatic [2,3]. Skin is the most commonly involved non-lymphoid organ. CLL is generally an indolent disease and there is a considerable variation in disease progression with survival from initial diagnosis ranging from 2 – 20 years. In the past, staging systems (Rai and Binet) were used to predict the overall survival. More recently, IgVH gene mutational status and CD38 expression has shown a correlation with the overall survival. Patients with mutated IgVH gene and 530% CD38 surface expression appear to have longer survival compared to patients with unmutated IgVH gene and 430% CD38 expression [4,5]. ZAP-70 expression can predict IgVH mutation status; therefore, it is a useful marker to predict time to disease progression and overall survival [6]. We report two female patients presented with urinary symptoms and treated as recurrent UTI for several years. Case 1 is a 60-year-old patient complaining of dysuria and microscopic hematuria since 1995. She has a history of rheumatoid arthritis and was treated as recurrent UTI with different courses of antibacterials without clinical improvement. She has had persistently negative urine cultures and microscopic examination revealed only red blood cells. In 1998, she was referred to the hematology department with a lymphocyte count of 306 10 l. Peripheral blood lymphocyte immunophenotyping showed cells positive for CD5, CD19, CD23, with weak expression of CD22 and smIg k and the diagnosis of B-CLL, Binet stage A was established. CD38 was expressed on 60% of lymphocytes. In 2000, she became iron deficient and anemic due to persistent hematuria. Her hemoglobin was 9.4 g dl with normal platelet and neutrophil count and low ferritin at 15 mg ml (20 – 300). Further evaluation revealed no evidence of hemolytic anemia. Her lymphocyte count increased from 32 – 706 10 l over a 4-month period. She then received six courses of chlorambucil and prednisone. The treatment has resulted in a remarkable improvement in her urinary symptoms. In 2002, she presented with frank hematuria. Platelet count, prothrombin time and partial thromboplastin time were normal. Abdominal ultrasound was normal. Intravenous urogram showed filling defects in the left superolateral aspect of her urinary bladder. Cystoscopy revealed patchy erythematous areas. Histological examination with hematoxylin and eosin stain revealed heavy lymphoid infiltration (Figure 1 (a,b)). On immunohistochemistry, lymphocytes coexpressed CD5 & CD20 in keeping with infiltration with B-CLL (Figure 1 (c,d)). She then received another six courses of chlorambucil therapy. This resulted into a remarkable improvement and disappearance of hematuria which lasted for 30 months. Case 2 is a 67-year-old patient referred with lymphocytosis in 2002. She has a history of type II diabetes mellitus and epilepsy. Full blood count revealed hemoglobin of 11 g dl, white cell count 90.76 10 l, platelets 1986 10 l and