Lymphatic Leukemia and Tuberculosis

Case / . W. Y., white, 78 year old farmer, was admitted to the Edward J. Meyer Memorial Hospital January 8, 1941, complaining of dyspnea, productive cough and 70 pounds loss in weight during the previous 4 years. Past history. Typhoid fever in 1890, pneumonia in 1900 and 1920, malaria in 1920 and herpes zoster in 1936. No family history of tuberculosis. History of present illness. Apparently began rather insidiously in 1936 with anorexia followed by gradual loss of weight. Later, a cough developed productive of moderate amounts of sputum with fatigue and dyspnoea on exertion, night sweats and occasional chills. For several months prior to admission his symptoms had increased in severity. Physical examination. A poorly developed, emaciated, senile white male, dyspneic, cyanotic and acutely ill. Chest examination revealed impaired resonance and fremitus of the left side with flatness and absent breath sounds at the base. Bronchovesicular breath sounds and medium coarse rales were heard over the upper lobes of both lungs. The heart sounds were regular, of poor tone with a systolic apical bruit. Blood pressure 128/68i In the left epigastrium a firm tender mass was palpated extending to just below the costal margin. The prostate was somewhat enlarged. There were numerous purpuric spots on the right ear, wrists, scrotal sac and legs. Cervical, axillary, epitrochlear and inguinal lymph nodes were palpable. Clinical course. Three days after admission approximately 1000 cc. of dark red bloody fluid was aspirated from the left chest. The patient ran a low grade fever daily (97°100.6°F.), remained cyanotic and dyspneic, rapidly became weaker, finally irrational and expired on January 23, 1940, or 15 days after admission. Laboratory and x-ray studies. Sputum positive for tubercle bacilli. Chest roentgenogram showed a fibrotic type of tuberculosis in the right lung from the apex to the 4th rib anteriorly with a cavity 2.5 cm. in diameter between the 1st and 2nd ribs. The left lung showed a fibrotic infiltration in the apex with a hazy homogeneous shadow occupying the lower half of the lung field, suggesting a pleural effusion. The pleural fluid had a specific gravity of 1.018, Rivalta test was 1+ and a smear showed 90 per cent lymphocytes, 5 per cent polymorphonuclear leukocytes and 5 per cent large monocytes. No organisms were found on culture. Blood count on admission showed a hemoglobin of 9.9 grams, RBC 3,640,000, WBC 87,799 with 99 per cent small lymphocytes. The urine was negative. The Wassermann and Kahn tests were negative. Blood count on January 12, 1940 showed a hemoglobin of 10.6 grams, RBC 3,710,000, WBC 88,200 with 98 per cent small lymphocytes. Because of the abnormal blood count a sternal bone marrow biopsy was performed. Supravital study (Dr. D. K. Miller) of smears of the biopsy material showed many adult lymphocytes and a few lymphoblasts. Very few cells of the erythroor granulopoietic series were seen. Sections stained with Giemsa showed an increase of the cellularity of the marrow, the fat cells being almost entirely replaced by cells of the lymphoid series as shown in figure 1. The .final clinical diagnosis was advanced pulmonary tuberculosis and chronic lymphatic leukemia. An autopsy was performed under the direction of Dr. W. F. Jacobs.