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BLOOD CONTAMINANT WAS THE KEY

2019; Elsevier BV; Volume: 156; Issue: 4 Linguagem: Inglês

10.1016/j.chest.2019.08.775

1931-3543

Rajamurugan Meenakshisundaram, Brent Kaufmann, Vishesh Paul,

Lung Cancer Treatments and Mutations

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Endobronchial Ultrasound (EBUS) with transbronchial needle aspiration (TBNA) specimens are used to evaluate for hilar and mediastinal lymph node pathology. Here we present the first case report of Chronic myeloid leukemia (CML) diagnosed with TBNA CASE PRESENTATION: A 62 years old female with a history of hypothyroidism and 45 pack-years of smoking was referred to the pulmonology clinic with worsening exertional shortness of breath, occasional night sweats and non-productive cough for 5 months. She denied fever, chills, chest pain, palpitations, leg swelling, and weight or appetite changes. On presentation, vitals were BP- 150/76 mm Hg, PR of 74/min, RR-20/min, SPO2-95% on room air. Rest of the physical examination was unremarkable. Initial outpatient blood work showed leucocytosis of 27.7 K cells/mm3, Hb of 13.3 gm/dL and platelet count-1,195K/mm3. CT chest with contrast showed 3-centimeter hilar mass with mediastinal and bilateral hilar lymphadenopathy. The patient underwent bronchoscopy along with EBUS and TBNA. Biopsy specimens were collected from the paratracheal, hilar, subcarinal lymph nodes. Histopathology and flow cytometry ruled out lymphoma and lung cancer. Surprisingly, the cytospin slide showed atypical myeloid cells, concerning for myeloid blasts. She was called back to go to the emergency department with the concern for blast crisis and the repeat blood work showed worsening leucocytosis of 154K cells/mm3 and thrombocytosis of 599K cells/mm3. Other significant laboratory findings were elevated creatinine (1.29), LDH 1151 and uric acid- 9.8. She was given one dose of hydroxyurea and All-trans retinoic acid with concern for acute promyelocytic leukemia. Further evaluation using FISH (Fluorescent In-Situ Hybridization) of peripheral blood and bone marrow specimens revealed BCR/ABL translocation consistent with Chronic myeloid leukemia (CML). CT abdomen showed extensive retroperitoneal and mesenteric lymphadenopathy. She was started on Nilotinib (Tyrosine kinase inhibitor) and her symptoms started to improve in a few weeks. Follow up CT chest/abdomen in 3 months showed significant improvement in lymphadenopathy. DISCUSSION: EBUS with TBNA has become a valuable tool to evaluate hilar and mediastinal pathology. Blood is often considered a hindrance in interpreting the histopathology of TBNA specimen. But in our patient, blood contamination lead to the diagnosis. In brief, CML has three phases: chronic asymptomatic, accelerated and blast crisis. In both accelerated and blast crisis, extramedullary lymph node involvement may occur. Since our patient had hilar and mediastinal lymph node involvement without significant blast ( CONCLUSIONS: TBNA blood contamination of the specimen guided the CML diagnosis. Reference #1: Kennedy MP, Jimenez CA, Bruzzi JF, et al Endobronchial ultrasound guided transbronchial needle aspiration in the diagnosis of lymphoma Thorax 2008; 63:360-365. Reference #2: Ohkubo R, Izumo T, Ochiai K, Kirishi S, Tamaoki J, Nagai A- Case of precursor T- lymphoblastic lymphoma/ leukemia diagnosed with endobronchial ultrasound-guided transbronchial needle aspiration Journal of the Japanese Respiratory Society 2010, 48; 12: 955-959. DISCLOSURES: No relevant relationships by Brent Kaufmann, source=Web Response No relevant relationships by Rajamurugan Meenakshisundaram, source=Web Response No relevant relationships by Vishesh Paul, source=Web Response