S1668 To Treat or Not to Treat?

INTRODUCTION: Chronic Lymphocytic Leukemia (CLL) is a B cell type malignancy which accounts for 30% of all leukemia cases. Clinical presentation can be broad, ranging from fatigue or malaise to more serious symptoms like anemia, thrombocytopenia or recurrent infections. Gastrointestinal tract CLL involvement is uncommon with very few cases reported in the literature. It generally occurs only after transformation of CLL to diffuse large B-cell lymphoma (DLBCL). We present a case of a 69-year-old male with history of Crohn’s disease who developed intestinal involvement of CLL, and how a multidisciplinary approach allowed for successful management of both of his conditions. CASE DESCRIPTION/METHODS: This is the case of a 69-year-old male with history of non-treated CLL and Crohn’s disease on infliximab who presented for a surveillance colonoscopy to the endoscopic unit. Labs revealed no anemia/thrombocytopenia, lymphocytosis >55%, and stable LFTs. Physical examination was unremarkable. Colonoscopy with normal colonic mucosa, however, biopsy from the terminal ileum revealed, prominent lymphoid aggregates with immunohistochemical analysis positive for a B cell population with CD20, CD5, CD23 and CD43, findings supporting involvement of intestinal mucosa with CLL, without evidence of DLBCL. Therefore, the oncology service recommended to start CLL treatment with obinutuzumab and venetoclax. Two years later, the patient presented with a Crohn’s disease flare and new colonic biopsies revealed non-neoplastic lymphoid infiltrates, suggesting a typical Chron’s disease flare rather than CLL involvement. Infliximab was increased from 5 mg/kg to 10 mg/kg without complications and no changes to his CLL treatment were recommended at that time. DISCUSSION: This rare extramedullary involvement of the gastrointestinal tract by CLL presents many management challenges. CLL increases the risk for progressive immunodeficiency, affecting all elements of the immune system which, in the setting of a concomitant condition like Crohn’s disease and the need for the use of additional immunosuppressors, increases even more the risk of severe infections from bacteria and viruses. For this reason, our case emphasizes the fact of how a multidisciplinary approach between sub-specialties can provide a better route map for managing difficult cases like this one, in which providing treatment for either condition can complicate the patient’s clinical picture.Figure 1.: Lymphocytic infiltration of the gastrointestinal mucosa.Figure 2.: Gastrointestinal mucosa.Figure 3.: Crohn's disease flare.