DA Ashdown M Saxby
Corresponding author Daniel Ashdown, Urology Secretaries, 4th Floor, Department of Urology, University Hospital, Birmingham, Edgbaston, Birmingham, B15 2TT
E-mail: d.ashdown@bham.ac.uk
SMJ 2006 52(1): 55
Case
report
We present an unusual primary presentation of Chronic Lymphocyte Leukaemia (CLL), which has not previously been described in the literature.
A 73 year old man presented to his G.P. with a six month history of scrotal swelling, but no urinary or systemic symptoms. Previous medical history included hypertension, atrial fibrillation, and bilateral venous leg ulcers. Medication included atenolol, frusemide, ramipril and aspirin. He was a non smoker.
He was referred to Urology on-call team with a supposed diagnosis of scrotal cellulitis as the cause for his scrotal swelling. Clinical examination showed massive scrotal oedema with chronic skin changes and non palpable testes. He had mild cardiac failure and chronic venous ulceration of his legs bilaterally. There was no palpable organomegaly or lymphadenopathy. Routine blood results were as follows; haemoglobin 13.4, white cell count (WCC) 26.5, platelets 232, urea 23, creatinine 240, and albumin 43.
Urgent ultrasound and CT scanning of his abdomen and scrotum suggested bilateral hydronephrosis and scrotal oedema but no organomegaly or lymphadenopathy. A provisional diagnosis of retroperitoneal fibrosis was made as a cause for his renal dysfunction and he was started on prednisolone. The haematologists also confirmed the diagnosis of Chronic Lymphocytic Leukaemia as the cause of his raised WCC.
This gentleman's renal and haematological condition deteriorated and he passed away four weeks after admission. At post mortem bilateral hydronephrosis and severely diseased kidneys were found, but no cause for the obstructive uropathy. There was also a moderately enlarged spleen and enlarged lymph nodes in both iliac regions. CLL lymphadenopathy causing venous outflow obstruction was identified as the cause of the scrotal oedema
Discussion
Chronic Lymphocytic Leukaemia is an incurable disease of elderly population characterised by an uncontrolled proliferation and accumulation of mature B-lymphocytes.1 Symptoms occur due to bone marrow failure i.e. bleeding, infarction and anaemia, hepatosplenomegaly and lymphadenopathy. Some patients however remain asymptomatic and die unaware of the disease. Average life expectancy is 2-8 years according to stage. In the asymptomatic population diagnosis is usually made by routine full blood count testing.
Scrotal oedema results from a variety of conditions including heart and hepatic failure, idiopathic lymphoedema and lymphatic and venous obstruction.2 Its presentation in the elderly should alert the physician to the possibility of malignancy, causing venous outflow obstruction, in the pelvis.
References
1) Kumar P, Clark M. Clinical Medicine (4th Ed). Saunders
2) Grainger AJ, Hide IG, Elliott ST. The ultrasound appearances of scrotal oedema. European Journal of Ultrasound 1998;8:33-7.