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J. E. C. BROMBERG1, W. P. VANDERTOP2 & G. H. JANSEN3
Abstract
An 81-year-old man with a recurrent subdural haematoma as the first and only manifestation of chronic lymphocytic leukaemia (CLL) is described. Microscopic examination of the encapsulated haematoma showed leukaemic infiltration and the diagnosis was confirmed by bone marrow aspiration and by pathological examination of the brain at autopsy.
Key words: Central nervous system CLL, chronic lymphocytic leukaemia (CLL), subdural haematoma.
Introduction
Chronic lymphocytic leukaemia (CLL) is a haematological disorder of older age groups, characterized by the clonal proliferation and accumulation of small lymphocytes, usually B-type, which appear morphologically mature but are immunologically incompetent. The majority of patients present with lymphadenopathy and moderate splenomegaly.
However, in 25% of cases CLL is discovered by chance and patients are entirely asymptomatic, the diagnosis being made on a routine blood count. Symptomatic central nervous system involvement in CLL is rare' and is most likely to occur in advanced stages of the disease as haemorrhage or infection.2 However, this neurological involvement can occur as the first manifestation, preceding haematological and general symptoms.34 We present a patient in whom a recurrent subdural haematoma was the first and only symptom of CLL.
Case report
An 81-year-old man presented with a 10-day history of slight speech impairment and progressive weakness of his right arm and leg. He was otherwise in good health and there was no history of trauma, use of oral anticoagulants or alcohol misuse. On physical examination some small, 0.5 cm in diameter, cervical and supraclavicular lymph nodes were found. There was no other lymphadenopathy or splenomegaly and general examination was otherwise unremarkable. Mental status was unimpaired.
Neurological examination showed slight motor dysphasia, a mild central facial weakness on the right side, and paresis of the right arm and leg. Muscle stretch reflexes were increased on the right, but there was no extensor plantar response. Sensory examination was normal. Routine blood examination and urinalysis showed no abnormalities apart from a white cell count of 14.6 x 109/1 with 62% lymphocytes, 33% neutrophils, 4% monocytes and 1% eosinophils. Thrombocyte count and haemostatic tests were normal. Computed tomography (CT) of the head showed a large, hypodense,...