Box 2.

Case study

Case presentation
A 51-year-old man was reviewed by his general practitioner (GP), as he reported generalised abdominal pain and a history of night sweats over the previous 6 weeks. He denied any weight loss and was otherwise fit and well. On examination, he had one 2 cm cervical lymph node and one 2 cm axillary lymph node on his left side. He had no hepatomegaly or splenomegaly. His GP conducted some baseline blood tests and the patient was found to have a lymphocyte count of 70.8 × 109/L. An urgent referral to haematology was made.
The patient was reviewed by the haematology team. To confirm the diagnosis, he had a full blood count, blood film and immunophenotyping requested. Other tests included urea and electrolytes, liver function tests, the direct antiglobulin test, calcium, immunoglobulins and serum protein electrophoresis. The patient was anaemic with haemoglobin of 93 g/L and had a lymphocytosis of 72 × 109/L with smear cells on the blood film. Flow cytometry confirmed the B lymphocytes that were positive for CD5 and CD23. He went on to have a bone marrow aspirate which showed 86% lymphocytic infiltrate. He was diagnosed with chronic lymphocytic leukaemia on the basis of confirmatory immunophenotyping.
The patient had a performance status of 0 and was worked up to start chemo-immunotherapy. Cytogenetics showed no del17p or TP53 mutation and he was started on fludarabine, cyclophosphamide and rituximab (FCR) with prophylactic antibiotics and allopurinol. 5 years later, his disease relapsed and he was started on ibrutinib with good response. Venetoclax would be the treatment of choice should third-line treatment be required in the future.