Coexistence of chronic lymphocytic leukemia and ...

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Dear Editor,. Autoimmune phenomena are seen frequently during the course of chronic lymphocytic leukemia (CLL). However, development of autoimmune ...
Ann Hematol (2006) 85:811–812 DOI 10.1007/s00277-006-0162-9

LETTER TO THE EDITOR

Coexistence of chronic lymphocytic leukemia and Hashimoto’s thyroiditis Cengiz Beyan & Kürşat Kaptan & Ahmet Ifran

Received: 25 April 2006 / Accepted: 5 June 2006 / Published online: 15 July 2006 # Springer-Verlag 2006

Dear Editor, Autoimmune phenomena are seen frequently during the course of chronic lymphocytic leukemia (CLL). However, development of autoimmune thyroiditis is very rare. A 66year-old male CLL patient was admitted to the hospital for his regular controls. His complaints, including sweating and weight loss, were present for 6 months. Advanced CLL was diagnosed 3 years ago, and six courses of fludarabine (30 mg/m2/day for 5 days) were administered. In physical examination, his general condition was good, and his spleen and thyroid were palpable. The complete blood count values were as follows: WBC 2.80×109/l, hemoglobin 10.4 g/dl, hematocrit 31.8%, and platelets 149×109/l. Peripheral blood smear showed normal distribution of cells with normal morphology. Red blood cells were normochromic and normocytic. Platelet clumps were adequate. Erythrocyte sedimentation rate was 51 mm/h. Thyroid function screening tests were as follows: free T3: 2.65 pg/ml (normal range 2.57–4.43), free T4: 1.33 ng/dl (0.93–1.70), thyroid stimulating hormone: 2.40 μIU/ml (0.27–4.20), antithyroglobulin antibody 4,000 IU/ml (0–115), and antiTPO antibody: 600.0 IU/ml (0–34). Both thyroid lobes were observed as minimally enlarged during the ultrasonographic examination. Ultrasonographic examination revealed that there were two isoechoic nodules in the gland, one located at the inferior part of left lobe with 18 mm diameter, and one located at just beside its superior, with 10 mm diameter. Echo pattern of the gland parenchyma C. Beyan (*) : K. Kaptan : A. Ifran Department of Hematology, Gulhane Military Medical Academy, 06010 Etlik, Ankara, Turkey e-mail: [email protected]

was heterogeneous. These findings were interpreted as “nodular hyperplasia of thyroid gland with heterogeneous echo pattern (thyroiditis)”. Biopsy specimen obtained from the larger nodule was reported as negative for malignancy. The case was diagnosed as “coexistence of CLL and Hashimoto’s thyroiditis”. Regular controls were planned for the patient; no medication was prescribed for the current condition. Hashimoto’s disease may be associated with other autoimmune endocrine disorders such as diabetes mellitus, Addison’s disease, hypoparathyroidism, hypopituitarism, Graves’ disease, and vitiligo [1]. In CLL patients, immune dysregulation manifests itself in various autoimmune diseases: autoimmune hemolytic anemia (AIHA), idiopathic thrombocytopenia, and pure red cell aplasia [2]. Besides primary hematological disease, in our case, administered fludarabine treatment is a second risk factor for the predisposition for autoimmune disorders. One of the main toxic effects of fludarabine is the precipitation or worsening of AIHA [3]. Autoimmune thrombocytopenia has been described as a complication of fludarabine therapy [4]. Evans syndrome post fludarabine has been reported [5]. No relation between the use of fludarabine and autoimmune thyroiditis was reported in the literature. There was approximately 1 year interval between the cessation of fludarabine treatment and the first complaints related to autoimmune thyroiditis in our case, so it is hard to attribute the development of autoimmune thyroiditis to the fludarabine treatment. Finally, because the pathogenesis of both conditions has similar features, we suggest that the probability of development of autoimmune thyroiditis in the follow-up of CLL patients should be kept in mind.

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References 1. Giordano C, Stassi G, De Maria R, Todaro M, Richiusa P, Papoff G, Ruberti G, Bagnasco M, Testi R, Galluzzo A (1997) Potential involvement of Fas and its ligand in the pathogenesis of Hashimoto’s thyroiditis. Science 275:960–963 2. Diehl LF, Ketchum LH (1998) Autoimmune disease and chronic lymphocytic leukemia: autoimmune hemolytic anemia, pure red cell aplasia, and autoimmune thrombocytopenia. Semin Oncol 25:80–97

Ann Hematol (2006) 85:811–812 3. Myint H, Copplestone JA, Orchard J, Craig V, Curtis D, Prentice AG, Hamon MD, Oscier DG, Hamblin TJ (1995) Fludarabinerelated autoimmune haemolytic anaemia in patients with chronic lymphocytic leukaemia. Br J Haematol 91:341–344 4. Montillo M, Tedeschi A, Leoni P (1994) Recurrence of autoimmune thrombocytopenia after treatment with fludarabine in a patient with chronic lymphocytic leukemia. Leuk Lymphoma 15:187–188 5. Shvidel L, Shtarlid M, Klepfish A, Sigler E, Berrebi A (1997) Evans syndrome complicating fludarabine treatment for advanced B-CLL. Br J Haematol 99:706