A generalized, progressive disease that's common in the elderly, chronic lymphocytic leukemia (CLL) is marked by an uncontrollable spread of abnormal, small lymphocytes in lymphoid tissue, blood, and bone marrow. Nearly all patients with CLL are men older than age 50. According to the American Cancer Society, this disease accounts for about 25% of all new leukemia cases annually.
Although the cause of CLL is unknown, researchers suspect hereditary factors (higher incidence has been recorded within families), still-undefined chromosome abnormalities, and certain immunologic defects (such as ataxia-telangiectasia or acquired agammaglobulinemia). The disease doesn't seem to be associated with radiation exposure, carcinogenic chemicals, or viruses.
Approximately 2 out of every 100,000 people develop CLL annually, with 90% of cases found in people who are older than age 50. Many cases go undetected by routine blood tests in people who are asymptomatic. The disease is common in Jewish people of Russian or Eastern European descent, and is uncommon in Asia.
CLL is the most benign and the most slowly progressive form of leukemia. Clinical signs derive from the infiltration of leukemic cells in bone marrow, lymphoid tissue, and organ systems.
In early stages, patients usually complain of fatigue, malaise, fever, and nodal enlargement. They're particularly susceptible to infection.
In advanced stages, patients may experience severe fatigue and weight loss, with liver or spleen enlargement, bone tenderness, and edema from lymph node obstruction. Pulmonary infiltrates may appear when lung parenchyma is involved. Skin infiltrations, manifested by macular to nodular eruptions, occur in about one-half of the cases of CLL.
As the disease progresses, bone marrow involvement may lead to anemia, pallor, weakness, dyspnea, tachycardia, palpitations, bleeding, and infection. Opportunistic fungal, viral, and bacterial infections commonly occur in late stages.
Typically, CLL is an incidental finding during a routine blood test that reveals numerous abnormal lymphocytes. In early stages, white blood cell (WBC) count is mildly but persistently elevated. Granulocytopenia is the rule, but the WBC count climbs as the disease progresses. Blood studies also show hemoglobin levels under 11 g, hypogammaglobulinemia, and depressed serum globulins. Other common developments include neutropenia (neutrophils less than 1,500/µl), lymphocytosis (lymphocytes more than 10,000/µl), and thrombocytopenia (platelets less than 150,000/µl). Bone marrow aspiration and biopsy show lymphocytic invasion.
Systemic chemotherapy includes alkylating agents — usually chlorambucil, cyclophosphamide, vincristine, or fludarabine (singly or in combination) — and steroids (prednisone) when autoimmune hemolytic anemia or thrombocytopenia occurs.
An advance in the treatment of CLL has been the emergence of the humanized monoclonal antibodies rituximab and alemtuzumab. Alemtuzumab acts as an antibody against the surface of CLL cells and is used when fludarabine fails. Rituximab, a monoclonal antibody, acts similiarly to alemtuzumab; studies are ongoing.
When chronic lymphocytic leukemia causes obstruction or organ impairment or enlargement, local radiation treatment can be used to reduce organ size. Allopurinol can be given to prevent hyperuricemia, a relatively uncommon finding.
Prognosis is poor if anemia, thrombocytopenia, neutropenia, bulky lymphadenopathy, and severe lymphocytosis are present.
❑Plan patient care to relieve symptoms and prevent infection. Clean the patient's skin daily with mild soap and water. Frequent soaks may be ordered. Watch for signs or symptoms of infection: temperature over 100° F (37.8° C), chills, redness, or swelling of any body part.
❑Watch for signs and symptoms of thrombocytopenia (black tarry stools, easy bruising, nosebleeds, bleeding gums) and anemia (pale skin, weakness, fatigue, dizziness, palpitations). Advise the patient to avoid aspirin and products containing aspirin. Explain that many medications contain aspirin, even though their names don't make this clear. Teach him how to recognize aspirin variants on medication labels.
❑Explain chemotherapy and its possible adverse effects. If the patient is to be discharged, tell him to avoid coming in contact with obviously ill people, especially children with common contagious childhood diseases. Urge him to eat high-protein foods and drink high-calorie beverages.
❑Stress the importance of follow-up care, frequent blood tests, and taking all medications exactly as prescribed. Teach the patient the signs and symptoms of recurrence (swollen lymph nodes in the neck, axilla, and groin; increased abdominal size or discomfort), and tell him to notify his physician immediately if he detects any of these signs.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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Title: Professional Guide to Diseases (Eighth Edition)
Authors: Springhouse
Publisher: Lippincott Williams & Wilkins
Copyright: 2005
ISBN: 1-58255-370-X
» Next page: Leukemia, acute (Handbook of Diseases)
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