Pt with CLL for many years, not on treatment, asymptomatic, with counts between 100k-150k, came to the hospital, AMS with same count, however went double in a day to become 300k? how do you approach this kind of patient / is this a CLL to Acute leukemia transformation? Are treatments like BTK inhibitors still ok for this patient, do they need something for cytoreduction?
Hello. Doubling of 100k to 300k in 24 hours does not happen frequently in CLL neither does transformation to acute leukemia. Either this is new onset acute leukemia or TP53 mutated CLL. For the first I recommend a peripheral blood smear evaluation to make sure there are no blasts. If it remains CLL then BTK inhibitors is the way to proceed. No need for cytoreduction. If unable to administer BTK inhibitor in the hospital then can consider one dose of bendamustine 90mg/m2 for 2 days. Rituximab on day 3 as infusion reactions are high with such high WBC counts. Lastly, AMS with wbc count of 300k worries me of leukostasis in acute leukemia and may require Leukapheresis. If you are not in a tertiary center I suggest transferring the patient quickly.
