PMC6434293_01
Axillary lymph node: (a) Haematoxylin and eosin stain showing monomorphic proliferation of small lymphocytes in keeping with CLL. (b) Immunoperoxidase stain showing positive staining of lymphocytes for CD5.
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Core biopsy (Figure 1) demonstrated abnormal lymphoid tissue with small- to medium-sized lymphocytes with irregular nuclei.
Imaging of left shoulder: (a) Plain radiograph showing lucency of humeral head. (b) MRI scan showing marrow infiltration of humeral head and shaft.
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Plain radiography showed an ill-defined lucency projected over the lateral aspect of the left humeral head (Figure 2(a)), and magnetic resonance imaging (MRI, Figure 2(b)) revealed extensive marrow infiltration of the humeral head and shaft, shoulder girdle, and ribs, together with axillary lymphadenopathy.
Patient's laboratory investigations and clinical events. Shaded areas represent reference ranges.
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During 2014, her lymphocyte count rose, and by early 2015 it was 22.6 x 109/L (Figure 3). Referral to the renal clinic in February 2016 was prompted by a decline in renal function (Figure 3).
Cardiac imaging: (a) Coronary angiogram showing normal unobstructed left coronary artery. (b) Coronary angiogram showing normal unobstructed right coronary artery. (c) Left ventricle 4 chamber cardiac MRI late gadolinium enhancement image showing area of near transmural infarction in the mid septum. (d) Left ventricle short axis cardiac MRI late gadolinium enhancement image at the papillary muscle level showing area of near transmural infarction of the mid septum.
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Coronary angiography showed no significant stenosis or thrombus within the coronary arteries (Figures 4(a) and 4(b)). Cardiac MRI demonstrated full-thickness enhancement in the midseptum with associated hypokinesia, consistent with an infarct (Figures 4(c) and 4(d)); left ventricular ejection fraction was well maintained at 72%.
Percutaneous renal biopsy: (a) Haematoxylin and eosin stain showing dense lymphoid infiltrate. (b) Immunoperoxidase stain showing positive staining of lymphocytes for CD5. (c) Haematoxylin and eosin stain showing lobulation of glomeruli in keeping with MPGN. (d) Silver stain showing thickening and double contouring of basement membrane in keeping with MPGN.
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She underwent percutaneous renal biopsy (Figure 5).