BMJ Case Reports 2018; doi:10.1136/bcr-2018-225893
  • Rare disease

Two distinct histological Richter’s transformations 23 years apart in a patient with chronic lymphocytic leukaemia

  1. Faysal Haroun1
  1. 1Hematology and Oncology, George Washington University, Washington, DC, USA
  2. 2Department of Hematology and Oncology, George Washington University, Washington, DC, USA
  3. 3George Washington University School of Medicine and Health Sciences, Washington, DC, USA
  1. Correspondence to Dr Umera Thebo, umerathebo{at}
  • Accepted 7 September 2018
  • Published 8 October 2018


A 53-year-old man with a 1-year history of chronic lymphocytic leukaemia (CLL) presented with a left bicep mass. Biopsy and staging workup revealed Richter’s transformation (RT) Ann Arbor stage 1E diffuse large B-cell lymphoma in the bicep. The patient was treated with combination chemotherapy with cyclophosphamide, doxorubicin, Vincristine and prednisone followed by site radiation and did well thereafter. His CLL progressed and required treatment on two more occasions 11 and 18 years after his initial diagnosis with fludarabine, Cytoxan and Rituxan and then with bendamustine and rituximab. 23 years after initial presentation, he developed diffuse lymphadenopathy and B-symptoms. A biopsy of an enlarged cervical lymph node demonstrated only CLL for which he was started on ibrutinib. Treatment was shortly discontinued thereafter due to intolerance and worsening symptoms. A second biopsy was performed which revealed concurrent CLL and Hodgkin’s lymphoma representing a second and histologically distinct RT.


  • Contributors All the authors listed (UT, RLM, JE and FH) made substantial contributions to conception and design, analysis and interpretation of data. UT drafted the article and revised it critically for important intellectual content.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Next of kin consent obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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