How should a patient with scleral jaundice, Chronic Lymphocytic Leukemia (CLL), and Congestive Heart Failure (CHF) be managed?

SOAP Note for Patient with Scleral Jaundice, CLL, and CHF

Subjective

• Chief Complaint: Scleral jaundice
• History of Present Illness: Patient presents with scleral jaundice, in the setting of known Chronic Lymphocytic Leukemia (CLL) and Congestive Heart Failure (CHF)
• Review of Systems:
  • Cardiovascular: Assess for dyspnea, orthopnea, paroxysmal nocturnal dyspnea, peripheral edema
  • Gastrointestinal: Assess for abdominal pain, distention, nausea, vomiting, changes in stool color
  • Constitutional: Assess for B symptoms (fever, night sweats, weight loss)
  • Hematologic: Assess for easy bruising, bleeding, recurrent infections

Objective

• Vital Signs: Check for tachycardia, hypotension, tachypnea, fever
• Physical Examination:
  • General: Scleral jaundice present
  • HEENT: Assess for pallor
  • Cardiovascular: Assess for elevated JVP, S3 gallop, murmurs
  • Respiratory: Assess for crackles, decreased breath sounds, pleural effusion
  • Abdominal: Assess for hepatomegaly, splenomegaly, ascites, right upper quadrant tenderness
  • Extremities: Assess for peripheral edema
• Laboratory Studies:
  • Complete blood count with differential
  • Comprehensive metabolic panel including liver function tests (total/direct/indirect bilirubin, ALT, AST, alkaline phosphatase)
  • Coagulation studies (PT/INR, PTT)
  • Serum beta-2 microglobulin
  • Direct antiglobulin test
• Imaging:
  • Chest X-ray
  • Abdominal ultrasound to assess liver size, echogenicity, and rule out biliary obstruction
  • Echocardiogram to assess cardiac function and LVEF

Assessment

1. Scleral jaundice - likely due to:

   • Hepatic congestion secondary to CHF (cardiogenic jaundice) 1, 2
   • Possible ischemic hepatitis if patient has had recent hypotension or decompensated heart failure 1
   • Less likely: CLL infiltration of liver or drug-induced liver injury from CLL treatments

2. Chronic Lymphocytic Leukemia (CLL) - requires assessment of:

   • Disease stage (Rai or Binet staging)
   • Genetic profile (del(17p), TP53 mutation, IGHV status)
   • Current treatment status and response
   • Presence of cytopenias (anemia, thrombocytopenia)

3. Congestive Heart Failure (CHF) - requires assessment of:

   • NYHA functional class
   • LVEF status (HFrEF vs. HFpEF)
   • Current medication regimen and adherence
   • Evidence of decompensation (volume overload)

Plan

1. Management of Jaundice

• Identify and treat underlying cause: Focus on optimizing CHF management as the likely primary driver of hepatic congestion 1, 2
• Monitor liver function tests closely during treatment

2. Management of CLL 3, 4

• If patient requires CLL treatment (based on disease progression, symptoms, or cytopenias):
  • Obtain genetic testing for del(17p), TP53 mutation, and IGHV mutational status before selecting therapy
  • For frail patients with significant comorbidities (including CHF):
    • Preferred regimens: Obinutuzumab plus chlorambucil, ofatumumab plus chlorambucil, or rituximab plus chlorambucil 3
    • Alternative: Obinutuzumab monotherapy (category 2B recommendation) 3
  • Avoid aggressive chemoimmunotherapy regimens due to cardiac comorbidity
  • Consider BTK inhibitors with caution due to cardiovascular side effects (especially with pre-existing CHF)

3. Management of CHF 3

• Optimize guideline-directed medical therapy:
  • For HFrEF: ACE-I/ARB, beta-blocker, MRA, and SGLT2 inhibitor (dapagliflozin or empagliflozin) 3
  • For HFpEF/HFmrEF: SGLT2 inhibitor (dapagliflozin or empagliflozin) 3
  • Diuretics for congestion to alleviate symptoms, improve exercise capacity, and reduce hospitalizations 3
  • Consider sacubitril/valsartan as replacement for ACE-I/ARB in HFrEF patients 3
• Enroll in multidisciplinary HF management program to reduce hospitalization risk and improve survival 3

4. Integrated Management Approach

• Prioritize CHF management to improve hepatic congestion and jaundice
• Carefully select CLL therapy considering cardiac comorbidity
• Monitor for complications:
  • Infections (common in both CLL and CHF)
  • Worsening cytopenias
  • Tumor lysis syndrome if initiating CLL therapy
  • Medication interactions between CLL and CHF treatments

5. Follow-up

• Close monitoring of liver function tests, complete blood count, and cardiac status
• Cardiology and hematology co-management with coordinated care plan
• Consider palliative care consultation for symptom management if advanced disease

The management of this patient should prioritize optimization of heart failure therapy to address the likely cardiogenic jaundice, while carefully selecting appropriate CLL treatment that minimizes cardiac risk. 3, 1