A 76-year-old female was diagnosed 3 years ago as suffering from chronic lymphocytic leukaemia (CLL). She has not required any therapy and was in good health until 4 weeks ago. She now complains of tiredness, polyuria and lethargy, and has also noticed increasing abdominal distension. On examination she is pale. She is not jaundiced, but she does have lymphadenopathy in both axillae. A marked swelling of the left elbow is noted. The spleen is easily palpable, and ascites is present. Neurological examination is normal.