Have you tried low dose methotrexate? 15 mg once a week?

Thank you for your suggestion, unfortunately he developed significant hepatitis from Methotrexate.and reluctant to retreat, Patient has significant cytopenias and background of RA

You can use G-CSF for the neutropenia; it might exacerbate the patient's joint problems; however, he could benefit from it, and you can combine it with extracorporeal photopheresis (ECP).

Yes we have GCSF on board unfortunately marrow is packed with leukaemic cells. Trying Cladribine and Rituximab (case reports - http://www.bloodjournal.org/content/122/9/1583?sso-checked=true )

He is in some trouble

Dear Jason, need to know more about the history. Are we dealing with T-LGL or NK-LGL? What was a previous treatment and what is the patient's status. What would be a reason for rituximab use - is there an expression of CD20 on tumor cells? 

Hi Martin

This is T-LGL with background of RA and the rationale is explained in the journal article.

I am not sure if G-CSF could exacerbate T-LGL. What about ECP, have you tried it?