ADULT ACUTE LYMPHOBLASTIC LEUKEMIA PRESENTING AS JAUNDICE

Abstract

Introduction: Jaundice is a rare presenting feature of acute lymphoblastic leukemia (ALL). We report the case of a patient with ALL who presented with jaundice, which regressed with chemotherapy. Case: A 43 year old male with no past medical history, presented to the hospital with symptoms of epigastric pain, fatigue, jaundice and pruritus of one month's duration. He was admitted with a presumed diagnosis of acute cholecystitis. Physical examination revealed scleral icterus and hepatosplenomegaly. Laboratory tests showed a white blood cell count of 2,400/μ X, hemoglobin of 14.5 g/dL, platelet count of 91,000/μ X, total bilirubin of 9.0 mg/dL, direct bilirubin of 8.0 mg/dL, aspartate aminotransferase of 66IU/L, alanine aminotransferase of 58IU/L and an alkaline phosphatase of 173 IU/L. Serologic tests for hepatitis A, B and C were nonreactive. Serum antibodies for autoimmune liver disease were not detected. An endoscopic ultrasound, computerized tomography scan and magnetic resonance imaging revealed hepatosplenomegaly and a thickened gallbladder wall, but no evidence of extrahepatic obstruction. Total bilirubin peaked at 16.5 mg/dL and direct bilirubin at 12.5 mg/dL eleven days following admission. Examination of the bone marrow revealed a markedly hypercellular marrow with diffuse immature lymphocytic infiltrates consistent with ALL. Following chemotherapy treatment with cyclophosphamide, vincristine and dexamethasone his liver chemistries normalized. Discussion: Jaundice as the presenting feature of ALL is a rare phenomenon and has been infrequently reported in the pediatric literature. We believe this is the first reported case of an adult with ALL whose presenting feature was jaundice. Due to the absence of extrahepatic obstruction on imaging studies and dramatic improvement of liver function tests following chemotherapy, we postulate that leukemic infiltration of the liver was responsible for the patient's symptoms. This case demonstrates that jaundice associated with acute leukemia responds well to successful treatment of the underlying hematologic malignancy.