Precursor B-cell acute lymphoblastic leukemia presenting as obstructive jaundice: a case report

Nelly Aoun,Muhammad N Siddique,Rabih Maroun,Qun Dai,Muhammad Popalzai,Michael Awasum

doi:10.1186/1752-1947-5-269

Abstract

IntroductionAcute leukemias very rarely present with jaundice. Herein we report a case of precursor B-cell acute lymphoblastic leukemia that presented with jaundice in an adult.Case presentationA 44-year-old Hispanic man presented with right upper quadrant abdominal pain and jaundice. His initial blood work revealed pancytopenia and hyperbilirubinemia. Direct bilirubin was more than 50% of the total. His imaging studies were unremarkable except for hepatomegaly. All blood screening tests for various hepatocellular etiologies were normal. A diagnosis of precursor B-cell acute lymphoblastic leukemia was made upon liver biopsy. It also showed lymphocytic infiltration of the hepatic parenchyma leading to bile stasis. The diagnosis was subsequently confirmed upon bone marrow biopsy. The patient was treated with a hyperfractionated cyclophosphamide/vincristine/doxorubicin/dexamethasone regimen.ConclusionAcute lymphoblastic leukemia should be one of the differential diagnoses that should be considered when initial work-up for jaundice is inconclusive. Some cases of acute lymphoblastic leukemia have been reported in both adults and children to have presented with the initial manifestation of jaundice, but only a few had no radiographic evidence of biliary obstruction. Such presentation can pose a serious diagnostic dilemma for clinicians. This manuscript attempts to highlight it. Moreover, we believe that if acute lymphoblastic leukemia presentations similar to this case continue to be reported in adults or children, a specific immunophenotypic expression and cytogenetic abnormality may be found to be associated with hepatic infiltration by leukemia. This may substantially contribute to the further understanding of the pathophysiology of this hematologic disease.

Highlights

Acute leukemias very rarely present with jaundice
Some cases of acute lymphoblastic leukemia have been reported in both adults and children to have presented with the initial manifestation of jaundice, but only a few had no radiographic evidence of biliary obstruction
We believe that if acute lymphoblastic leukemia presentations similar to this case continue to be reported in adults or children, a specific immunophenotypic expression and cytogenetic abnormality may be found to be associated with hepatic infiltration by leukemia

Summary

Conclusion

In this description of an unusual presentation of ALL in our patient, we have attempted to emphasize that hematologic malignancies, especially ALL, should be considered in the differential diagnosis of jaundice. Identification of a pattern of specific cytogenetic abnormalities and immunophenotypic expression associated with such cases may help clinicians to understand the pathogenesis of the disease’s progression in general and that of liver involvement in particular. This is why detailed results of IHC and flow cytometry for our patient are being published here. RM was involved in the patient’s care as the medical attending physician and was a contributor to the Conclusions section. QD was involved with the patient’s care as the attending hematology/oncology physician and made critical revisions of the manuscript. Competing interests The authors declare that they have no competing interests

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