Leukaemia presenting with fulminant hepatic failure in a child

Abstract

In all children with fulminant hepatic failure, the differential diagnosis of leukaemia should be considered, particularly if there is hepatosplenomegaly, pancytopenia and a high lactate dehydrogenase. Early bone marrow aspiration should be performed to confirm diagnosis, as peripheral blood smears may often be normal.Hepatomegly is a common feature of leukaemia but acute liver failure as the first presentation is extremely uncommon [1,2].We report a 4-year-old girl with a 2-week history of lethargy, vomiting and fluctuating sensorium for 2 days. There was no history of drug or toxin ingestion. She was icteric with liver 15 cm and spleen 9 cm below the costal margin respectively. Due to grade 3 encephalopathy, she was mechanically ventilated on the liver intensive care unit.Laboratory investigations revealed the following: haemoglobin 91 g/l (reference range 115-155 g/l), WBC 0.85·10 9 /l (reference range 5.5-15.5·10 9 /l), neutrophil count 0.5·10 9 /l (reference range 3-5.8·10 9 /l), platelet count 29·10 9 /l (reference range 150-400·10 9 /l) and no blasts were seen in the peripheral smear. Furthermore, INR 2.6 (reference range 0.8-1.2), D-dimer 1925 ng/ml, AST 714 IU/l (reference range 15-55 IU/l), total bilirubin 6 mg/dl (103 lmol/l; reference range 3.4-17 lmol/ l), LDH 4289 IU/l (reference range 150-500 IU/l), ammonia 102 lmol/l (reference range 34-47 lmol/l), lactate 9 mmol/l (reference range 0.9-1.7 mmol/l) and creatinine 94 lmol/l (reference range 27-62 lmol/l).Ultrasonography revealed a heterogeneous liver with multiple hypoechoic areas. Viral screen was negative. Bcell ALL, type L3 (Burkitt) was diagnosed from bone marrow examination done at 12 h.Early haemofiltration was started because of fulminant hepatic failure (FHF) and to prevent tumour lysis syndrome. Following pre-hydration and rasburicase, intravenous vincristine (1 mg/m 2 ) on days 1 and 8; and oral prednisolone (60 mg/m 2 ) daily (day 2 onward) was started. On day 4, after correction of her coagulopathy, a first dose of triple intrathecal chemotherapy (methotrexate 15 mg, cytosine arabinoside 30 mg and hydrocortisone 15 mg) was administered. The cytospin of the CSF was clear of leukaemic cells.

A toddler with pallor and recurrent infection

“…15 Jaundice aside, this patient had no signs of haemolysis or acute hepatitis at presentation, making prehepatic and hepatic jaundice unlikely. However, cholestatic jaundice is a well recognised, if infrequent, complication of haematological malignancies.…”

Liver transplantation in an adolescent with acute liver failure from acute lymphoblastic leukemia

“…Although exceedingly rare, hematologic malignancies can cause acute liver failure by massive infiltration of leukemic cells leading to hepatic necrosis. Case reports have described this phenomenon in the setting of ALL, CLL, and adult T‐cell leukemia . In these reported cases, liver transplantation was not pursued because the diagnosis of hematologic malignancy was firmly established up front.…”

“…There are a few isolated case reports of AML, CLL, and adult T‐cell leukemia leading to acute liver failure . More commonly described is acute liver failure from B‐cell ALL and T‐cell ALL . Liver transplantation has not been reported in any of these cases.…”

Massive Infiltration of Liver by Metastatic Adenocarcinoma: A Rare Cause of Acute Hepatic Failure

“…There are reports in literature of hematological [1][2][3][4][5][6][7] and non hematological malignancies [8][9][10][11][12][13][14][15][16][17] presenting as FHF. In a study of 4020 histological specimen of FHF, 0.44% showed evidence of a hematological malignancy.…”