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

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.

Acute lymphoblastic leukemia presenting as cholestatic jaundice in a 7-year-old boy

“…While there are reports in the literature of pediatric B-cell ALL and adult T-ALL presenting with cholestasis, we found none describing cholestatic jaundice as the presenting symptom in pediatric T-ALL. 11–13…”

Obstructive Jaundice due to Pancreatic Involvement as an Initial Presentation of Adult Acute Lymphoblastic Leukemia

“…These receptors bind to the chemokine stromal-cell-derived factor-1 (SDF-1), a potent molecule for chemotaxis of lymphocytes found in the bone marrow and other tissues [14]. Rare cases of pancreatic and hepatic involvement with extrahepatic and intrahepatic bile duct obstruction causing cholestatic jaundice as an initial presentation have also been reported in adult ALL [6, 7].…”

“…Daniel et al reported the first case of obstructive jaundice from pancreatic masses compressing the common bile duct (CBD) in adult ALL [7]. Another rare case of leukemic infiltration of hepatic sinusoids resulting in cholestasis without pancreatic involvement was described by Siddique et al [6].…”

“…Physical findings commonly include pallor, ecchymosis, petechiae, lymphadenopathy, and splenomegaly. So far, only few cases of obstructive jaundice resulting from leukemic infiltration of the pancreas in acute lymphoblastic leukemia have been reported in literature [6, 7].…”

B Cell Acute Lymphocytic Leukemia Presenting as a Bile Duct Stricture Diagnosed With Cholangioscopy

“…Previous case reports of lymphocytic leukemia have presented with cholestasis symptoms, but both were intrahepatic and diagnosed by liver biopsy. 6 , 7 A study of 6610 patients in MD Anderson Cancer Center to define the role of ERCP after hematopoietic stem cell transplant in patients presenting with jaundice, found that out of 40 patients that underwent ERCP, 17 had biliary strictures. From those 17, 76% (n = 13) were malignant.…”