Acute lymphoblastic leukemia

Case contributed by Hoe Han Guan
Diagnosis almost certain


Unwell for 6 months, developed shortness of breath, lethargy and hematemesis.

Patient Data

Age: 10 years
Gender: Female

Liver is enlarged with a measurement of 15.3 cm (right midclavicular line, normal size 9.5-13.5 cm for her age). No focal liver lesion. Liver edge and margin are smooth and regular.

Spleen is at the upper limits of normal, measuring 10.3cm (normal size for her age and gender 6.4 to 10.5cm). No focal splenic lesion or splenic varices.

Gallbladder, both adrenal glands, pancreas and both kidneys are normal.

Urinary bladder is markedly distended. The urinary Foley catheter is mal-positioned with the tip and balloon located in the vagina.

Moderate amount of non-enhancing ascites at the lower abdomen and pelvis.
No abdominal and pelvic lymphadenopathy

No abnormal bowel wall thickening, bowel loops dilatation and bowel-related mass.

Large area of ground glass opacities in both lower lobes (right more than left side) with interspersed smooth thickened interlobular septae.  A few subpleural focal areas of consolidations in both lower lobes. Patchy ground glass opacities at the right upper lobe. 

Generalized osteopenic changes and multiple lytic lesions over the imaged bone, especially at the sites of red marrow namely spine, pelvic bone, sternum, and metaphyses of both femurs and humerus. The spine has coarsened trabeculation. 

Case Discussion

Hepatosplenomegaly and generalized bony osteopenia with lytic bony lesions and coarsened trabeculation. In the clinical context of bicytopenia with hyperleukocytosis, the likely differential diagnosis to consider is leukemia. The musculoskeletal changes on the axial skeleton suggest the chronicity of the disease and anemia. 

Admission full blood count showed hemoglobin of 1.8, white blood cell of 45 and plateles of 65,000.

Peripheral blood film study showed features of pancytopenia with leucoerythroblastic picture and 1% circulating blast cells seen.

Confirmed with bone marrow aspiration to be acute lymphoblastic leukemia and treated accordingly.

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