Siddique et al. Journal of Medical Case Reports 2011, 5:269 http://www.jmedicalcasereports.com/content/5/1/269 jaundice, as reported by Lee et al and as referred to above. Hepatic insufficiency at presentation of malignancies may pose an important therapeutic challenge as it may reduce tolerance to intensified chemotherapy. Biliary drainage procedures may prove helpful prior to adminis- tering chemotherapy in patients with biliary obstruction but may not be possible in patients with diffuse infiltra- tion of hepatic parenchyma by leukemic blast cells [8]. Some authors have suggested a short course of predni- sone prior to instituting full dose chemotherapy [9]. Once a downward trend in bilirubin level is established, one can proceed with further chemotherapy [10]. We followed a similar plan for our patient. In our patient, pre-treatment with prednisone resulted in reduction of the bilirubin after which hyper-CVAD was administered. We continue to follow this patient and plan to publish more about his disease in the event it takes an unusual course. Conclusion In this description of an unusual presentation of ALL in our patient, we have attempted to emphasize that hema- tologic malignancies, especially ALL, should be consid- ered in the differential diagnosis of jaundice. Moreover, we believe it would be interesting to study the disease characteristics of ALL in this specific subset of patients if similar cases continue to be reported. 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 pub- lished here. Consent Written informed consent was obtained from the patient for publication of this case report and any accompany- ing images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Abbreviations Hyper-CVAD: hyperfractionated cyclophosphamide/vincristine/doxorubicin/ dexamethasone; IHC: immunohistochemistry; pre-B-cell ALL: precursor B-cell acute lymphoblastic leukemia. Author details 1Department of Medicine, Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY 10305, USA. 2Department of Hematology/ Oncology, Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY 10305, USA. 3Department of Pathology, Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY 10305, USA. Authors’ contributions MNS was in the patient’s care and was a major contributor in writing the abstract, case presentation and conclusion (as the primary author). MP was a Page 4 of 4 major contributor to the Discussion section. was involved in the patient’s care (as an oncology fellow) and supervised the drafting of the manuscript. RM was involved in the patient’s care as the medical attending physician and was a contributor to the Conclusions section. MA performed the histopathology of liver and bone marrow. QD was involved with the patient’s care as the attending hematology/oncology physician and made critical revisions of the manuscript. It is hereby certified that all coauthors have seen and agree with the contents of the manuscript and that (aside from abstracts) the manuscript is not under review by any other publication. Competing interests The authors declare that they have no competing interests. Received: 28 November 2010 Accepted: 1 July 2011 Published: 1 July 2011 References 1. Scheimberg IB, Pollock DJ, Collins PW, Doran HM, Newland AC, van der Walt JD: Pathology of the liver in leukemia and lymphoma: a study of 110 autopsies. 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JOP 2010, 11:72-74. 8. Takamatsu T: Preferential infiltration of liver sinusoids in acute lymphoblastic leukemia. Rinsho Ketsueki 2001, 42:1181-1186. 9. Rajesh G, Sadasivan S, Hiran KR, Nandakumar R, Balakrishnan V: Acute myeloid leukemia presenting as obstructive jaundice. Indian J Clin Gastroenterol 2006, 25:93-94. 10. Comeau TB, Phillips DL: Chemotherapy dosing with elevated liver function test results in acute leukemia. Ann Pharmacother 2005, 39:1752-1754. doi:10.1186/1752-1947-5-269 Cite this article as: Siddique et al.: Precursor B-cell acute lymphoblastic leukemia presenting as obstructive jaundice: a case report. Journal of Medical Case Reports 2011 5:269. 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