Siddique et al. Journal of Medical Case Reports 2011, 5:269 http://www.jmedicalcasereports.com/content/5/1/269 C A S E R E P O R T JOURNAL OF MEDICAL CASE REPORTS Open Access Precursor B-cell acute lymphoblastic leukemia presenting as obstructive jaundice: a case report Muhammad N Siddique1*, Muhammad Popalzai2, Nelly Aoun2, Rabih Maroun1, Michael Awasum3 and Qun Dai2 Abstract Introduction: Acute 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 presentation: A 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. Conclusion: Acute 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. Introduction Acute lymphoblastic leukemia (ALL) is a clonal hemato- logic disorder. It involves excessive proliferation and impaired differentiation of leukemic blasts that lead to inadequate normal hematopoiesis. Thus patients usually present with symptoms resulting from bone marrow failure. The extra-medullary form of this disease is rarely reported. However, when found, it most commonly involves the bones, followed by soft tissue, skin and lymph nodes. It is extremely rare for patients with ALL to present with hepatic manifestations. Herein we pre- sent a case of precursor B-cell (pre-B-cell) ALL that manifested as obstructive jaundice. The case elaborates this unique presentation and that infiltrative involve- ment of leukemia should be considered when the initial * Correspondence: mnaumansiddique@gmail.com 1Department of Medicine, Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY 10305, USA Full list of author information is available at the end of the article work-up for obstructive jaundice is inconclusive. More- over, it highlights the challenges in planning chemother- apeutic treatment in the presence of an already compromised hepatic function. Case presentation A 44-year-old Hispanic man presented to our hospital with the chief complaints of pain in the right upper quadrant of the abdomen and jaundice. These symp- toms were associated with intermittent nausea and vomiting, generalized weakness, poor appetite, clay- colored stools and mild, generalized itching. The patient’s symptoms had developed gradually and had worsened over the course of a few weeks. He denied a history of fever or chills or a change in bowel habits. He did report weight loss of about 20 pounds during the six months prior to presentation. It was not entirely unin- tentional, however, as he was attempting to lose some weight. This symptom was not associated with night © 2011 Siddique et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.