Heincelman Marc, Karakala Nithin, Rockey Don C
Medical University of South Carolina, Charleston, SC, USA.
J Investig Med High Impact Case Rep. 2016 Sep 22;4(3):2324709616665866. doi: 10.1177/2324709616665866. eCollection 2016 Jul-Sep.
Acute lymphoblastic leukemia (ALL) in adults is a relatively rare malignancy. The typical presentation includes signs and symptoms associated with bone marrow failure, including fevers, infections, fatigue, and excessive bruising. In this article, we report an unusual systemic presentation of ALL in a previously healthy 18-year-old man. He initially presented with several-day history of nausea and vomiting, 10-pound weight loss, and right upper quadrant abdominal pain with evidence of acute hepatocellular liver injury (elevations in aspartate aminotransferase/alanine aminotransferase) and elevation in serum creatinine. Further history revealed that he just joined the Marine Corp; in preparation, he had been lifting weights and taking protein and creatine supplements. A complete serological evaluation for liver disease was negative and creatine phosphokinase was normal. His aspartate aminotransferase and alanine aminotransferase declined, and he was discharged with expected improvement. However, he returned one week later with continued symptoms and greater elevation of aminotransferases. Liver biopsy was nondiagnostic, revealing scattered portal and lobular inflammatory cells (primarily lymphocytes) felt to be consistent with drug-induced liver injury or viral hepatitis. Given his elevated creatinine, unresponsive to aggressive volume expansion, a kidney biopsy was performed, revealing normal histology. He subsequently developed an extensive left lower extremity deep venous thrombosis. Given his deep venous thrombosis, his peripheral blood was sent for flow cytometry, which revealed lymphoblasts. Bone marrow biopsy revealed 78% blasts with markers consistent with acute B-cell lymphoblastic leukemia. This report emphasizes that right upper quadrant abdominal pain with liver test abnormalities may be the initial presentation of a systemic illness such as ALL.
成人急性淋巴细胞白血病（ALL）是一种相对罕见的恶性肿瘤。典型表现包括与骨髓衰竭相关的体征和症状，如发热、感染、疲劳和过度瘀伤。在本文中，我们报告了一名此前健康的18岁男性ALL的不寻常全身表现。他最初表现为有几天的恶心、呕吐病史，体重减轻10磅，右上腹腹痛，伴有急性肝细胞损伤（天冬氨酸转氨酶/丙氨酸转氨酶升高）及血清肌酐升高。进一步询问病史发现他刚加入海军陆战队；为此，他一直在举重并服用蛋白质和肌酸补充剂。全面的肝病血清学评估结果为阴性，肌酸磷酸激酶正常。他的天冬氨酸转氨酶和丙氨酸转氨酶下降，随后他出院，病情预期会改善。然而，一周后他因症状持续且转氨酶进一步升高而再次就诊。肝脏活检未明确诊断，显示散在的门脉和小叶炎性细胞（主要为淋巴细胞），认为与药物性肝损伤或病毒性肝炎相符。鉴于他的肌酐升高，积极扩容治疗无效，遂进行了肾脏活检，组织学检查正常。随后他发生了广泛的左下肢深静脉血栓形成。鉴于他的深静脉血栓形成，其外周血被送去做流式细胞术检查，结果显示有原始淋巴细胞。骨髓活检显示78%的原始细胞，其标志物与急性B淋巴细胞白血病相符。本报告强调，伴有肝功能检查异常的右上腹腹痛可能是ALL等全身性疾病的首发表现。
