Grand Rounds

Massive Hepatomegaly - Can it be acute lymphoid leukemia?

Himali Meshram, Ira Shah
Department of Pediatric Gastroenterology and Hepatology, B J Wadia Hospital for Children, Mumbai, India

Address for Correspondence: Himali Meshram, 54-Harihar nagar, Beltarodi road, Besa, Nagpur 440034, India. Email:

Keywords: Hepatomegaly,lymphoid leukemia

Clinical Problem:
A 9 years old female child presented to our Pediatric Liver clinic with loss of weight of 2.5 kgs in 6 months, abdominal distension and loss of appetite for 3 months. There was no fever, bleeding manifestations, bone or joint pain, or need for any blood transfusion. On presentation, her weight was 20kg (between 3rd-10th percentile as per Indian Academy of Pediatrics (IAP) growth chart), height 129 cm (25th-50th percentile as per IAP growth charts). She had large hepatomegaly and a just palpable spleen. Other systems were normal. Investigations showed hemoglobin 13.5 gms/dl, white blood count 6,440 cells/cumm with polymorphs 52%, lymphocytes 39%, monocytes 8 % and platelets of 2,40,000 cells/cumm. Liver function tests were normal. Abdominal ultrasound showed moderate hepatomegaly with mild splenomegaly and normal portal doppler scan. HIV, Hepatitis C Elisa and HBsAg were negative. Serum ceruloplasmin level was normal. Antinuclear antibody (ANA) was weakly positive (+), anti-liver kidney muscle (LKM) and anti-smooth muscle antibodies (ASMA) were negative. Alfa-fetoprotein (AFP) was below 0.2 ng/ml. CT Abdomen showed hepatosplenomegaly with no lesions. Suspecting storage disorder, liver biopsy was done which showed features of metastasis of hematolymphoproliferative malignancy to liver. Hence bone marrow aspiration was performed which showed increased lymphocytes with blast like cells. Flow cytometry (CD10 – 74%, CD19 – 41%, CD20 – 68%) confirmed the diagnosis of B cell acute lymphocytic leukemia (ALL). Child has been started with chemotherapy.

Why did the child have normal blood counts inspite of metastatic liver involvement?

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