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Cirrhosis With Splenomegaly and Pancytopenia Complicating a Concurrent Diagnosis of Acute Lymphoblastic Leukemia

Pancytopenia, a hematologic condition, is a decrease in all three blood cell lines. The two main etiologies include decreased production or increased destruction of cells, as seen in nutritional deficiencies or liver cirrhosis, respectively. Pancytopenia commonly presents with fever, splenomegaly, a...

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Autores principales: Kanakamedala, Swathi, Danak, Shivang U, Conway, Earl J, Kotla, Venumadhav
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Cureus 2022
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9767793/
https://www.ncbi.nlm.nih.gov/pubmed/36561590
http://dx.doi.org/10.7759/cureus.31707
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author Kanakamedala, Swathi
Danak, Shivang U
Conway, Earl J
Kotla, Venumadhav
author_facet Kanakamedala, Swathi
Danak, Shivang U
Conway, Earl J
Kotla, Venumadhav
author_sort Kanakamedala, Swathi
collection PubMed
description Pancytopenia, a hematologic condition, is a decrease in all three blood cell lines. The two main etiologies include decreased production or increased destruction of cells, as seen in nutritional deficiencies or liver cirrhosis, respectively. Pancytopenia commonly presents with fever, splenomegaly, and lymphadenopathy. Initial workup includes complete blood count, metabolic panel, peripheral smear, anemia panel, erythrocyte sedimentation rate, C-reactive protein, and lactate dehydrogenase. Workup also involves excluding toxins, human immunodeficiency virus (HIV), drug effects, and infectious etiologies. Malignancies can cause impaired production of cell lines. For hematologic malignancies, a bone marrow biopsy is performed. In patients above the age of 55 who are diagnosed with acute leukemia, acute lymphoblastic leukemia (ALL) is known to make up approximately 20% of all cases. Furthermore, ALL requires the presence of more than 20% lymphoblasts seen on bone marrow biopsy. Treatment includes induction, consolidation, and maintenance chemotherapy. We report the case of a 63-year-old male with a history of liver cirrhosis from non-alcoholic fatty liver disease who presented for consultation due to pancytopenia without signs of fever or lymphadenopathy. Imaging revealed cirrhosis, ascites, and moderate splenomegaly while the workup for toxins, infections, and HIV was negative. He presented to the hospital with worsening anasarca and acutely worsening pancytopenia. Peripheral smear showed pancytopenia with no definitive blasts, whereas bone marrow biopsy revealed B-lymphoblastic leukemia. He was transferred to a tertiary center for induction chemotherapy but ultimately transitioned to supportive care due to intolerance. This case demonstrates the importance of having a high suspicion for leukemia with an acute decline in all three cell lines, thereby prompting a bone marrow biopsy. Although lacking in the literature, adult patients with ALL can present with splenomegaly without fever or lymphadenopathy. These examination findings are clinical clues to evaluate for underlying malignancies in patients with pancytopenia, although coexisting etiologies may exist. Lastly, peripheral smear alone is insufficient to screen for diagnosis of ALL as it can be normal despite bone marrow involvement.
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spelling pubmed-97677932022-12-21 Cirrhosis With Splenomegaly and Pancytopenia Complicating a Concurrent Diagnosis of Acute Lymphoblastic Leukemia Kanakamedala, Swathi Danak, Shivang U Conway, Earl J Kotla, Venumadhav Cureus Internal Medicine Pancytopenia, a hematologic condition, is a decrease in all three blood cell lines. The two main etiologies include decreased production or increased destruction of cells, as seen in nutritional deficiencies or liver cirrhosis, respectively. Pancytopenia commonly presents with fever, splenomegaly, and lymphadenopathy. Initial workup includes complete blood count, metabolic panel, peripheral smear, anemia panel, erythrocyte sedimentation rate, C-reactive protein, and lactate dehydrogenase. Workup also involves excluding toxins, human immunodeficiency virus (HIV), drug effects, and infectious etiologies. Malignancies can cause impaired production of cell lines. For hematologic malignancies, a bone marrow biopsy is performed. In patients above the age of 55 who are diagnosed with acute leukemia, acute lymphoblastic leukemia (ALL) is known to make up approximately 20% of all cases. Furthermore, ALL requires the presence of more than 20% lymphoblasts seen on bone marrow biopsy. Treatment includes induction, consolidation, and maintenance chemotherapy. We report the case of a 63-year-old male with a history of liver cirrhosis from non-alcoholic fatty liver disease who presented for consultation due to pancytopenia without signs of fever or lymphadenopathy. Imaging revealed cirrhosis, ascites, and moderate splenomegaly while the workup for toxins, infections, and HIV was negative. He presented to the hospital with worsening anasarca and acutely worsening pancytopenia. Peripheral smear showed pancytopenia with no definitive blasts, whereas bone marrow biopsy revealed B-lymphoblastic leukemia. He was transferred to a tertiary center for induction chemotherapy but ultimately transitioned to supportive care due to intolerance. This case demonstrates the importance of having a high suspicion for leukemia with an acute decline in all three cell lines, thereby prompting a bone marrow biopsy. Although lacking in the literature, adult patients with ALL can present with splenomegaly without fever or lymphadenopathy. These examination findings are clinical clues to evaluate for underlying malignancies in patients with pancytopenia, although coexisting etiologies may exist. Lastly, peripheral smear alone is insufficient to screen for diagnosis of ALL as it can be normal despite bone marrow involvement. Cureus 2022-11-20 /pmc/articles/PMC9767793/ /pubmed/36561590 http://dx.doi.org/10.7759/cureus.31707 Text en Copyright © 2022, Kanakamedala et al. https://creativecommons.org/licenses/by/3.0/This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
spellingShingle Internal Medicine
Kanakamedala, Swathi
Danak, Shivang U
Conway, Earl J
Kotla, Venumadhav
Cirrhosis With Splenomegaly and Pancytopenia Complicating a Concurrent Diagnosis of Acute Lymphoblastic Leukemia
title Cirrhosis With Splenomegaly and Pancytopenia Complicating a Concurrent Diagnosis of Acute Lymphoblastic Leukemia
title_full Cirrhosis With Splenomegaly and Pancytopenia Complicating a Concurrent Diagnosis of Acute Lymphoblastic Leukemia
title_fullStr Cirrhosis With Splenomegaly and Pancytopenia Complicating a Concurrent Diagnosis of Acute Lymphoblastic Leukemia
title_full_unstemmed Cirrhosis With Splenomegaly and Pancytopenia Complicating a Concurrent Diagnosis of Acute Lymphoblastic Leukemia
title_short Cirrhosis With Splenomegaly and Pancytopenia Complicating a Concurrent Diagnosis of Acute Lymphoblastic Leukemia
title_sort cirrhosis with splenomegaly and pancytopenia complicating a concurrent diagnosis of acute lymphoblastic leukemia
topic Internal Medicine
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9767793/
https://www.ncbi.nlm.nih.gov/pubmed/36561590
http://dx.doi.org/10.7759/cureus.31707
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