Discussion
Acute lymphoblastic leukemia, although the most common hematologic
neoplasm in children, is less common in adolescents and adults and has a
survival rate of 20% to 40.11-13 Symptoms of the
disease are nonspecific and often include fever, fatigue, bruising and
bleeding due to thrombocytopenia and infection due to neutropenia, but
other symptoms include hepatomegaly and splenomegaly and joint pain.
However, the occurrence of cholestatic jaundice in this disease and as
one of the early manifestations is very rare.9, 10, 14,
15 Acute lymphoblastic leukemia is a type of non-Hodgkin’s lymphoma and
among the types of lymphomas that are divided into two categories:
Hodgkin’s and non-Hodgkin’s, non-Hodgkin’s lymphomas, unlike Hodgkin’s
lymphomas, often spread to the lymphatic tissues and especially spread
to the Gastrointestinal tract.5, 16 ALL, due to
over-proliferation and abnormalities in the differentiation of leukemic
blasts following inadequate normal hematopoiesis, usually has a rare
extra-medullary shape, but if it does occur, it will affect most of the
bones and then the soft tissue, skin and lymph nodes, and hepatic
manifestations are rare in leukemia patients.14, 15,
17 There are limited reports in this regard, one of which mentions
malignant infiltration of the internal bile duct in a girl with leukemia
with jaundice and cervical lymphadenopathy at the beginning of the visit
and also Intrahepatic cholestasis has been observed in two other
children with leukemia.6, 18
The development of liver failure during malignancies can also be
challenging for the patient’s treatment process, as it can reduce the
patient’s tolerance to intensified chemotherapy. Therefore, some
recommend a short course of prednisolone before starting full-dose
chemotherapy until the treatment reduces bilirubin levels so that
chemotherapy can be continued with greater vigor.8, 19,
20 Drainage methods may also be useful in patients with biliary
obstruction, but in the case of diffuse infiltration of the liver
parenchyma, this procedure is not beneficial.21
The patient was also infected with Epstein-Barr virus (EBV) according to
tests performed, which is asymptomatic in more than 90% of patients,
and only some patients develop infectious mononucleosis and usually
resolve on their own.1, 22, 23 EBV is an oncogenic
lymphotropic DNA virus belonging to the herpes virus family and can play
a role in the development of leukemia and lymphoma by cloning B memory
cells.24-26 It is estimated that 15 to 20 percent of
all tumors are associated with infection by a direct tumorigenic agent,
and EBV has been shown to cause Burkitt’s lymphoma and some other types
of neoplasms, and one of the malignancies associated with infection in
childhood is acute lymphoblastic leukemia.27-30Maternal infection with EBV has been shown to be associated with an
increased risk of ALL in children31, In two studies,
the high serum prevalence of EBV in children with ALL has been observed,
which, along with the transcription activity of the latent membrane
protein gene 1 (LMP1) of EBV, in a significant proportion of patients
with ALL, supports its role in this disease.32-34
Finally, bone marrow sampling of this patient showed the presence of
non-Hodgkin’s lymphoma and in the final diagnosis was known as ALL case,
which along with the rare symptoms of jaundice and the possible role of
Epstein-Barr virus in its development was very significant.