A challenging case of acute lymphoblastic leukemia with bone marrow necrosis

Acute lymphoblastic leukemia (ALL) is the most prevalent hematological malignancy in children. The use of corticosteroids without an accurate diagnosis can result in serious complications. In this discussion, we highlight a case of undiagnosed ALL in which corticosteroid treatment created diagnostic dilemmas and led to delays in diagnosis. Additionally, we examine the value of special stains, immunohistochemistry, and comprehensive diagnostic approaches in managing this intricate case. An 18-year-old male arrived at our facility exhibiting severe cachexia. He had previously sought treatment for fever, malnutrition, and headaches. Bone marrow and peripheral blood examinations displayed significant cytopenia across all lineages with marrow necrosis. Upon reviewing his medical history, we discovered that he had been treated with corticosteroids, which suppressed all blood lineages and hindered the ability to diagnose ALL. The patient was diagnosed with ALL based on the results of the peripheral blood smear analysis and flow cytometry performed seven days after the bone marrow examination. This case indicates that even a few doses of corticosteroids can modify the presentation of undiagnosed ALL, making diagnosis challenging due to the bone marrow's response to anti-inflammatory medications. Therefore, a comprehensive workup is crucial before initiating any treatment, including corticosteroids, as they can disrupt the precise haematological diagnostic parameters necessary for identifying conditions like leukemia.