Isolated Bilateral Nephromegaly as the Initial Presentation of Acute Lymphoblastic Leukaemia: A Rare Case and Review of the Literature.

INTRODUCTION

Acute lymphoblastic leukaemia (ALL) is an aggressive hematologic malignancy, with T-cell ALL (T-ALL) accounting for approximately 25% of adult cases. Renal infiltration is recognized but rarely presents as isolated bilateral nephromegaly with acute kidney injury (AKI) in adults.

CASE DESCRIPTION: A 32-year-old previously healthy man presented with progressive bilateral flank pain, abdominal heaviness, fatigue, intermittent fever, night sweats, and unintentional weight loss. Physical examination revealed large bilateral flank masses without peripheral lymphadenopathy. Laboratory tests initially showed normal blood counts but significant renal impairment (creatinine 3.5 mg/dl, urea 82 mg/dl). Imaging demonstrated massive bilateral kidney enlargement (~20 × 20 cm). Percutaneous renal biopsy revealed diffuse infiltration by medium-sized lymphoblasts expressing CD3 and TdT, confirming T-ALL. Within 1-week, hematologic abnormalities developed, including leucocytosis, anaemia, and thrombocytopenia, alongside worsening renal function and tumour lysis syndrome, necessitating dialysis and allopurinol therapy. The patient was started on a pre-phase corticosteroid regimen followed by intensive hyper-CVAD (hyperfractionated cyclophosphamide, vincristine, doxorubicin [Adriamycin], and dexamethasone) induction chemotherapy. Initial radiologic improvement occurred; however, the clinical course was complicated by neutropenic sepsis, ultimately resulting in death.

CONCLUSION

This case highlights a rare adult presentation of T-ALL in which renal involvement preceded hematologic abnormalities. Clinicians should consider hematologic malignancy in adults presenting with unexplained bilateral nephromegaly and AKI, even if initial blood counts are normal. Early recognition and timely intervention are critical to improve renal and overall outcomes.

LEARNING POINTS: Renal infiltration is recognized but rarely presents as isolated bilateral nephromegaly with acute kidney injury (AKI) in adults.This report underscores the importance of considering underlying hematologic malignancy in adults presenting with unexplained bilateral nephromegaly and AKI, even when initial hematologic investigations are normal.