Acute onset facial oedema: an unusual presentation of acute lymphoblastic leukaemia in a child

A previously fit and well girl of middle-childhood age presented to her local emergency department after waking with upper-facial swelling. She had a 24-hour preceding history of mild vomiting illness and fatigue. Examination revealed palpable splenomegaly and mild cervical lymphadenopathy, with pitting oedema of the forehead, nasal bridge and eyelids. Admission full blood count showed anaemia and neutropenia, and further investigations confirmed a diagnosis of acute lymphoblastic B-cell leukaemia. X-ray of the chest and CT imaging did not reveal any local facial mass, veno-occlusive disease or mediastinal pathology to explain her facial swelling. She was referred to the tertiary paediatric oncology service for commencement of induction chemotherapy.