Supplementary Material for: Orbital edema secondary to a sphenoidal mass as the presenting symptom of high-risk precursor B cell acute lymphoblastic leukemia: a case report

Introduction
Acute lymphoblastic leukemia (ALL) is the most common childhood malignancy, known to present with ocular manifestations in rare cases.

Case presentation
We describe the case of a 9-year-old previously healthy male who developed a 2-day history of periocular swelling and was found on MRI to have a large sphenoidal mass. Further work up showed involvement of the spinal cord, iliac crests, and kidneys. His initial blood work showed no hematological abnormalities. A bone marrow biopsy taken from the iliac crest demonstrated >90% B lymphoblasts and flow cytometry was positive for CD19. Overall, his investigations were consistent with a diagnosis of precursor B cell ALL (pre B-ALL). His neuro-ophthalmic exam showed right sided subtle periocular edema, decreased palpebral fissure height, and proptosis. Posterior exam showed mild nasal elevation of the right optic disc without vessel obscuration and mild tortuosity of the peripheral vessels. He otherwise had no overt signs of afferent or efferent dysfunction despite the proximity of the mass to his optic nerve and globe.

Conclusion
This case demonstrates that high risk pre B-ALL, a childhood cancer not commonly associated with orbital manifestations, can present with orbital edema and normal leukocyte count in an otherwise healthy child.

引言
急性淋巴细胞白血病（Acute lymphoblastic leukemia, ALL）是儿童最常见的恶性肿瘤，罕见情况下可出现眼部表现。

病例报告
我们报告一例既往健康的9岁男性患儿，出现为期2天的眶周肿胀，磁共振成像（MRI）检查发现巨大蝶骨肿块。进一步检查显示其脊髓、髂嵴及肾脏受累。初始血液学检查未发现血液系统异常。髂嵴骨髓活检显示＞90%的B淋巴母细胞，流式细胞术检测CD19阳性。综上，各项检查结果符合前体B细胞急性淋巴细胞白血病（precursor B cell ALL, pre B-ALL）的诊断。神经眼科检查可见右侧轻度眶周水肿、睑裂高度降低及眼球突出。眼底检查显示右侧视盘轻度鼻侧隆起，无血管遮蔽，周边血管轻度迂曲。尽管肿块紧邻视神经及眼球，但患儿未出现明显的传入或传出功能障碍体征。

结论
本病例表明，既往健康儿童罹患通常较少伴眼眶表现的高危前体B细胞急性淋巴细胞白血病时，可表现为眼眶水肿且白细胞计数正常。