A 37-year-old male had presented with progressive abdomen pain and distention for last 3 months. His physical examination was notable for ascites without any hepatosplenomegaly and lymphadenopathy. Blood investigations revealed normal complete blood counts with 30 % atypical cells on peripheral blood smear. His liver function tests were normal. Ascitic fluid cytology analysis showed blasts having 2 to 3 times the size of small mature lymphocytes, high N/ C ratio, round to cleaved nuclei, fine chromatin , conspicuous nucleoli and moderate amount of basophilic to vacuolated cytoplasm (Giemsa stain; 400 x) (figure 1). Contrast enhanced computed tomography of the abdomen was suggestive of peritoneal thickening and gross ascites. Bone marrow examination revealed 48% blasts which were myeloperoxidase positive (MPO) (figure 2). Flowcytometry on bone marrow sample confirmed the diagnosis of acute myeloid leukemia with monocytic differentiation. Molecular genetics was positive for inversion 16. Patient was started on injection azacitidine and venetoclax due to poor performance status. His ascites subsided after 3 cycles of azacitidine and venetoclax.

Leukemic ascites can be a rare initial presentation of acute myeloid leukemia and carries poor prognosis. Leukemic ascites though very rare, is an important differential diagnosis in a patient with ascites.