Haemophagocytic lymphohistiocytosis (HLH) that occurs concomitantly with leukaemia can be initially missed due to overlapping clinical features. In a series of three cases, Tanabe and colleagues illustrate the need for prompt recognition of HLH and institution of HLH-directed therapy to prevent hyperinflammation-mediated multi-organ damage and death. Commentary on: Tanabe et al. Paediatric acute lymphoblastic leukaemia-associated haemophagocytic lymphohistiocytosis develops during prednisolone prephase. Br J Haematol 2024 (Online ahead of print). doi: 10.1111/bjh.19755.