A 61-year-old Thai man presented with abdominal pain, fever and dyspnea for 2 weeks.

• V/S: BT 37.7 C PR 93/min RR 22/min 
• HEENT: moderate jaundice with mild pallor, bilateral cervical LN palpable 1 cm 
• Abdomen: liver span 15 cm., no splenic dullness  
• CBC WBC 46,610 x10^3/UL HCT 36.2% Platelet 267,000x10^3/UL N 26% L 63% M 10% E1%
• FBS 102 BUN 14 Cr 0.89 Na 136 K 3.9 Cl 102 CO2 21
• LFT: TP 5.8 Alb 3.2 TB 10.96 DB 10.16 AST 1247 ALT 1000 ALP 571
• HBsAg neg, AntiHAV IgM neg, AntiHAV IgG neg, AntiHIV neg

Question 1:  What is the most proper next step investigation?

• A. ERCP
• B. MRI with MRCP
• C. BM study
• D. Liver biopsy
• E. Gastroscopy with colonoscopy

โดย น.ท.หญิง เพ็ชชรี พลมณี อาจารย์หน่วยอายุรศาสตร์โรคระบบทางเดินอาหาร กองอายุรกรรม รพ.ภูมิพลอดุลยเดช พอ.

ANSWERs

C.BM study & D.Liver biopsy

Liver biopsy result:

Question 2:  What is the most likely diagnosis?

• A. Drug induce liver injury 
• B. Acute HEV infection
• C. Ischemic hepatitis
• D. Lymphoma 
• E. Autoimmune hepatitis 

IHC of liver pathology:  

Final diagnosis:  "Hepatic lymphoma"

Liver histology of lymphoma: 

• Common Histological Type:
  • The most common type of lymphoma found in the liver is diffuse large B-cell lymphoma (DLBCL). 
• Infiltration Patterns:
  • Portal tract infiltration: Lymphoma cells cluster around the portal veins in the liver.
  • Sinusoidal infiltration: Tumor cells spread throughout the liver sinusoids.
  • Nodular infiltration: Distinct tumor masses within the liver parenchyma. 
• Hepatic lymphoma can be divided into

  • A primary form primary hepatic lymphoma also requires the absence of distant disease (distant lymphadenopathy, splenic infiltration or bone marrow disease) within six months of diagnosis

  • A secondary (metastatic) form, the two forms having different prognoses.

  • Non-Hodgkin lymphoma predominates in both forms

  • The clinical manifestations of primary and secondary hepatic lymphoma include hepatomegaly, right upper quadrant pain, jaundice, and systemic (B) symptoms (fever, weight loss, and night sweats)

References:

- Insights Imaging. 2015;6:679–692. 

- Radiol Bras 2019 Sep-Oct;52(5):325–330.

โดย น.ท.หญิง เพ็ชชรี พลมณี อาจารย์หน่วยอายุรศาสตร์โรคระบบทางเดินอาหาร กองอายุรกรรม รพ.ภูมิพลอดุลยเดช พอ