1429 Choledocholithiasis in Primary Hepatic Lymphoma (PHL): An Additional Hurdle to PHL Diagnosis?

Abstract

INTRODUCTION: Primary hepatic lymphoma (PHL) is a rare disorder involving solely liver at the time of initial presentation. Diffuse large B-cell lymphoma (DLBCL) variant in PHL is scarce. Patients with Immune suppression and HIV infection are at increased risk for the PHL-DLBCL variant. We present an individual, whose initial clinical presentation is masked my choledocholithiasis, subsequently diagnosed with PHL-DLBCL by histopathology. CASE DESCRIPTION/METHODS: A 59-year-old-man with prostate cancer (Gleason score of 7) managed conservatively for the last two years presented to the ED with intermittent epigastric pain of one-week duration associated with subjective fever and night sweats. On examination, he was afebrile and hemodynamically stable. The liver was palpable below the right costal margin and found to have inguinal lymphadenopathy. The laboratory data revealed obstructive jaundice with a cholestatic pattern (Table 1). Abdominal U/S and MRCP revealed cholelithiasis with normal biliary anatomy. Viral hepatitis, autoimmune and metabolic markers of liver disease were normal. Given the worsening of the obstructive pattern of liver tests, the patient underwent ERCP which showed two small stones in the distal CBD. Cholestasis improved, and the patient was discharged home in stable condition. Three weeks later he was readmitted with significant weight loss, malaise and night sweats. The laboratory investigation showed worsening of cholestasis with no imaging evidence of biliary stent obstruction. Hence, liver biopsy was performed to evaluate infiltrative liver disease. His hospital course was complicated by multiple organ failure requiring mechanical ventilator support and renal replacement therapy. Despite all resuscitative efforts, patient's general condition deteriorated and expired. His liver biopsy was reported with findings suggestive of DLBCL. Extrahepatic involvement was ruled out by negative lymph node biopsy. DISCUSSION: PHL is very rare primary hepatic malignancy and, DLBCL variant is extremely rare. As laboratory and imaging findings in PHL are non-specific, it is difficult to distinguish from infiltrative, granulomatous and other malignant liver diseases. Liver biopsy is essential for diagnosis and identifying the immunophenotype. It is vital to consider this condition as outcomes in PHL vary from other liver diseases. Our patient is a unique example where coexistent choledocholithiasis posed a diagnostic challenge like prior reported cases in literature.