A diagnostic challenge presented in a 37-year-old man with severe weight loss and

Abstract

[1] A 37-year-old man, Iranian resident in Zanjan, presented to the gastroenterology clinic of Taleghani Hospital; a teaching referral hospital in Tehran, Iran, with chief complaint of a significant weight loss about 20 kg in recent 4 months. He denied any concomitant systemic signs and symptoms except for a generalized malaise. He did not mention any change in bowel habit and eating pattern but a slight decrease in appetite without nausea and vomiting. He denied smoking and use of any illicit drug or alcohol. His past medical history was negative. He was admitted for further work regarding his unexplained weight loss. On admission, he was well with stable vital signs. His blood pressure was 110/70 mmHg, body temperature: 36.5 o C, heart rate: 84 bites per minute, and respiratory rate: 13 per minute all within normal limits. His physical exam was only notable for a mild epigastric and right upper quadrant (RUQ) tenderness. His laboratory tests were normal except for a normochromic normocytic anemia with a hemoglobin concentration of 12 mg/dl. Serum iron level was 37 mcg/dl with a total iron binding capacity (TIBC) level of 275 mcg/dl and a ferritin level of 10 mcg/l revealing an iron deficient erythropoiesis. Further laboratory tests evaluating tumor markers, thyroid function tests, liver function tests, serum bilirubin level, urine analysis and stool examination were all normal. We decided to proceed with an upper gastrointestinal endoscopy and colonoscopy in the next step of the management of the patient with significant weight loss. Total colonoscopy was unremarkable and esophagogastroduodenoscopy demonstrated a sessile polyp in antrum pathologically consistent with hyperplastic polyp. His spiral chest CT scan was normal but an abdominopelvic CT scan revealed dilation of intrahepatic ducts disseminated all over the liver prominently in the periphery of the right hepatic lobe. Periductal parenchyma was enhanced in some parts indicative of infective or neoplastic processes. Scattered celiac and mesentric lymph nodes with maximum diameter of 6 mm were also detected (figure 1). To have a better visualization of extrahepatic ducts besides intrahepatic ducts, an endoscopic ultrasound (EUS) was performed. As reflected in figure-2, findings of EUS were unremarkable except for 3 hypoechoic and round hilar lymph nodes with the largest diameter of 21mm, most probably indicative of reactive lymph nodes. This patient’s signs and symptoms continued to remain stable, so he was discharged and was advised to follow other diagnostic modalities in the outpatient clinic. Some months later, he referred to the gastroenterology clinic with similar complaints of inability to weight gain and anorexia. Given the previous history of intrahepatic duct dilation, an MRCP was demanded which revealed heterogeneity of the liver parenchyma due to multiple masses or microabscesses in the liver. Laboratory results were negative for infectious, helminthic and parasitic disorders for this kind of liver involvement, and imaging reports were unable to rule out a neoplastic process and give a definite diagnosis. This made us proceed with a liver biopsy. What is your diagnosis? What is the next step? Received: 24 September 2020 Accepted: 8 December 2020 Reprint or Correspondence: Saeed Abdi, MD. Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran. E-mail: saeedabdi75@yahoo.com ORCID ID: 0000-0002-2375-3748