An Atypical Presentation of Alcoholic Hepatitis

Abstract

Significant alcohol consumption leads to a variety of alcoholic liver diseases ranging from alcoholic fatty liver disease to alcoholic cirrhosis. Alcoholic hepatitis carries a high risk of mortality; therefore, it is important to identify patients early to guide treatment and management. We discuss an atypical presentation of alcoholic hepatitis, with initial concern for lymphoproliferative disease. Our patient was a 28—year—old Cantonese—American man presenting with one month of abdominal pain, fevers, night sweats, and weight loss. His social history was not impressive for chronic alcohol use;he was a social drinker who drank 1 beer and 3 whisky shots every 4 months. Physical exam revealed tachycardia, abdominal tenderness, hepatosplenomegaly, and diffuse jaundice with no stigmata of chronic liver disease. Labs revealed leukocytosis with white blood cell count of 22x103/uL, conjugated hyperbilirubinemia (total bilirubin:4.4mg/dL), elevated alkaline phosphatase(183 U/L), and an INR of 1.43. An infectious process was ruled out when cultures and CXR were unrevealing. An abdominal ultrasound revealed hepatomegaly and ascites, but no ductal dilatation,which was confirmed on MRCP. Given his age, presence of B symptoms, and lack of significant alcohol history, there was concern for underlying malignancy. A CT abdomen showed abdominal lymphadenopathy and hepatosplenomegaly with a subsequent PET—CT scan showing diffuse lymphadenopathy and increased bone marrow activity. Hematology performed a bone marrow biopsy that revealed no signs of a neoplastic process. Patient's bilirubin continued to rise to 20mg/dL so a transjugular liver biopsy was obtained. Measurements revealed portal hypertension with HVPG of 10 and histology demonstrated steatosis, mild portal fibrosis,and Mallory body formation with neutrophilic infiltrates, suggestive of alcoholic hepatitis. The patient's Maddrey Discriminant Function score was elevated at 34 and he was started on prednisolone. At day 7 his Lille score was 0.04, indicating response to steroids. He completed a 28—day course of prednisolone and had complete resolution of fevers, ascites and biochemical abnormalities, while remaining abstinent. This is a case of alcoholic hepatitis presenting atypically with B symptoms, lack of strong drinking history, and diffuse lymphadenopathy, all suggestive of lymphoma. This case highlights the importance of pursuing a liver biopsy early on to confirm a diagnosis of alcoholic hepatitis.