An Unusual Case of Cirrhosis

Abstract

Leukemic liver infiltration is an uncommon cause of acute liver failure. Chronic lymphocytic leukemia (CLL) has an indolent disease course and rarely involves the liver. A 63-year-old male presented to the hospital with a 10 day history of increasing abdominal distension and mild confusion. Six years prior to admission, he was diagnosed with stage II B CLL. He was monitored by oncology and no treatment was recommended. Two weeks prior to admission, ultrasound showed a moderate amount of ascites. He underwent paracentesis with 5 L of bloody fluid removed and SAAG was 1.9, cytology negative for malignant cells. No reported history or family history of underlying liver disease or alcohol use. Physical examination revealed shifting dulless, a fluid wave and splenomegaly. No palpable lymph nodes. CT scan showed serration of the liver surface contour consistent with cirrhosis, superior mesenteric vein nonocclusive thrombus, moderate ascites, enlarged spleen, and prominent periportal, mesenteric and retroperitoneal lymph nodes. Laboratory tests showed white blood cells 28.10×109/L (N 4. 80-10.80×109/L), hemoglobin 10.2 mg/dL (N: 14-18 mg/dL), platelets 162×109/L (N: 150-400×109/L), sodium 144 mmol/L (N: 136-147 mmol/L), potassium 4.2 mmol/L (N: 3.5-5.0 mmol/L), total bilirubin 0.3 mg/dL (N: 0.1-1.2 mg/dL), aspartate aminotransferase 74 U/L (N: 10-31 U/L), alanine aminotransferase 25 U/L (N: 10-40 U/L), alkaline phosphatase 77 U/L (N: 31-129 U/L), lactate dehydrogenase 252 U/L (N: 135-225 U/L), INR 1.0. Serology was negative for Tuberculosis, hepatitis A, B, and C viruses. Screening for alcohol and acetaminophen was negative. Work up for autoimmune hepatitis, Wilson disease, Hemochromatosis, and α1-antitrypsin deficiency was negative. Repeat paracentesis was done with 3L bloody fluid removed and negative cytology. Liver biopsy revealed involvement of CLL and preserved liver parenchyma with a slight increase in fibrosis. He was discharged and to follow up for evaluation of Richter transformation and initiation of chemotherapy. Acute liver failure caused by leukemia or lymphoma has been reported in four prior cases. It is not a common cause of liver failure. Obtaining a liver biopsy was critical in this patient which influenced the initiation of chemotherapy. For treatment purposes, it is critical to exclude liver involvement in a patient with a diagnosis of CLL who presents with liver failure.Figure: Immunohistochemical stain showing CLL on liver biopsy.