Diffuse Large B Cell Lymphoma Presenting With Obstructive Jaundice

Abstract

Diffuse Large B cell Lymphoma (DLBCL) is the most common histologic subtype of non-Hodgkin's lymphoma(NHL). Although jaundice occurs in a fair number of patients with lymphoma, it is rarely seen as a presenting complaint. We present a case of DLBCL presenting with biliary obstruction.Figure: ERCP showing dilated right, left hepatic ducts and common hepatic duct. There is narrowing of common bile duct.Figure: CT scan of the abdomen/pelvis showing a new intrahepatic and extrahepatic biliary ductal dilatation.A 62 year old male presented to the emergency room with jaundice and was found to have a total bilirubin of 13.2 and a direct bilirubin of 8.1. CT abdomen and pelvis showed new intra hepatic and extra hepatic biliary ductal dilatation, new extensive lymphadenopathy within the lower chest and upper abdomen. The patient underwent ERCP which showed a biliary stricture due to compressive lymphadenopathy. A retrievable plastic stent was placed after endoscopic balloon dilation. Patient was also noted to have extensive inguinal lymphadenopathy. A right inguinal lymph node biopsy favored a diagnosis of diffuse large B cell lymphoma. He was started only on rituximab and prednisone chemotherapy initially. After biliary stent placement, total bilirubin reduced to 4 and direct bilirubin to 1.7. Doxorubicin based chemotherapy was delayed until total bilirubin was 4, due to its excretion through bile. R-CHOP chemotherapy regimen was started at this time. A follow up PET scan in three months showed interval improvement in the lymphadenopathy and the biliary stent was removed. There is a paucity of treatment guidelines due to infrequent initial presentation of DLBCL with jaundice. Role of biliary stent placement is controversial as it provides relief of obstruction and symptoms but does not cure underlying disease. Our case highlights excellent response of DLBCL with sequencing and dosing of chemotherapeutic agents preceded by biliary drainage. Jaundice in patients with lymphoma can be due to direct hepatic/biliary involvement, extra hepatic bile duct obstructions, toxic hepatitis due to drug treatment or tumor related hemolysis. Although a rare cause of obstructive jaundice, NHL should be considered in the differential diagnosis.