Hepatic Abscess as an Initial Manifestation of Crohn Disease in a Patient With History of Lymphoma

Abstract

The use of immuno-modulating treatments in Crohn disease is associated with increased risk of lymphoma. It is not well-described whether lymphoma and its treatment regimens can put predisposed patients at risk of developing inflammatory bowel disease. We present a complex case of a 28-year-old female with history of lymphoma who presented with hepatic abscess as an initial manifestation of Crohn disease. A 28-year-old female with history of Hodgkin lymphoma presented with worsening abdominal pain. She endorsed right upper quadrant pain radiating to the back of several weeks duration with associated fever, chills, nausea and vomiting. She had no diarrhea or hematochezia. She was successfully treated for lymphoma 3 years prior. She had no evidence of recurring lymphadenopathy based on positron emission tomography (PET) scan; however, it did reveal a small focus in her distal small bowel. Follow up computed tomography (CT) enterography was normal. She had a family history of Crohn disease, and a remote personal diagnosis of irritable bowel syndrome with a history of normal colonoscopy. On exam, vitals were stable. She had right upper quadrant tenderness. White blood cell counts and hemoglobin were normal. She had no transaminitis but alkaline phosphatase was mildly elevated at 155 (46-116) U/L. She underwent CT abdomen which showed an ill-defined heterogeneity in the anterior left hepatic lobe with more focal low-attenuation lesions, suspected to be a pyogenic abscess. She was started on intravenous antibiotics and the abscess was drained under radiologic guidance. Her pain improved and she underwent colonoscopy a month later. Pathology revealed ileitis with active ulceration, and she was diagnosed with Crohn disease. She was started on 6-mercaptopurine. TNF-alpha inhibitors were avoided due to her history of lymphoma and risk of relapse. The known association between Crohn disease and subsequent lymphoma is linked to immuno-modulators used for treatment; namely, TNF-alpha inhibitors. This case begs the question of whether lymphoma or its treatment regimens can increase the risk of developing Crohn disease in a genetically susceptible individual. We also highlight the rarity of our patient's presentation with hepatic abscess being her initial manifestation of Crohn disease.