S2745 Chronic Lymphocytic Leukemia: An Unusual Cause of Hepatic Granulomas

Abstract

Introduction: Hepatic granulomas (HG) are localized collections of inflammatory cells, found in 2 to 10% of patients who undergo liver biopsy. HG has a wide differential and, in some cases, may not lead to a definitive diagnosis. We present a rare case of chronic lymphoid leukemia (CLL) presenting as HG. Case Description/Methods: 70-year-old male with past history of CLL presented with fever, chills and night sweats for 2 weeks. Admission labs were significant for WBC count 25 and elevated LFTs with total bilirubin 3.67, Alkaline phosphatase 281, AST 41 and ALT 144. CT liver protocol showed diffuse hypodense liver lesions, classified as LIRADs 3 indeterminate lesions. MRI was contraindicated due to incompatible hardware. Infectious work up including cultures, viral and tick serologies, and acute and chronic liver serologies were negative and patient was observed off antibiotics and discharged. Subsequent liver biopsy revealed nodules of necrotizing granulomas but negative for CLL, Richter transformation, fungal or TB on special stains. Work up was expanded to rule out autoimmune causes, fungal, atypical viral, TB infections, hemochromatosis and sarcoidosis as a cause of HG, all of which resulted negative. Due to unclear diagnosis and persistent abnormal liver imaging, repeat liver biopsy was performed which revealed periportal and sinusoidal atypical lymphoid infiltrate with necrotizing granulomatous inflammation. Flow cytometry showed small CD 19+ B cells, consistent with CLL. This upstaged patient’s disease to Rai stage 2 and he was started on chemotherapy, which normalized LFTs and improved symptoms. Discussion: HG remains a diagnostic challenge for many clinicians. Common malignancies associated with hepatic granulomas are lymphoma, renal cell carcinoma and liver metastasis. CLL is not a well defined cause of hepatic granuloma. Other causes include drugs, bacterial, fungal, viral or parasitic infections, autoimmune disorders, TB and sarcoidosis. The histologic subtypes (caseating vs non caseating) may give a clue to the diagnosis. Progressive fibrosis, portal hypertension, and cirrhosis can rarely develop if not identified early. In patients with CLL, liver involvement may upstage the disease, necessitating more aggressive treatment. Assessment for associated clinical symptoms, targeted lab and radiological investigations, and characterization of the morphology and localization of granulomas will usually lead to a definitive diagnosis and appropriate treatment.