Primary hepatic lymphoma mimicking acute hepatitis
A 57-year-old woman visited the emergency department at our hospital with generalized edema which developed a month previously. Her clinical history did not include any specific disease, and her family history was unremarkable. On physical examination, there was no abnormal finding except splenomegaly. The initial results of laboratory investigations were as follows: serum total bilirubin level of 3.0 mg/dL (normal range: 0.2-1.2 mg/dL), direct bilirubin level of 1.5 mg/dL (normal range: 0-0.4 mg/dL), aspartate aminotransferase (AST) of 54 U/L (normal range: 0-37 U/L), alanine aminotransferase (ALT) of 10 U/L (normal range: 0-40 U/L), gamma-glutamyl transpeptidase (γGT) of 177 U/L (normal range: 11-43 U/L), alkaline phosphatase (ALP) of 240 U/L (normal range: 42-98 U/L), and lactate dehydrogenase (LDH) by 842 U/L (normal range: 211-423 U/L). Prothrombin time (PT) and activated partial thrombin time (aPTT) were initially within normal range. On peripheral blood cell count, all of the blood cell counts declined: red blood cell count of 3.12×106/mL (normal range: 4.2-6.3×106/mL), white blood cell count of 1.5×103/mL (normal range: 4-10×103/mL), and platelet count of 80×103/mL (normal range: 130-400×103/mL). The test for peripheral blood cell morphology also showed normocytic, normochromic anemia, leukopenia and thrombocytopenia. Serological tests for hepatitis A, B and C viruses, Ebstein-Barr virus and cytomegalovirus were all negative.\nInitial abdominal CT demonstrated hepatosplenomegaly, edematous wall thickening of the gallbladder, and effusion in the pleural and pericardial spaces. The initial diagnosis was acute hepatopathy with unknown cause. There was no evidence of lymphadenopathy in the abdomen (). On the abdominal ultrasonography (US) performed 3 days after the CT study, the echogenicity of the liver parenchyma was mildly coarse, supporting the CT diagnosis of parenchymal disease ().\nOn the 10th hospitalized day, the laboratory evaluation showed deteriorating hepatic function: the international normalized ratio (INR) of PT was elongated to 1.81. The levels of total and direct bilirubin were also elevated to 27 and 16 mg/dL, respectively. As the next step, US-guided liver biopsy was performed using an automatic biopsy gun (Tru-cut, TSK laboratory, Japan). Two pieces of specimen were obtained, and histopathology showed numerous lymphocytes infiltrating into the periportal space and hepatic sinusoid. On high-power field of microscopy, variably sized, hyperchromic nuclei with mitotic activity in the lymphocytes were seen. The results of immunochemical profiles of this specimen revealed B cell lineage. The final pathologic diagnosis was diffuse large B-cell type of non-Hodgkin's lymphoma.\nThe patient refused to receive any treatment for the lymphoma and expired 27 days after initially being hospitalized due to hepatic failure.