S2878 High-Grade B-cell Lymphoma Presenting With Abnormal Liver Function Test

Introduction: High-grade B cell lymphoma is the most common type of Non-Hodgkin's lymphoma and accounts for about thirty percent of Non- Hodgkin's lymphoma. We present a case of high-grade B cell lymphoma initially presenting with abnormal liver function tests in a patient without a history of liver disease. Case Description/Methods: A seventy-four-year-old man with an unremarkable history presented due to cough, fatigue, and subjective weight loss and was admitted for community-acquired pneumonia. Liver function tests were previously normal; however, admission tests showed mild liver enzyme elevations (Aspartate aminotransferase (AST) 99, Alkaline phosphatase (ALKP) 185, Alanine aminotransferase (ALT) 30, International Normalized Ratio (INR) 1.24, and a total bilirubin level of 1.3). The liver enzymes peaked at AST of 871, ALT of 159, ALKP of 670, total bilirubin of 3.6, an INR of 1.29. The patient was thrombocytopenic to 30. The viral hepatitis panel and Human Immunodeficiency Virus tests were negative for acute infection. ANA was positive (1:40), the iron panel was not suggestive of hemochromatosis, CMV and HSV were negative. The liver enzyme pattern was not consistent with the antibiotics used during admission. Ultrasound showed fatty infiltration of the liver with a common bile duct measuring 4 mm. Computerized tomography scan (CT) of his chest, abdomen, and pelvis with and without contrast showed right and left lung consolidation, unremarkable liver, no evidence of mass or suspicious lymphadenopathy. Liver biopsy showed atypical lymphoid infiltration of the liver positive for CD 20 and negative for CD 3, which supported B Cell lymphoma infiltration of the liver. This was confirmed with a Bone marrow (BM) biopsy showing hypercellular marrow with atypical medium-sized lymphoid cells positive for CD20, CD43, CD10, and BCL6. Ki-67 was very high (>90%), consistent with a high-grade CD10+ B-cell lymphoma. The patient died on hospital day fourteen after chemotherapy was initiated. Discussion: The diagnosis of diffuse large B cell lymphoma (DLCBL) is challenging and requires a high level of suspicion, especially with the lack of lymphadenopathy. Physicians should consider lymphoma, tuberculosis, sarcoidosis, or other infiltrative diseases in patients with unexplained elevated LFT, constitutional symptoms, and with non-specific findings on imaging. Unfortunately, DLCBL is often diagnosed late, where therapeutic intervention is of little utility.Figure 1.: A- Liver core biopsy, H and E stain 10x. An arrow showing patchy atypical lymphoid infiltrate. B-Positive for CD 20 immunochemical stain on liver biopsy. An arrow is showing strong membrane positivity. C-Bone marrow biopsy, H and E stain, 50x. The arrow is showing sheets of atypical medium-sized lymphoid cells.Table 1.: Liver enzyme trend throughout hospitalization.