A rare case of acute liver failure due to diffuse large b-cell lymphoma: image negative presentation posing a diagnostic challenge

SESSION TITLE: Critical Care Case Report Posters 70 SESSION TYPE: Case Report Posters PRESENTED ON: 10/09/2023 02:10 pm - 02:55 pm INTRODUCTION: Acute Liver Failure (ALF) due to infiltration of the liver by diffuse large B-cell lymphoma( DLBCL) is an extremely rare condition with poorly understood clinical and radiological features. Here, we describe an unusual case of ALF due to DLBCL with an image negative on presentation posing diagnostic difficulty. CASE PRESENTATION: A 74-year-old male with a past medical history of interstitial lung disease, atrial fibrillation, and diabetes mellitus presented ED with complaints of progressive abdominal pain, distension, and constipation. On examination, the abdomen was mildly distended but non-tender. CT of the abdomen and pelvis showed moderate colonic stool, no focal lesions in the liver, and enlarged pelvic, mediastinal, and retroperitoneal lymph nodes (a mild increase in size since the last imaging in 2018). An ultrasound scan of the abdomen was negative for biliary tree or gallbladder disease. He underwent an endoscopy which revealed a gastric ulcer with an oozing hemorrhage. It was treated with bipolar cautery and IV pantoprazole. He refused to do a bone marrow or lymph node biopsy for further workup of his lymphadenopathy. His serum immunofixation showed an M spike in the background of polyclonal gammopathy. Flow cytometry was negative for the lymphoproliferative disease. Eight days later, he complained of worsening abdominal pain. He was found to have altered mental status and asterixis.ALT 101, AST 328, lactic acid 4.2, total bilirubin 2.5, INR 6.35, ammonia level 117 µmol/L. Serology was negative for HAV, HBV, HCV, HIV, EBV, Lyme, CMV, ANA, and anti-smooth muscle antibodies. Unfortunately, his condition worsens with the development of gram-negative bacteremia, septic shock, and acute respiratory failure. He was intubated and started on broad-spectrum antibiotics with vasopressors. He continued to deteriorate with worsening lactic acidosis, coagulopathy, severe anemia, elevated liver enzymes, and thrombocytopenia. The patient passed away on day fourteen of hospitalization. The autopsy findings revealed DLBCL involving multiple organs including the liver, lung, bone marrow, and multiple lymph nodes. DISCUSSION: Acute liver failure is defined as a severe acute liver injury with encephalopathy and impaired synthetic function (INR >1.5) in a patient without pre-existing liver disease. DLBCL manifested as ALF is an uncommon but significant cause of ALF with a very dismal prognosis. The majority of reported cases died a few days after reporting to the hospital while some were diagnosed on autopsy, and very few survived with chemotherapy. CONCLUSIONS: It should be suspected in patients with lactic acidosis, coagulopathy, and rising ammonia levels indicating loss of liver function in the setting of lymphadenopathy even in the absence of radiographic abnormalities. A proper diagnosis by liver biopsy is important in suspected cases to start early chemotherapy and improve mortality. REFERENCE #1: Kapuria D, Strasse K, Qasem A. Diffuse large B-cell lymphoma causing acute liver failure: a rare case of survival. BMJ Case Rep. 2015,http://dx.doi.org/10.1136/bcr-2015-209328. REFERENCE #2: G. Ostapowicz et al., "Results of a prospective study of acute liver failure at 17 tertiary care centers in the United States," Ann. Intern. Med., vol. 137, no. 12, pp. 947–954, Dec. 2002, doi: 10.7326/0003-4819-137-12-200212170-00007. REFERENCE #3: S. Mochida et al., "Diagnostic criteria of acute liver failure: A report by the Intractable Hepato-Biliary Diseases Study Group of Japan," Hepatol. Res. Off. J. Jpn. Soc. Hepatol., vol. 41, no. 9, pp. 805–812, Sep. 2011, doi: 10.1111/j.1872-034X.2011.00860.x. DISCLOSURES: No relevant relationships by Shubhneet Bal No relevant relationships by Gunjan Gupta No relevant relationships by David Maslak No relevant relationships by Oluwole Odujoko No relevant relationships by Prabasha Weeraddana No disclosure on file for Niwanthi Weerasooriya