[Fulminant non-Hodgkin lymphoma presenting as lactic acidosis and acute liver failure: case report and literature review]

Abstract

Hepatic dysfunction caused by malignancy is uncommon and can be the result of primary hepatocellular carcinoma, liver metastasis, secondary malignancies, or a complication of chemotherapeutic agents. Hematological malignancies, as leukemia, non-Hodgkin lymphoma, and Hodgkin lymphoma, typically do not result in hepatic dysfunction and rarely manifest as fulminant liver failure.

Case presentation: A 43 year-old male was referred with 2-week diarrhea, nausea and vague abdominal discomfort. He was treated with oral antibiotics. However, symptoms progressed and he was admitted with advanced liver failure. On admission the patient was jaundiced, agitated, with tachycardia and hypotension. There were echymosis around the eyes and chest, active bleeding at sites of vein punctures and macroscopic hematuria. The abdomen was tender with an enlarged liver. Admission laboratory findings were consistent with acute hepato-renal failure. Viral hepatitis serology was negative, antinuclear antibody screen was negative, and iron panel was normal. Abdominal ultrasound showed liver and spleen enlargement. He developed refrac- tory hypoglycemia, further increase in serum lactate and died 5 days after admission.

Conclusions: Acute liver failure is uncommon as the presenting feature of lymphoma. This fact may delay diagnosis, contributing to the reported poor prognosis. Establishing a diagnosis of malignancy as the cause of acute liver failure is difficult and requires a high index of suspicion. Given the poor prognosis associated with late or missed diagnosis and the potential benefits of early chemotherapy, lymphoma should be considered in any patient presenting with acute liver failure without an obvious etiology and associated with lactic acidosis and hepatomegaly.