Acute Liver Failure Secondary to Primary Large B-cell Lymphoma Complicated by Malignancy-related Hemophagocytic Syndrome: A Case Report

Abstract

Acute liver failure is a catastrophic condition characterized by the sudden and severe impairment of hepatic function. We report the case of a 36-year-old patient who presented with significant dehydration, generalized jaundice, evidence of hepatic encephalopathy, generalized edema with abdominal distension, and hepatosplenomegaly. A liver biopsy was performed, yielding the final diagnosis of primary large B-cell lymphoma. Subsequently, a bone marrow aspirate and biopsy were performed, confirming the diagnosis of hemophagocytic syndrome. The patient was managed with R-CHOEP (rituximab, cyclophosphamide, doxorubicin, vincristine, etoposide, prednisone) chemotherapy. After 21 days, the patient was successfully discharged to continue treatment on an outpatient basis.

Keywords: acute liver failure (alf); diffuse large b cell lymphoma (dlbcl); hemophagocytic syndrome (hs); lymphoma; non-hodgkin lymphoma (nhl).

Figure 1. 18F-FDG PET-CT images

(A) Coronal PET and (B) Coronal PET/CT fusion show increased focal metabolic activity in the spleen and abdominopelvic lymph nodes (red arrows), and diffuse metabolic activity in the liver, associated with hepatosplenomegaly. (C) Axial CT in arterial phase, (D) Axial PET, and (E) Axial Lumbar Interbody Fusion demonstrate a heterogeneous spleen with multiple lesions (blue arrow) and a liver with diffuse metabolic increase. 18F-FDG: 2-deoxy-2-[^fluorine-18]fluoro-D-glucose

Figure 2. Hepatic infiltration by large B-cell lymphoma: histological and immunohistochemical findings

Liver biopsy shows destruction of the hepatic architecture with a pattern of portal and sinusoidal infiltration by large atypical lymphoid cells, characterized by vesicular nuclei, prominent nucleoli, and abundant cytoplasm, features are consistent with large cells (A) (hematoxylin and eosin, 10x). Neoplastic cells are seen to express CD20 (B), CD30, MUM1 (50%), Ki67 (95%) (C), BCL6 (D) (immunohistochemistry, 10x), and BCL2; and are negative for C-MYC, CD3, and CD5.

Figure 3. Bone marrow smear (Wright-Giemsa stain) showing features of hemophagocytosis lymphohistiocytosis

A large macrophage at the center (arrow) with abundant cytoplasm is observed, containing numerous phagocytosed hematopoietic cells in various stages of degradation, including erythrocytes and myeloid/erythroid precursors.