36

Case 36


History



A 58-year-old gentleman with a history of hypertension presents with a painless lump in the neck for 3 months. Fine needle aspiration of the mass and bone marrow examination shows a diffuse large B-cell lymphoma (DLBCL). Staging CT shows multiple enlarged lymph nodes in the neck, thorax and retroperitoneum (circles), compatible with stage IIIA DLBCL (Figures 36.1 to 36.3).






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Physical examination


Temperature 37.2°C, pulse 72 bpm, BP 124/64mmHg, SaO2 98-100% on RA.


Alert, no flapping tremor.


Examination of the hands reveals no clubbing and normal-appearing palmar creases.


Head and neck examination is unremarkable with no lymph nodes palpable.


Cardiovascular: HS dual, no murmur.


His chest is clear on auscultation.


Abdominal examination reveals a soft, non-tender abdomen, with no hepatosplenomegaly.


No signs of oedema.


Investigations


CBC:


WBC 9.6 x 109/L;


haemoglobin 12g/dL;


platelets 265 x 109/L.


Bilirubin normal.


ALP normal.


ALT normal.


The patient is referred to an oncologist. A pre-chemotherapy work-up is done showing negative HBsAg, anti-HCV and anti-HIV. IgG anti-HBc is positive. HBV DNA is not checked.


Chemotherapy is commenced and the patient responds well to chemotherapy. A follow-up CT after the fifth cycle of treatment shows that most of the lymph nodes have resolved.


However, the patient develops jaundice before the sixth cycle of R-CHOP (rituximab, cyclophosphamide, hydroxydaunorubicin, Oncovin® and prednisolone). He is subsequently referred to the hepatology clinic for assessment.


What is the differential diagnosis?


Flare up of hepatitis B.


Other viral hepatitis (e.g. hepatitis A, E).


Drug-induced liver injury.

Oct 23, 2019 | Posted by in GASTROENTEROLOGY | Comments Off on 36
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