Case 36


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).




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.



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.

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

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