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.
•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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