SHM Converge Scientific Abstract ePoster Gallery-When the Biopsy Is Negative: A Diagnostic Dilemma

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This case highlights a diagnostic challenge in diffuse large B-cell lymphoma (DLBCL), the most common subtype of non-Hodgkin lymphoma. A 65-year-old man with chronic immunosuppression from prednisone for idiopathic pulmonary fibrosis presented with 2 months of fevers, abdominal pain, malaise, and major weight loss. He also had anemia, thrombocytopenia, elevated LDH, and marked cholestatic and hepatocellular liver enzyme abnormalities. Initial workup, including peripheral smear, flow cytometry, broad infectious testing, CT imaging, and bone marrow biopsy, was unrevealing except for hepatomegaly.<br /><br />Because symptoms persisted despite a negative evaluation, hepatology recommended a liver biopsy. Pathology showed sparse intrasinusoidal infiltration by large atypical CD20-positive lymphocytes, confirming DLBCL involving the liver. Subsequent PET scan demonstrated cervical and mediastinal lymphadenopathy, indicating more extensive disease, even though the liver had normal uptake on imaging.<br /><br />The report emphasizes several teaching points: DLBCL often presents with rapidly enlarging lymph nodes or abdominal mass, but “B” symptoms may be the main clue. Absence of generalized lymphadenopathy, hepatomegaly, or bone marrow involvement does not exclude the diagnosis. Extranodal disease occurs in a substantial proportion of patients, and liver involvement can be associated with worse outcomes. Diagnosis requires tissue biopsy with immunohistochemistry or flow cytometry to confirm B-cell lineage.<br /><br />The patient deteriorated rapidly before treatment could begin, developing atrial fibrillation with rapid ventricular response and refractory multiorgan shock, and ultimately died after transition to comfort care. The case underscores the importance of maintaining suspicion for lymphoma in immunosuppressed patients with unexplained systemic symptoms and repeating diagnostic evaluation when initial studies are negative.

Asset Subtitle

Aisha Uraizee

Meta Tag

Author List Aisha Uraizee, Alexandra Harrington, Babajide Adio, Janice Chiou

Category Clinical Vignettes

Concept Diffuse Large B-Cell Lymphoma

Concept B-Symptoms

Concept Excisional Biopsy

Concept Rapid Enlargement

Concept Extranodal disease

Distinguished Non-Finalist

Presenter Organization Medical College of Wisconsin

Presenting Author Aisha Uraizee

Track Adult

Keywords

diffuse large B-cell lymphoma

DLBCL

liver biopsy

intrasinusoidal infiltration

CD20-positive lymphocytes

immunosuppression

B symptoms

hepatomegaly

extranodal lymphoma

multiorgan shock

Diffuse Large B-Cell Lymphoma

B-Symptoms

Excisional Biopsy

Rapid Enlargement

Extranodal disease