PMC5364191_01
A)-B) The esophagogastroduodenoscopy findings. A) The stomach. The red arrowheads indicate irregular ulcer lesions in the body of the stomach. B) The duodenum. The red arrowheads indicate multiple flat elevations in the second portion of the duodenum. Biopsies were performed from <1-<2 and <4-<6, and all of the samples revealed diffuse large B-cell lymphoma. C)-E) The contrast-enhanced computed tomography findings. C) A CT image showing the enlargement of multiple lymph nodes from the neck. D) A CT image showing a thickened gastric wall caused by lymphomatous lesion. E) A CT image showing the ascites on the surface of the liver. A cytological analysis of the ascites revealed class V.
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B). Biopsies of these lesions (<4 - <6 in Fig. 1A and <1 - <2 in Fig. 1B) revealed diffuse large B cell lymphoma (DLBCL). Computed tomography (CT) showed multiple adenopathy of the lymph nodes of the neck, axilla, mesentery, and paraaorta (Fig. 1C-E), with the uptake of fluorodeoxyglucose.
A) The clinical course of the present patient, including the timing of CT (as shown as B-E). NM: nafamostat mesilate, G: glycyrrhizic acid, UDCA: ursodeoxycholic acid. B) A contrast-enhanced CT image shows hepatomegaly and geographic low density area at the posterior segment of the liver. C)-E) CT images showing the increase of ascites and the progression of liver atrophy.
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The treatment reduced his body temperature and serum LDH concentration (Fig. 2A). His hepatobiliary enzyme levels were elevated again after the second cycle of R-CODOX-M/IVAC (Fig. 2A); for example, the concentrations of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were 516 IU/L and 288 IU/L, respectively, and the concentrations of total and direct bilirubin were 5.5 mg/dL and 3.9 mg/dL, respectively. The bilirubin level to rise until it peaked at 34.4 mg/dL (Fig. 2A). CT showed hepatomegaly with a geographic low density area at the posterior segment of the liver (Fig. 2B). Follow-up CT showed progressive atrophy of the liver and an increase in ascites (Fig. 2C-E), followed by CMV pneumonia.
The liver biopsy results. A) Hematoxylin and Eosin (H&E) staining (x20). Hepatocellular necrosis was not observed in the lobular and periportal area. B) H&E staining (x400). The arrow represents a bile plug. C) H&E staining (x100). The arrow represents a preserved bile duct. Mild inflammation was observed in the portal area. D) H&E staining (x20) showing congestion in the parenchymal area. E) H&E staining (x200) the arrowhead shows dilatation of the sinusoid and congestion caused by erythrocytes. F) Azan-Mallory staining (x400). The arrow represents the central vein which shows no venular occlusion.
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A liver biopsy specimen showed bile congestion of the bile capillaries and hepatocytes, as well as sinusoidal dilatation, but the structure of the bile duct was preserved and there was no evidence of central vein stenosis or obstruction (Fig. 3).
The pathological findings of the liver at autopsy. A) The macroscopic findings of the liver. Congestion and cholestasis are found. B) H&E staining (x400) showing the dilation of the sinusoid due to erythrocytes (arrowhead) and a bile plug (arrow). C) Azan staining (x400) showing the growth of connective tissue under the sinusoidal endothelial cells (arrowhead). D) H&E stainingg (x20) showing the congestion of the parenchyma. E) H&E staining (x400) showing stenosis of the central vein (arrowhead) and ischemic necrosis of the hepatocytes. F) Azan staining (x400) showing the deposition of connective tissue around the central vein, which caused stenosis of the central vein (arrowhead). CV: central vein
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His liver weighted 1,175 g, and its surface division resembled nutmeg liver (Fig. 4A). The latter finding is considered to be a characteristic of hepatic SOS (Fig. 4B-F). We also observed congestion of the central vein due to the occlusion of venules, ischemic necrosis of the hepatocytes, the growth of connective tissue under SECs by the dilatation of the sinusoids, along with the narrowing and occlusion of the sinusoids (Fig. 4B-F).