Treatment Dilemma in Hodgkin’s Lymphoma with Fulminant Hepatic Failure

Introduction:
Classical Hodgkin’s Lymphoma (cHL) presenting as cholestatic or obstructive jaundice often has a complicated clinical course. The cause of jaundice can be attributed to cHL infiltration of the liver, infections, and extrahepatic mass compression of the external bile ducts. Although in general the survival rate of cHL treated with systemic chemotherapy is high, concurrent hepatic failure complicates its management when using chemotherapeutic regimens requiring hepatic metabolism and elimination.
Methods:
A 35-year-old African-American patient with HIV disease presented with one-week history of intractable abdominal pain, jaundice, and drenching night sweats. Laboratory parameters showed hyponatremia, acute renal failure (sCr 6.6mg/dL), and obstructive jaundice (TB 12.7mg/dL, SGOT 128units/L, SGPT 87units/L and alkaline phosphatase 1374units/L). LDH and beta-2-microglubilin were 446units/L and 8.2mg/dL respectively. CBC showed normocytic anemia. Hepatitis B and C profile were negative. His CD4+ cell count was 120cells/mL and HIV viral load was 284copies/mL. CT abdomen/pelvis showed an increased number of prominent retroperitoneal lymph nodes. He underwent biliary stent placement, and liver biopsy. Liver biopsy consistent with cHL, mixed cellularity subtype. A staging PET/CT scan showed increased FDG uptake in multiple chains of lymph nodes in both upper and lower diaphragm and heterogeneity in the bone marrow consistent with a clinical stage IVB with IPS score of 5. We overcame this challenging situation with sequential use of doxorubicin, bleomycin, vinblastine, dacarbazine (ABVD). We initially treated our patient with steroids, bleomycin and dacarbazine, drugs that were not limited in its dosing by his liver dysfunction. Once his liver function improved and his total bilirubin was Results:
Patients with stage IV cHL, are treated with ABVD. More recently and based on the ECHELON-1 study, brentuximab vedotin (Bv) combined with AVD is another frontline therapeutic option for patients with stage III–IV disease with no known neuropathy, IPI score of 4 or higher, age Discussion:
Initial presentation of cHL with obstructive jaundice is rare and often with fatal complication. The sequential administration of steroids, bleomycin and dacarbazine followed by doxorubicin and vinblastine once the liver functions improve, is a useful strategy in treating this group of patients.