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Immunomodulatory therapy in Crohn's disease as a cause of Cryptococcus neoformans pneumonia

Introduction: It is common to find malignant infiltration of the liver in hematogenous malignancies such as acute leukemia or lymphoma. Hepatic involvement is usually mild and clinically silent at the time of diagnosis. We present a case in which jaundice and abnormal liver chemistries led to the diagnosis of acute lymphoblastic leukemia with marked infiltration of the liver. Case: A 63 year-old man presented to the hospital with three weeks of jaundice and malaise. The patient denied a personal or family history of liver disease, hepatitis, drug abuse, blood transfusion, or recent travel. On admission, physical examination was significant for cervical and inguinal adenopathy, scleral icterus, slight right upper quadrant tenderness and palpable liver edge six cm below the costal margin. Laboratory evaluation on admission revealed a WBC cound of 2.4 10 cells/L, a hemoglobin of 10.5 g/dL, and a platlet count of 85 10 platlets/L. Liver function tests revealed an aspartate aminotransferase of 86 IU/L, alanine aminotransferase of 96 IU/L, alkaline phosphatase of 1146 IU/L, total bilirubin of 19.7 mg/dL and direct bilirubin of 9.1 mg/dL. Further testing was done to evaluate the abnormal liver function tests and pancytopenia. An ultrasound of the abdomen showed a normal liver and normal sized common bile duct. An MRI of the abdomen revealed hepatomegaly with the liver measuring 21.5 cm, mild splenomegaly, and normal biliary system. A blast was noted on peripheral blood smear. A liver biopsy revealed hepatic infiltration by leukemic cells. A bone marrow biopsy showed a hypercellular bone marrow. The entire bone marrow space was effaced with an immature appearing cell population. Normal hematopoietic elements were minimal. More than 90% of the nucleated red blood cells represented blasts. Flow cytometry was consistent with precursor B cell acute lymphoblastic leukemia. Chemotherapy was started promptly with improvement in jaundice and liver function tests. Conclusion: In acute lymphocytic leukemia and lymphoma, hepatic involvement at diagnosis is not commonly reported. The case presented illustrates that hematologic malignancies can present and be diagnosed based on their hepatic manifestation.