Primary hepatic Epstein-Barr virus-positive diffuse large B-cell lymphoma associated with azathioprine immunosuppression: a case report

• Published in: Journal of medical case reports Vol. 17; no. 1; p. 175
• Main Authors: Marell, Paulina S, Shi, Min, Wingo, Majken T
• Format: Journal Article
• Language: English
• Published: England BioMed Central Ltd 02.05.2023; BioMed Central; BMC
• Subjects: Abdomen; Azathioprine; Biopsy; Bone marrow; Case Report; Case reports; Cholangiocarcinoma; Cysts; Diagnosis; Drug dosages; Epstein-Barr virus; Epstein-Barr Virus Infections; Esophagus; Female; Hematologic Neoplasms; Hepatitis; Herpesvirus 4, Human; Humans; Hydrochlorothiazide; Hyperplasia; Iatrogenesis; Immune system; Immunosuppression; Immunosuppression Therapy; Immunotherapy; Liver; Liver - pathology; Liver cancer; Lymphoma; Lymphoma, Large B-Cell, Diffuse; Magnetic resonance imaging; Middle Aged; Risk factors; Tomography; Tumors; Ultrasonic imaging; Weight control; Case report; Immunosuppression; Azathioprine; Lymphoma
• ISSN: 1752-1947; 1752-1947
• DOI: 10.1186/s13256-023-03907-z

Hepatic masses are relatively common findings, and the diagnostic approach often begins by identifying patient and mass characteristics that are risk factors for malignancy. Chronic immunosuppression is a known risk factor for various malignancies, and azathioprine in particular has been reported in association with solid and hematologic malignancies, including diffuse large B-cell lymphoma. A 46-year-old white woman presented to clinic with several weeks of gastrointestinal symptoms and was found to have a hepatic mass on imaging. Her history was notable for neuromyelitis optica spectrum disorder on chronic immunosuppression with azathioprine. It was initially thought to be an inflammatory adenoma. On 6-month follow-up imaging, the mass had grown rapidly in size and was surgically resected. Further workup determined the mass to be an iatrogenic immunodeficiency-associated Epstein-Barr virus-positive diffuse large B-cell lymphoma confined to the liver. Azathioprine was discontinued and the patient underwent treatment with rituximab with no evidence of recurrence 2 years after the initiation of treatment. This case report describes the first time hepatic Epstein-Barr virus-positive diffuse large B-cell lymphoma has been reported with azathioprine, which highlights the unique sequelae of chronic immunosuppression, including atypical hematologic malignancies, and the importance of considering chronic immunosuppression in the diagnostic evaluation of a hepatic mass.