Hodgkin Lymphoma Presenting as a Cholestatic Liver Disease with Portal Venous Infiltration: A Rare and Unusual Presentation

no proteinuria.ABG reports, before demise, showed metabolic acidosis.The excision biopsy from the right inguinal lymph node was suggestive of Hodgkin lymphoma (investigations detailed in Tables 1 and 2).Radiology (PET-CT) Dr Rajender K Basher: Whole-body MIP image showed a diffuse uptake in the lower abdomen and focal uptake in the inguinal region.On the transaxial images, there was a fibrocalcific change in the lung fields, without uptake.A few calcified lymph nodes in the mediastinum were seen.Apart from this, single lymph node in the right hilar region with mild uptake (SUV max of 4.3) was noted.Liver is grossly enlarged and measures 21 cm in craniocaudal dimension.Spleen is also enlarged, measuring 14 cm in craniocaudal dimension.There were multiple lymph nodes in the retroperitoneum, of which few were calcified, though showed no FDG uptake.The periaortic and para-aortic lymph nodes showed intense FDG uptake with SUV max of 12.7, and most of them were enlarged up to a maximum dimension of 2 cm.Pelvic cavity and inguinal region showed multiple lymph nodes with intense FDG uptake.A few of the lymph nodes in the pelvic cavity showed necrosis, possibly old TB.There is a focal uptake in the inferior pubic ramus with moderate FDG uptake of SUV max 5.7.In addition, spleen showed a cystic lesion without any FDG uptake.The image-based diagnosis is FDG-avid lymph nodes on both sides of the diaphragm along with marrow-based lesions, suggestive of lymphomatous involvement (Fig. 1). Presentation o f CaseDr Sunil Taneja (hepatologist): A 40-year-old male presented with fever and jaundice for 3 months duration.Fever was high grade, intermittent, up to 103°F, with evening rise of temperature associated with night sweats, not associated with chills or rigors, and relieved with medication.There was no history of sore throat, headache, altered mental status, skin rash, joint pains, bowel, or urinary complaints.A history of jaundice for 3 months, insidious onset, gradually progressive was present.No history of clay-colored stools, pruritus, pain abdomen, or feeling of lump abdomen.There was loss of appetite and weight loss (documented as 12 kg over the last 6 months).No history of melena, hematemesis, abdominal distension, or decreased urine output.Additionally, history of pulmonary tuberculosis (TB) in 2020 was present, which was treated with antitubercular therapy (ATT) for 6 months.There is no history of diabetes, hypertension, or thyroid disease.This patient was evaluated for fever and abdominal lymphadenopathy in January 2024 and was started on ATT by an outside hospital, stopped after 10 days due to worsening of jaundice, for which he visited PGIMER.On general examination, he was conscious, oriented, cooperative, and thin built.Pulse rate was 84/minute.Blood pressure (BP) of 100/60 mm Hg with respiratory rate of 20/minute and saturation was 97 at room air.He had pallor and icterus with bilateral pitting pedal edema.Lymphadenopathy present (inguinal region).Cyanosis and clubbing were not seen.Jugular venous pressure (JVP) was not raised.Respiratory and cardiovascular system (CVS) examination was essentially normal.On per abdomen examination, liver was palpable 6 cm below the right costal margin.It was firm, smooth, and nontender.Central nervous system (CNS) examination was normal.The investigations showed pancytopenia with normal sodium level of 136 mEq/L (135-145 mEq/L) and creatinine of 0.47 mg/dL (0.6-1.1 mg/dL).There was conjugated hyperbilirubinemia.AST and ALT showed mild elevation with marked rise in alkaline phosphatase levels.Serum albumin was 1.85 gm/dL (3.4-5.4 gm/dL), and there was significantly high alkaline phosphatase level of 3,362 U/L (44-147 U/L).Lipidogram showed cholesterol of 201 mg/dL (<200 mg/dL), triglycerides 189 mg/dL (<150 mg/dL), LDL 148 mg/dL (<100 mg/dL), and HbA1c of 5% (<5.7%).TSH was normal, and vitamin D was on the lower side, and vitamin B12 was 1,836 pg/mL (200-9,000 pg/mL).Peripheral blood smear showed normocytic normochromic red cells with few macrocytes, microcytes, tear drop cells, and elliptocytes.The blood and urine culture were sterile, and urine examination was normal.There was