Case Presentation: A 54-year-old Hispanic woman presented with 5 days of subjective fevers, jaundice, nausea, vomiting, and right-sided abdominal pain. On presentation, she was febrile with borderline hypotension and tachycardia, abdominal tenderness, and laboratory values notable for leukopenia and transaminitis with direct hyperbilirubinemia. The patient received vancomycin, cefepime, metronizadole, and intravenous fluids per sepsis protocol. She was intubated for an emergent ERCP, which revealed a possible common bile duct stricture for which a stent and cholecystectomy drain were placed. Bile cultures grew Staphylococcus epidermidisEnterococcus faecalis and candida, while blood cultures remained negative.

Despite antibiotics, the patient remained persistently febrile with worsening hyperbilirubinemia and altered mental status. MRI of the abdomen revealed numerous hyperintense lesions of the liver and MRCP confirmed multiple hepatic lesions. A liver biopsy was performed with pathology revealing Epstein-Barr virus positive mixed inflammatory cells with immunophenotype studies consistent with a diagnosis of classical Hodgkin’s lymphoma (HL). She received one dose of doxorubicin and gemcitabine, however, she was unable to tolerate further chemotherapy and died within days after treatment.

Discussion: With an incidence of 2.6 per 100,000 people per year in the United States, Hodgkin’s lymphoma is a rare disease. It typically presents with constitutional “B symptoms” such as fevers, night sweats, weight loss, and fatigue, in addition to painless lymphadenopathy. Though liver infiltration is frequently seen in patients with advanced HL, initial presentation with acute cholangitis leading to a diagnosis of HL is rarely seen. As such, the patient’s hepatic lesions on the MRI were thought to be most likely foci of abscesses, given her clinical context of septic cholangitis. It was only after the pathology report was released that a hematological malignancy was considered as the underlying illness. Our patient’s clinical presentation is attributable to lymphomatous cells infiltrating the liver, causing bile duct necrosis, obstruction and ultimately cholangitis. 

Conclusions: The key to appropriate diagnosis of HL in this patient was MRI of the abdomen with contrast followed by tissue biopsy, as CT scans or ultrasonography would not be adequate imaging modalities when suspecting hepatic lymphoma.  It is important to consider cholangitis as an atypical presentation of HL to prevent delays in treatment and misdiagnosis, as HL has an excellent prognosis when treated early.