First reported case of disease: peliosis hepatis as cardinal symptom of Hodgkin's lymphoma

We present the case of a 25-year-old woman with a history of weakness, weight loss, anemia, and elevated liver enzymes. Outpatient diagnostic evaluation, including abdominal ultrasound and endoscopies, revealed no conclusive explanation for the clinical picture and the patient was admitted to our clinic. Because of the hepatosplenomegaly together with the elevated liver enzymes, one of our differential diagnoses was that of liver disease. To clarify this, we performed a minilaparoscopy, which showed multiple diffuse distributed spots of livid color without clear margins distributed all over both liver lobes. A biopsy taken from these areas revealed the diagnosis of peliosis hepatis with irregular and diffusely enlarged hepatic sinusoids with an irregular structure. Peliosis hepatis is associated with numerous infectious and neoplastic diseases, but also occurs as a result of toxic liver damage. Further evaluation of our patient with an x-ray and a computed tomography (CT) scan revealed a mediastinal mass and a CT-guided biopsy showed classical Hodgkin's lymphoma. After completing further screening, a definitive diagnosis of Hodgkin's lymphoma stage II/N/B (Ann-Arbor) was established and chemotherapy according to the German Hodgkin's study group protocol with bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone (the BEACOPP regimen) was initiated. After the first chemotherapy cycle, the patient's symptoms and laboratory values improved rapidly. Taken together, we present the case of a patient with peliosis hepatis as an uncommon manifestation of Hodgkin's lymphoma. Despite an extensive literature search, we could not find any case of peliosis hepatis associated with a de novo diagnosis of classical Hodgkin's disease.

[Peliosis hepatitis during intestinal lymphomatous polyposis treated with chemotherapy and radiotherapy. Regression after antibiotic therapy]

We report a case of regressive peliosis hepatis, which occurred in a 55 year-old woman with diffuse intestinal lymphomatous polyposis in remission after treatment with chemotherapy and radiotherapy, and which was cleared after one month treatment with erythromycin. The Warthin-Sarry stain, performed to identify a specific agent such as Rochalimaea quintana and henselae, was negative, and the polymerase chain reaction technique could not be performed. Regressive cases of peliosis hepatis are rare, and 4 out of 7 have been reported after antibiotic treatment. Two of them were observed after an antibiotic regimen with erythromycin in patients with HIV disease, and the bacilli Rochalimaea quintana and henselae were identified in liver tissue with Warthin-Starry stain and polymerase chain reaction technique. The observation and the regressive cases recently reported elsewhere, suggest that appropriate antibiotic treatment should be proposed when peliosis hepatis occurs.

[A new bacterium: Rochalimaea]

Originally limited to trench fever, infections due to Rochalimaea now comprise manifestations particular to patients with human immunodeficiency virus (bacillary angiomatosis and hepatic peliosis), but also manifestations as diverse as isolated fever, septicaemia, endocarditis, lymphocytic meningitis, or central neurological disorders, in immunodepressed or immunocompetent subjects. The involvement of Rochalimaea in cat-scratch fever remains debated. Microbiological analysis used for diagnosis has been modified to allow isolation of these new bacteria, whose culture is slow and difficult, in the course of the above-cited clinical manifestations, which should further extend the range of Rochalimaea infections.

Bacillary peliosis hepatis as a cause of acute anemia in a patient with the acquired immunodeficiency syndrome

A 33-year-old white homosexual man, infected with the human immunodeficiency virus, presented with acute anemia and thrombocytopenia not responsive to transfusions or to treatment with steroids and intravenous gamma-globulin. Hematologic workup was compatible with peripheral sequestration or loss of blood cells; however, there was no evidence of gastrointestinal or other sources of hemorrhage, and the only significant finding was a progressive liver enlargement. An abdominal computerized tomographic scan showed a massive homogeneous liver without focal lesions, a very small amount of ascites, and no retroperitoneal fluid collections. A transjugular liver biopsy specimen showed the cystic, blood-filled cavities characteristic of peliosis hepatis. Cavities varied in size, all contained pooled erythrocytes, and some had areas suggestive of thrombi in various stages of organization. Bacteria similar in morphology to those described in bacillary peliosis hepatis were seen in the peliotic spaces. The clinical picture began resolving shortly after treatment with zidovudine and ampicillin/sulbactam was started and had totally resolved 6 months after presentation. This case shows that bacillary peliosis hepatis is a reversible entity that may produce acute sequestration of blood in the liver.

Effect of cimetidine on the hepatic extraction of indocyanine green, the portal pressure and the systemic circulation in patients with cirrhosis of the liver

The effect of cimetidine on hepatic and systemic haemodynamic parameters was studied in seven patients with portal hypertension due to alcohol-induced cirrhosis of the liver and in one patient with peliosis hepatis following oral contraceptive steroids. The intravenous administration of cimetidine (350 mg as bolus, followed by 2 mg/min over 60 min) reduced the hepatic extraction of continuously infused indocyanine green (ICG) by 27%; this was statistically significant (P less than 0.01). Since the ICG clearance, calculated independently of hepatic perfusion, was lowered by 19%, this effect seems to be mainly due to a reduced capacity of the liver to remove the dye from the blood, rather than due to changes in perfusion. Cimetidine did not influence the elevated portal pressure in the patients with cirrhosis, or the normal pressure in the patient with peliosis hepatis. No significant effect was observed on heart rate, mean arterial pressure, pulmonary artery pressure, pulmonary capillary pressure and cardiac output. These studies indicate that the reduction of the hepatic ICG extraction following cimetidine is more the result of an inhibited capacity of the liver to remove the dye than of changes in the hepatic perfusion or in the systemic circulation.

[Pathogenesis, clinical course and morphology of peliosis]

On the basis of two cases and a survey of literature the syndrome of the peliosis of liver, spleen and bone marrow is described and its pathogenetic factors are demonstrated. For peliosis is a syndrome which is characterized by multiple cavities filled with blood in the parenchyma. It is established that the peliosis has changed from very rare autopsy findings in a prognostically unfavorable basic disease has changed to a clinically significant and therapeutically controllable complication of the hormone therapy.