A 43-year-old man with acute lymphoblastic leukemia was treated with three cycles of hyper-CVAD (hyper fractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone) followed by allogeneic hematopoietic stem cell transplantation (HCT) from a sibling. Six months later, the patient presented with jaundice for the previous 10 days. Ultrasonography did not reveal any ductal dilatation, and the Doppler study noted patency of the hepatic vessels. Serum chemistry tests were remarkable for total bilirubin of 8.4 mg/ dL, direct bilirubin of 5.4 mg/dL, aspartate aminotransferase of 109 U/L, alanine aminotransferase of 128 U/L, alkaline phosphatase of 600 U/L, and international normalized ratio of 1.1. Acute viral hepatitis A, hepatitis B, and cytomegalovirus were excluded, and no new drug exposure was documented. Of note, the patient was weaned off tacrolimus 2 weeks prior to the development of symptoms. Prednisone administered at 80 mg/ day was empirically started and a transjugular liver biopsy was performed.
On low-power magnification, histologic sections of the liver demonstrated a portal tract infiltrate composed of small lymphocytes, along with obscured bile duct contours due to infiltration of the biliary epithelium by these lymphocytes (Fig. 1A, arrow). The biliary epithelium displayed evidence of injury, including cellular elongation, Abbreviations: GVHD, graft-versus-host disease; HCT, hematopoietic stem cell transplantation.