We report the case of a 70-year-old man who presented recurrent abdominal pain and distention, accompanying skin irritation and pruritus for more than 9 months. The patient denied a family history or special occupational exposures, without drinking history, and was admitted to hospital with a possible diagnosis of decompensated cirrhosis.
On admission, physical examination revealed abdominal bulge and tenderness with shifting dullness but without jaundice and caput medusa. An abdominal ultrasound revealed multicavity effusion, especially massive peritoneal effusion. Chest-computed tomography (CT) scan showed a limited amount of pleural effusion, and contrast-enhanced abdominal CT indicated early-stage cirrhosis and splenomegaly complicated by abdominal-pelvic fluid accumulation. Beyond these, a subcapsular effusion of the right liver lobe, gastric wall edema lesion, and subcutaneous edema were in the imaging (shown in  Figure 1 ). Further full-body PET-CT images correspond to contrast-enhanced abdominal CT and disclosed no significant hypermetabolism (shown in  Figure 1 ). Blood tests excluded multiple organ failure and potential virus infection, which was caused by hepatitis B, C virus (HBV, HCV), Epstein-Barr (EB) virus, and Kaposi sarcoma herpesvirus (KSHV)/human herpesvirus-8 (HHV8) virus. The investigation of liver function showed normal hepatic enzymes in alanine aminotransferase (ALT) 13.90 U/L, aspartate aminotransferase (AST) 32.40 U/L, total bilirubin (TBIL) 9.06 umol/L, direct bilirubin (DBIL) 3.43 umol/L, indirect bilirubin (IBIL) 5.63 umol/L, and slightly increased alkaline phosphatase (ALP) 101.0 IU/L and gamma-glutamyltranspeptidase (GGT) 68.9 IU/L, while there was an obvious reduction of total protein (TP) 51.72 g/L and albumin (ALB) 24.21 g/L. A representative antibody for primary biliary cirrhosis (PBC), antimitochondrial M2 (AMA-M2), was positive. Routine blood tests indicated anemia and thrombocytopenia with red blood cell count (RBC) 3.07 x 1012/L, hemoglobin (Hb) 88 g/L, and platelet count (PLT) 115.0x109/L. Furthermore, a slight elevation in high-sensitivity cardiac troponin T (hs-cTnT) 0.019 ng/ml was also noted.
In an attempt to a definitive diagnosis, ascites and marrow were examined. The biochemical test of ascites found an abnormally high in lactate dehydrogenase (LDH) 4538.0 IU/L. Histology suggested that the ascites puncture cytology contained aggressive of large-sized B lymphocytes positive for CD20, CD79alpha, LCA, c-MYC (shown in  Figure 2 ), and other biomarkers, such as PAX5(+), CD3(+), CD19(+), CD34(-), HHV8(-), Ki-67(+, 60%), BCL-6(+), MUM1(-), sox11(-), EMA(-), and MPO(+) consistent with the result of the immunohistochemical staining of bone marrow biopsy, which presented CD20(+), CD79alpha(+), CD3(+), BCL-6(-), MPO(+) (shown in  Figure 3 ), CD10(-), Ki-67(+, 1%<), and MUM(-).
According to available information, a cogitative diagnoses, FOALBCL, of this patient was produced. All symptoms could be completely recovered and vanished after peritoneal drainage by percutaneous puncture catheterization. Liver dysfunction returned to normal (ALT 10.40 U/L, AST 21.40 U/L, TBIL 15.16 umol/L, DBIL 5.66 umol/L, IBIL 9.50 umol/L, ALP 79 IU/L, GGT 28.13 IU/L) and hypoproteinemia was improved (TP 64.30 g/L, ALB 35.20 g/L) after receiving albumin prepared from human plasma injection (total 130 g). Despite the fact that anemia has not been corrected (RBC 2.53 x 1012/L, Hb 77 g/L, PLT 103.0 x 109/L), myocardial enzyme indicators have normalized (hs-cTnT 0.013 ng/ml) without any targeted-oriented therapy. Over 1-monthly symptomatic and supportive treatment, the patient made a discharge decision for seeking subsequent therapy by a local hospital. Before compiling the data and writing up this manuscript, informed consent and subsequent therapies have been confirmed by conducting a telephone follow-up on the patient. Follow-up information suggested that the patient was still alive and was undergoing chemotherapy smoothly without apparent adverse effects.