Hematological malignancy manifesting as ascites

Background: A 63-year-old Caucasian woman presented with intermittent, left-sided abdominal discomfort without other symptoms. Physical examination revealed massive splenomegaly and complete blood counts showed thrombocytopenia. Splenectomy was recommended but the patient declined. She was lost to follow-up twice but returned with tense ascites about 2 years after the initial presentation. Despite aggressive medical management, the ascites did not improve. Investigations: Bone-marrow and liver biopsies, abdominal ultrasound, esophagogastroduodenoscopy, abdominal CT scan and peripheral blood smear. Diagnosis: Primary splenic lymphoma with hepatic infiltration causing portal hypertension and ascites. Management: Paracentesis, dietary sodium restriction and diuretics splenectomy, splenorenal shunt and chemotherapy (cyclophosphamide, doxorubicin, vincristine and prednisone).