2782 Disguised as IBD: A Rare Presentation of Diffuse Large B Cell Lymphoma in a Young Male

Abstract

INTRODUCTION: About 1-4% of all gastrointestinal malignancies are primary non-Hodgkin Lymphoma (NHL) and the most common pathologic subtype is diffuse large B-cell lymphoma (DLBCL). Risk factors include environmental exposure, Epstein Barr Virus (EBV), immunosuppression, Helicobacter Pylori (H.Pylori), and human T-cell leukemia virus type 1. The majority of patients are males over the age of 40. Patients can present with vague abdominal pain, dyspepsia, vomiting, weight loss, and bleeding. Endoscopic findings vary and include ulcers, erosions, nodules, mass, erythema, and gastric fold thickening. With appropriate therapy, the 5 year survival can be up to 90%. This case illustrates a rare presentation of gastric DLBCL, emphasizes the importance of both a broad differential diagnosis in the immunocompromised and prompt endoscopy in those with alarm symptoms. CASE DESCRIPTION/METHODS: An 18 year old male with selective IgA deficiency and a family history of Crohn’s in his father presented with 3 months of cramping abdominal pain, diarrhea with small amounts of blood and tenesmus. He also reported night sweats and a 10 pound weight loss. History was negative for fevers, localizing infectious symptoms, arthralgias, skin or visual manifestations of IBD. Laboratory evaluation revealed normal WBCs at 7.2 × 109/L with relative lymphocytosis [lymphocytes: 68% (Norm 18-52%), Neutrophils: 22% (Norm 18-52%)]. The rest of labs including Hbg, liver enzymes, albumin and CRP were normal. Given concern for Crohn’s, EGD and colonoscopy were performed. Colonoscopy to the terminal ileum with ileal and colonic biopsies was normal. EGD revealed a 1 cm non-bleeding cratered gastric ulcer with elevated edges and mild erythema in the gastric body. Biopsy of the ulcer demonstrated atypical dense lymphoid cell infiltrate with morphology and immunohistochemical features consistent with EBV + DLBCL. Duodenal biopsies were negative for Celiac disease. Gastric biopsies were negative for H. Pylori. He completed chemotherapy with R-CHOP and is in remission. DISCUSSION: This case illustrates a rare presentation of primary gastric DLBCL, given his young age and presentation with bleeding (occurring in ∼10% of cases). Even though this patient had a seemingly classic presentation for Crohn’s Disease, it is critical to maintain a broad differential diagnosis in immunocompromised patients and prioritize endoscopy in those with type B symptoms (weight loss, night sweats) in order to lead to prompt diagnosis and treatment.