Small intestinal follicular lymphoma induced by methotrexate: a case report

Abstract

Background Methotrexate-associated lymphoproliferative disorder (MTX-LPD) is a rare but critical complication that develops in patients treated with MTX. Although MTX-LPD has been recently reported, the incidence of follicular lymphoma in the intestine is very low. Case presentation A 73-year-old woman who had been receiving MTX for over 10 years visited our hospital complaining of postprandial abdominal pain and nausea. Upper and lower digestive tract endoscopies did not show any abnormal findings. A patency capsule was stagnated at the proximal part of the ileum with a mild dilation on the oral side. An oral balloon endoscopy revealed shallow ulcerative lesions in the jejunum. She was diagnosed with MTX-LPD based on histopathological findings. The symptoms did not improve with the discontinuation of MTX, and the patient required partial resection of the small intestine. The test result for Epstein-Barr virus-encoded small RNA was negative. She was diagnosed with follicular lymphoma based on the histology findings of a surgical specimen. Postoperative positron emission tomography-computed tomography and bone marrow aspiration did not show any findings of lymphoma. On follow-up, no recurrence was noted four years after the surgery. Conclusions Herein, we report the first case of follicular lymphoma that occurred in the small intestine, negative for Epstein-Barr virus-encoded small RNA. If intestinal symptoms occur during MTX administration, it is important to directly observe by endoscopy and perform histological examination.

Polymorphic lymphoproliferative disorder arising in a rheumatoid arthritis patient, presenting as fibrin‐associated large B‐cell lymphoma‐like lesions in aortic and mitral valves

“…6 Among MTX-LPD, 40−50% occur in extranodal sites, including the gastrointestinal tract, skin, liver, lung, and kidney. 7 Polymorphic LPDs constitute approximately 15% of MTX-LPD, histologically displaying heterogeneous lymphoid cell infiltrate with variable numbers of B-cells exhibiting a full spectrum of B-cell differentiation that efface the architecture of the involved tissues. 1 EBV is seen in variable proportions, including both small and large cells; hence, it is called destructive EBV-positive LPD.…”

“…However, approximately 50% of the patients remit spontaneously after discontinuing methotrexate (MTX), known as MTX‐associated LPD (MTX‐LPD) 6 . Among MTX‐LPD, 40−50% occur in extranodal sites, including the gastrointestinal tract, skin, liver, lung, and kidney 7 …”