GI TRACT LYMPHOMA MIMICKING BENIGN CONDITIONS

Document Type

Conference Proceeding

Publication Date

6-27-2024

Publication Title

J Gen Intern Med

Keywords

amoxicillin plus clavulanic acid, antibiotic agent, azithromycin, clindamycin, cyclophosphamide plus doxorubicin plus etoposide plus prednisolone plus vincristine, abdominal pain, adult, airway obstruction, analgesia, anastomosis, body weight loss, case report, clinical article, conference abstract, diagnosis, drug therapy, emergency ward, epiglottitis, female, flexible laryngoscopy, gastrointestinal lymphoma, high flow nasal cannula therapy, human, human tissue, hypoxia, ileum, intestine perforation, malabsorption, male, malnutrition, melena, non-Hodgkin lymphoma, odynophagia, oropharynx, peripheral T cell lymphoma, respiratory failure, respiratory tract infection, risk factor, secondary prevention, small bowel adenocarcinoma, small intestine, sore throat, streptococcal pharyngitis, surgery, T cell lymphoma, T lymphocyte, tonsil, tonsillitis, treatment outcome

Abstract

CASE: A 69-year-old male presented to the emergency department with sore throat, odynophagia associated with poor oral intake and unintentional weight loss of 30 pounds over the last year. Patient reports difficulty in following up with PCP, and often utilizes urban Emergency Department (ED) for care. Patient was treated with 4 courses of antibiotics including azithromycin, augmentin, clindamycin over 6 weeks for presumed respiratory infection, but found no relief from these regiments. Further workup was performed via ultrasound, CT imaging, and flexible laryngoscopy with findings revealing soft tissue thickening of the oropharynx, ulceration of base of tongue with right sided tonsillar mass highly suspicious for malignant neoplastic process. Oropharyngeal mass had rapidly progressed within 11 days, and prominent lymph nodes were also seen in level 1 and 2 bilaterally. Patient reported severe abdominal pain and melanotic stool, and CT imaging revealed free intraperitoneal air without a clear source. A diagnostic laparoscopy demonstrated a small bowel perforation of the ileum with multiple serosal masses s/p resection of 60cm small bowl with primary anastomosis and placement of GJ tube to address malnutrition and feeding needs. Biopsy of oropharyngeal and small bowel masses preliminary revealed high-grade aggressive mature T-cell lymphoma with a nuclear proliferative rate of 80%. Patient's initial EPOCH chemotherapy was delayed due to acute hypoxia respiratory failure likely due to the oropharyngeal mass causing airway obstruction and aspiration. Patient was intubated and given high flow nasal cannula therapy. Patient started on EPOCH chemotherapy and palliative care for pain management for Stage IV T-cell lymphoma. IMPACT/DISCUSSION: The patient's initial diagnostic differential included epiglottitis, tonsillitis, streptococcal pharyngitis however malabsorption, poor oral intake, and unintentional significant weight loss should increase clinical suspicion for Gastrointestinal tract lymphoma. This is particularly important in cases with prolonged non-responsiveness to standard treatments such as antibiotics. The GI tract, including oropharynx, is the most common site of extranodal non-Hodgkin lymphoma, accounting for 20-40% of all extranodal lymphomas. More specifically, about 10-25% of all lymphomas of the intestines are of T-cell origin. Other significant malignancies that can cause symptoms of malabsorption and weight loss include adenocarcinoma of the small intestine, colon, or pancreas or metastasis of other cancers to the GI tract. In this case T cell lymphoma presented insidiously, masquerading as benign conditions, but other malignancies would present more obviously. Identifying these red flags early on remains pivotal in swiftly diagnosing and managing malignancies, ensuring improved patient outcomes. CONCLUSION: Recognition of malabsorption and weight loss symptoms as easily identifiable risk factors for malignancies can lead to crucial diagnosis and early treatment.

Volume

39

First Page

S306

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