Intestinal T-cell lymphoma presenting as colonic perforation in the setting of ulcerative colitis: a case report
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CASE REPORT
Intestinal T‑cell lymphoma presenting as colonic perforation in the setting of ulcerative colitis: a case report Ali Phillip Mourad1 · Marie Shella De Robles1 · Robert Duncan Winn1 Received: 20 July 2020 / Accepted: 19 October 2020 © Japanese Society of Gastroenterology 2020
Abstract The intestinal T-cell lymphomas are a rare group of lymphatic malignancies arising from the gastrointestinal tract. They frequently manifest with non-specific clinical and radiographic findings that may mimic several other disease processes. The most common subtype is linked with refractory coeliac disease and commonly affects the small intestine. We report a case where the diagnosis was uncovered endoscopically in a patient presenting with colonic perforation on a background of long-standing ulcerative colitis. Surgical source control was required prior to considering chemotherapy, which is the usual treatment option in lymphatic malignancies. The case highlights the importance endoscopic evaluation in inflammatory conditions of the colon. Keywords T-cell lymphoma · Intestinal neoplasms · Enteropathy-associated T-cell lymphoma · Intestinal perforation · Ulcerative colitis
Introduction
Case report
The intestinal T-cell lymphomas are an extremely rare group of extra-nodal lymphatic malignancies arising from the gastrointestinal (GI) tract. Together, they represent less than 10% of all T-cell lymphomas with the majority based in the small intestine [1]. The WHO has recognised two major subtypes: Enteropathy-associated T-cell lymphoma (EATL) and monomorphic epitheliotropic intestinal T-cell lymphoma (MEITL); the former of which is closely linked with coeliac disease. Those that do not meet the necessary immunohistochemical criteria are then classified into the group known as intestinal T-cell lymphoma Not Otherwise Specified (NOS) [2]. Unfortunately, the initial lack of specific clinical features coupled with the aggressive nature of this condition has meant that prognosis remains poor, with a median overall survival of 10 months from the time of diagnosis [3]. In this report, we present a case where the diagnosis was uncovered following perforation of the sigmoid colon in a patient referred to our unit.
A gentleman in his early 60s presented to his gastroenterologist with a 6-month history of fatigue, 5 kg of unexplained weight loss, diarrhoea and progressive lower abdominal pain. This is on a background of a 15-year history of ulcerative colitis (UC) well controlled with azathioprine 200 mg daily and mesalazine 1000 mg twice daily. There was no recent history of UC flares requiring corticosteroids or biological agents. Initial abdominal examination revealed tenderness in the left lower abdomen along with a palpable mass. CT abdomen was performed demonstrating an 18-mm thickened rectosigmoid alongside a small mesenteric abscess (Fig. 1a). He was referred to our inpatient unit for surgical opinion—there was radiological evidence of a contained perforation without evidence of active colitis elsewhere. The aetiology a
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