2778 A Cytomegalovirus Masquerade

Abstract

INTRODUCTION: Plasmablastic lymphoma (PBL) is a very rare but highly aggressive lymphoma seen in HIV patients. It is typically seen in the oral cavity and extraoral involvement is even rarer. We present a unique case of gastric plasmablastic lymphoma initially thought to be cytomegalovirus (CMV) gastritis. CASE DESCRIPTION/METHODS: A 30-year-old HIV positive female presented with epigastric pain. She had an esophagogastroduodenoscopy (EGD) that showed non-bleeding erosive gastropathy 6 weeks before presentation. Biopsy showed CMV gastritis. She was given valganciclovir. Repeat EGD 4 weeks later showed a cardia ulcer with an adherent clot and oozing that was treated with epinephrine. She was given a proton pump inhibitor and valganciclovir. Her pain worsened after discharge despite treatment leading her to present to our facility. She was tachycardic and tender to palpation of the abdomen. Labs revealed CD4 246, viral load of 2760 and platelets of 1.1 million. A CT scan showed diffuse gastric thickening up to 2 cm (Figure 1.) EGD revealed an edematous, friable and oozing mucosa with scattered Forrest III ulcerations (Figure 2). Gastric biopsies were consistent with plasmablastic lymphoma without H pylori. She had six cycles of chemotherapy with complete response at 6 months. Repeat EGD at 6 months showed erythematous gastropathy (Figure 3.) Biopsies revealed chronic active gastritis with H. pylori and no lymphoma. She completed quadruple therapy for the H. pylori infection. DISCUSSION: PBL is a rare disorder seen in the HIV population, usually involving the oral cavity. EBV is seen in 74% of AIDS-related PBL. There has been no association with CMV or Helicobacter pylori reported in the literature. PBL is associated with an aggressive course and poor survival. Despite good initial response to chemotherapy, relapse rates are as high as 54% within the first year. The endoscopic appearance of gastric lymphoma is nonspecific presenting as tumor lesions, thickened folds, ulcerative, infiltrating, bulky, or as gastritis-like changes. CMV gastritis is typically seen with CD4 count < 50. A high index of suspicion was required to make an alternative diagnosis of PBL in this patient with a CD4 count > 200.