An Unusual Cause of Rapidly Developing Massive Ascites in Early Stage Hepatitis C Cirrhosis and Celiac Disease

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Introduction: Primary omental/peritoneal carcinomatosis is an unusual presentation of lymphomas. Epidemiologic studies have shown that hepatitis C has a strong association with lymphoproliferative disorders. Celiac disease is also a risk factor for malignancies. While T-cell lymphoma represents 50% of all malignancies in patients with celiac disease, very few cases of B-cell intestinal lymphomas have been reported. We present a rare case of a patient with chronic hepatitis C virus-related cirrhosis and celiac disease who developed B-cell omental/peritoneal lymphomatosis. Case: A 52-year-old Caucasian man with history of celiac disease, chronic hepatitis C (genotype 1B) and cirrhosis (MELD 9) presented with a 1-week history of abdominal distention and pain. He completed 1-year treatment of peg- interferon and ribavirin, with no response. Peripherally enhancing liver masses and a lesion in the liver were detected in an MRI of the abdomen which was performed three months prior to the admission. There was a concern for metastatic disease. Patient did not follow up at that time. He was admitted to Johns Hopkins Hospital. Physical exam revealed anicteric sclera, markedly distended and tense abdomen with ascites. No lymphadenopathy was noted. Colonoscopy revealed erythematous colonic mucosa and superficial ulcers. Biopsies were all normal. Repeated MRI of the abdomen showed increased numbers and sizes of peripherally-enhancing liver masses and omental nodularity, which was suspicious for metastatic disease. Tumor markers such as AFP, CEA and CA 19-9 were normal. Patient underwent exploratory laparotomy. Liver biopsy showed only cirrhotic features. The omental biopsy was consistent with diffuse, large B-cell lymphoma. Immunohistochemical studies were positive for CD45, CD20, CD-10, BCL-6 and BCL-2. Cytokeratin AE1/AE3, CAM5.2, pCEA and S100 and in-situ hybridization study for EBV were negative. He was given a cycle of R-CHOP chemotherapy and discharged. Unfortunately, he was later admitted to a local hospital with massive ascites and neutropenic fever. He eventually died from complications. Discussion: Although there is a link between hepatitis C infection and lymphoid malignancies, an association of B-cell lymphoma with celiac disease is very unusual. In this case, chronic hepatitis C infection might have played a role as a triggering factor for changes in cellular immune system, predisposing lymphoproliferative disorder. In conclusion, omental/peritoneal lymphomatosis can be the cause of rapidly growing ascites and it is vital to keep this entity in the differential diagnosis among HCV patients with ascites presenting with sudden deterioration of otherwise well-compensated disease state.