An Unusual Presentation of HCV-Associated Gastric MALT Lymphoma

Abstract

Extranodal marginal zone lymphoma of mucosa associated lymphoid tissue (MALT Lymphoma) is a form of non-Hodgkin's lymphoma(NHL), commonly found in the gastrointestinal tract. The average age of diagnosis is between fifth and seventh decade. MALT Lymphomas are well documented to be associated with chronic inflammation of either autoimmune or infectious etiology. Chronic Helicobacter Pylori (H. Pylori) is associated with approximately 90% of the affected gastric MALT Lymphoma. Treatment of H. Pylori with regimen of antibiotics and PPI associated gastric Maltomas has an approximately 70% cure rate. While there are no current guidelines for management of patient who are H. Pylori negative, recognition and resolution of the underlying inflammatory process is paramount. 34-year-old man with no medical history presented after a syncopal event with tachycardia, hypotension, and black stool on exam. Reported fatigue for several hours preceding the event. Labs were notable for Cr of 1.6, total protein 7.3, albumin 2.5, and Hgb of 3.1. TSH and free T4 were both within normal limits. CT revealed a gastric ulcer 1.2x1.0 cm. Once patient was stabilized, EGD revealed a 4cm non-bleeding necrotic gastric ulcer and a 1cm clean based gastric ulcer. Pathology results read as MALT lymphoma with negative H. Pylori on immunochemistry. Subsequent lab work revealed Hepatitis C viral load of 744,000 IU/ml. Unfortunately, patient left the hospital against medical advice prior to finalized pathology report. A year later he presented again after another syncopal episode. Repeat EGD revealed a 10cm Gastric H. Pylori Negative MALT Lymphoma. The patient left against medical advice again. Gastric MALT lymphomas present with non-specific symptoms including abdominal pain, loss of appetite, and weight loss. Occult blood loss is a reported symptom in less than 20% of cases. In our case, gastric MALT lymphoma is diagnosed on EGD as part evaluation of these non-specific complaints. Given negative histology for H. Pylori from two separate EGDs, gastric MALT lymphoma was likely secondary to chronic HCV.His age, HCV association, negative H.Pylori, and presenting complaint of syncope are all very atypical for gastric MALT Lymphoma. While antibiotics are curative in H. Pylori positive MALT Lymphoma, treatment of active HCV in our patient may not be curative treatment of gastric MALT lymphoma. Additional conventional approaches like surgery, chemotherapy and radiotherapy may be required.2611_A Figure 1. Necrotic Gastric Ulcer2611_B Figure 2. 10cm Gastric MALT Lymphoma