Gastrointestinal Burkittʼs Lymphoma Initially Presenting as Nephrolithiasis and Appendicitis

Abstract

Primary gastrointestinal (GI) lymphomas account for 1-4% of all GI cancers, typically Non-Hodgin's lymphomas (NHL), and most commonly occur in the stomach, ileocecum, and colorectum. The median age of primary GI lymphoma is 55 and it most commonly occurs in men. Sporadic Burkitt's lymphoma accounts for < 1% of all adult lymphomas and presents with an abdominal mass in 90% of cases. Burkitt's lymphoma rarely presents as an acute abdomen, with 0.015% of cases being primary appendicular lymphomas. These cases are more common in children and young adults. We present a rare case of adult, non-bulky, appendicular, sporadic Burkitt's lymphoma.Figure 1Figure 2A 53-year-old male, with no past medical history presented to the Emergency Department with a complaint of generalized abdominal pain and left sided flank pain. He was diagnosed with nephrolithiasis and appendicitis on CT. Labs revealed severe anemia and thrombocytopenia with a hemoglobin of 7.2 g/dL and a platelet count of 19,000/uL. He underwent an appendectomy and bone marrow biopsy. After surgery, he developed acute renal failure secondary to suspected tumor lysis syndrome, requiring Rasburicase and hemodialysis. Bone marrow biopsy results were consistent with NHL and surgical pathology of the appendix revealed Burkitt's lymphoma. The EBV serology was negative. Staging CT scan did not reveal any evidence of bulky disease or involvement of the GI tract. An endoscopy showed erosive gastritis and nodularity in the duodenal bulb which were significant for high grade Burkitt's lymphoma on pathology. Colon biopsies were unrevealing for lymphoma. He subsequently started chemotherapy with Codox- M. This is a rare case of newly diagnosed sporadic Burkitt's lymphoma presenting as two common diagnoses of acute appendicitis and nephrolithiasis without evidence of lymphadenopathy or bulky disease within the GI tract. The approximate lifetime risk of appendicitis in males is 9% and nephrolithiasis is 1%. Nephrolithiasis can occur with tumor lysis syndrome which is commonly seen in NHL and was present in our patient. Despite lack of evidence of GI tract involvement on imaging, endoscopic findings were significant for malignant disease. In patients with Burkitt's lymphoma, endoscopic evaluation may be a crucial step in determining the extent of disease and guiding management and follow-up. A lack of imaging findings for disease should not preclude endoscopic evaluation in these patients.