Monomorphic Epitheliotropic Intestinal T-Cell Lymphoma: A Rare Cause of Chronic Diarrhea

Abstract

Introduction Chronic diarrhea is a frustrating and sometimes difficult diagnosis for patients and physicians alike. The etiology is vast and variable. Periodically, numerous studies are required to determine a diagnosis. We present a case of voluminous chronic diarrhea with associated weight loss caused by monomorphic epitheliotropic intestinal T-cell lymphoma (MEITL). Case report A 62-year-old African-American male with a history of hypertension, seizures, and schizophrenia was admitted for hypovolemic shock secondary to severe chronic diarrhea. He lost greater than 100lbs in the past year and had multiple hospitalizations. The patient was having 8-10 watery bowel movements daily not associated with food or medication. He had two previous colonoscopies and an upper endoscopy, both of which were negative. Stool culture several months ago was positive for Aeromonas, which was treated with Bactrim and loperamide with clinical improvement. Several months later he presented with the same symptoms. During this admission, he was negative for: C. Diff, fecal culture, fecal WBC, fecal ova and parasites, microsporidium, calprotectin, HIV, celiac panel, VIP, and 24 hour urine 5-HIAA. Computed tomography of the abdomen and pelvis showed distension of the colon and small bowel, which was consistent with chronic diarrhea. While pending lab results, push enteroscopy with jejunal biopsies were pursued, which revealed findings consistent with MEITL. Upon evaluation by oncology, he was determined to have a poor prognosis and was considered an unsuitable candidate for chemotherapy. The patient decided to forgo chemotherapy and pursue comfort care. Discussion/Conclusion Enteropathy associated T-cell lymphoma (EATL) consists of less than 5% of all gastrointestinal lymphomas and less than 1% of all Non-Hodgkin's lymphomas. Formerly, it was classified as Type I (associated with celiac disease) and type II (not associated with celiac disease). Type II has recently been recognized as its own distinct entity and is now referred to as MEITL. On histology, the tumor cells express CD3, CD8, and CD56, but has shown variability in some studies. This is considered a very aggressive form of lymphoma with an associated medial survival of only 7 months. Treatment includes high-dose chemotherapy and autologous stem cell transplantation. Our case revealed that the etiology of chronic diarrhea is indeed extensive and MEITL should be considered on the differential diagnosis.2537_A Figure 1 No Caption available.2537_B Figure 2 No Caption available.2537_C Figure 3 No Caption available.