Primary Gastric Diffuse B Cell Lymphoma in Association with Chronic Hepatitis C

Abstract

Introduction: The association between chronic hepatitis C virus (HCV) infection and diffuse large B-cell lymphoma (DLBCL) is rare, but recent studies have demonstrated a modestly increased risk of DLBCL in HCV infection. We report a rare presentation of DLBCL in the setting of an underlying HCV infection. Case: A 64 year-old male presented with a one day history of epigastric pain associated with meals, hematemesis, dark stools, anorexia and a 20 pound weight loss in two months. He had a history of intravenous drug use but denied alcohol or NSAID use. On physical examination, he appeared cachectic and had right upper quadrant tenderness without rebound, Murphy's sign or palpable organomegaly. Rectal exam confirmed melena. Initial investigations demonstrated normocytic anemia, hemoglobin of 9 mg/dl and no evidence of hepatic synthetic dysfunction. Additionally, viral serology was positive for Anti-HCV antibodies. HBsAg and HIV-Ab were negative. Esophagogastroduodenoscopy revealed bulky, ulcerated masses in the gastric body with no stigmata of active bleeding. Biopsies showed heavy atypical lymphocytic infiltration into the submucosa without evidence of Helicobacter pylori infection. Immunohistochemistry demonstrated atypical lymphocytes positive for CD20 and BCL-6. An abdominal MRI illustrated a gallbladder mass extending into the hepatic parenchyma along with hepatic nodularity and para-aortic lymphadenopathy. A diagnosis of primary gastric DLBCL with gallbladder and hepatic metastasis was made. Discussion: We present a unique presentation of HCV associated DLBCL involving the gall bladder and presenting with hematemesis. HCV has major pathogenetic roles in several extra-hepatic dysplastic conditions. HCV is known to lower the activation threshold of B cells and initiates a multi-step cascade of malignant B cell transformation. Recent evidence suggests association of DLBCL and sero-positivity for HCV. Further, HCV positive patients have higher risk features of DLBCL at presentation; including being older and having more frequent splenic involvement and higher lactate dehydrogenase levels. A small retrospective study has demonstrated that antiviral treatment in HCV-positive non-Hodgkin's lymphoma is associated with a longer disease free survival and hence may reinforce the results of a successful chemotherapy regimen. In conclusion, we present a rare case of primary gastric DLBCL in a patient with HCV. The above observations illustrate the potential association between HCV infection and B-cell lymphoma, as well as provide some future prospects for therapeutic research.