S2516 Rare Cause of Diarrhea in a Liver Transplant Recipient

Abstract

INTRODUCTION: We present a case of a 63-year-old male who underwent a liver transplant that was found to have diffuse mantle cell lymphoma (MCL) after work-up for diarrhea. CASE DESCRIPTION/METHODS: A 63-year old orthotopic liver transplant (OLT) patient with a past medical history of Hepatitis C cirrhosis complicated by hepatocellular carcinoma pre-transplant presented to the clinic with progressive non-bloody diarrhea and weight loss of 15 pounds. The patient denied night sweats and fatigue. There were no concerning findings on abdominal exam. Abdominal Magnetic Resonance Imaging was completed 3 months before he visited our clinic for abnormal liver function tests and showed stable prominent mesenteric lymph nodes. Colonoscopy showed mild erythema in the rectum and sigmoid colon up to 30 cm proximal to the anal verge (Figure 1). Biopsies were taken from the duodenum, right colon, and left colon. Histologic sections of colonic mucosa revealed prominent infiltrate of small atypical lymphocytes that have round to irregular nuclei, mature chromatin, and scant to moderate clear cytoplasm (Figure 2). The biopsies were suspicious for lymphoma, which prompted a bone marrow biopsy. Pathology revealed 10% of the marrow was mantle cell; Fluorescence In Situ Hybridization revealed 11 ;14 translocations. The patient was later diagnosed with stage 4 MCL with diffuse gastrointestinal involvement; all biopsies tested positive for MCL. DISCUSSION: Often MCL presents in men in their 60's with lymphadenopathy, blood and bone marrow involvement, and splenomegaly. Our patient’s lack of classic symptoms made the diagnosis of MCL quite challenging. To our knowledge, MCL is a rare cause of diarrhea in a post-OLT patient. It is plausible that his atypical presentation may be related to partial masking of symptoms related to immunosuppression. Post-transplant patients are at an increased risk for Hodgkin's Lymphoma in the setting of immunosuppression. However, an increased risk of MCL has not been shown as a complication of immunosuppression. The challenge in this patient is balancing his chemotherapeutic and anti-rejection medications. Cyclosporine was continued with the addition of Ibrutinib. While Ibrutinib has shown promising results in patients with MCL, there have been cases reporting hepatotoxic reactions. Thus far, our patient has not had any drug-induced liver injury from Ibrutinib. In conclusion, it is important to maintain MCL along with a broad differential when working up diarrhea in post-transplant patients.Figure 1Figure 2