T cell lymphoma—presentation as cecal gangrene

Abstract

Editor, Although the gastrointestinal tract is the most common site of extranodal lymphoma, colorectal lymphomas account for only 15 % to 20 % of these [1]. A 29-year-old man, with no previous comorbid illness, presented with severe lower abdominal pain, fever and vomiting for 2 days. On evaluation, he had signs of peritonitis, hemodynamic shock and lactic acidosis. The differential diagnoses were appendicular perforation, with a lesser possibility of obstructed ileocecal tuberculosis with perforation or enteric fever perforation. X-ray abdomen showed dilated bowel loops and the ultrasound reported thickened bowel loops in the right iliac fossa with moderate free fluid in the peritoneal cavity. In view of his deteriorating general condition, a CT scan abdomen was not done and he underwent an emergency laparotomy. Intraoperatively, we found two large areas of cecal gangrene with imminent perforation. There were few enlarged pericecal lymph nodes but there was no obvious mass lesion. The cecal wall was thickened and edematous. There was approximately 200 mL of serosanguinous fluid in the peritoneal cavity. We performed a right hemicolectomy and ileotransverse anastomosis as there was no fecal contamination. He made an uneventful recovery. The gross specimen (Fig. 1a) showed congested, dusky, outer surface of the cecum and proximal colon with the mucosal surface appearing dark brown, ulcerated, edematous and focally lined by exudate and small nodules, 0.1 cm to 0.5 cm in diameter. Microscopy (Fig. 1b) showed a patchy, focally perivascular infiltrate of medium-sized lymphoid cells with vesicular nuclei accompanied by transmural acute inflammation, edema and patchy foci of necrosis of the cecal wall. Few enlarged pericecal lymph nodes, largest 1.5 cm in diameter, were found. These were replaced by an atypical infiltrate which was positive for CD3, TIA1, CD8 and granzyme B, and focally positive for CD56 and CD30. There were no features of enteropathy. Immunohistochemistry for Epstein-Barr virus latent membrane protein was negative. The final report was high grade peripheral Tcell lymphoma of cytotoxic T/NK cell phenotype of the cecum, with regional lymph nodes. Further investigations included complete blood count, LDH levels in serum, HIV serology, abdominal and chest imaging to look for hepatosplenomegaly, intraabdominal, retroperitoneal or mediastinal lymphadenopathy and bone marrow biopsy. The bone marrow was free of disease. Abdominal and chest imaging did not reveal hepatosplenomegaly or lymphadenopathy elsewhere. Postoperative colonoscopy was not done. Our patient fulfilled the Dawsons criteria needed to identify a primary GI lymphoma [2]: