Large B-cell Lymphoma Presenting Research Articles

Diffuse Large B-Cell Lymphoma Presenting as an Unusual Paraneoplastic Neurologic Syndrome Affecting the Central and Peripheral Nervous Systems

A 68-year-old man presented with a two-week history of ascending, symmetric, sensory neuropathy concerning an acute inflammatory demyelinating polyneuropathy that briefly responded to intravenous immunoglobulin (IVIg) therapy. The initial workup was negative for acquired causes. After three months of poor response to standard therapies, he was hospitalized for severe disability, unintentional weight loss, and additional, unexplained neurologic symptoms including cerebellar ataxia, dysarthria, and muscle twitching. Positron emission tomography revealed hypermetabolism isolated to the bone marrow. Bone marrow biopsy confirmed the diagnosis of diffuse large B-cell lymphoma (DLBCL). Due to rapidly worsening performance status, plasmapheresis was initiated prior to treatment with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) chemotherapy. His symptoms initially improved following plasmapheresis and resolved with chemotherapy. One year following treatment, he remains in complete remission. This case describes a unique paraneoplastic neurologic syndrome involving the central and peripheral nervous system that responded well to plasmapheresis and systemic chemotherapy.

Intravascular Large B-cell Lymphoma Presenting as Lumbosacral Radiculopathy (2417)

Intravascular Large B-cell Lymphoma Presenting as Lumbosacral Radiculopathy (2417)

Use of Brentuximab Vedotin in a Non-HIV Patient with Primary Effusion Lymphoma.

Primary effusion lymphoma is a rare entity in non-HIV patients, so there are no clinical trials regarding therapeutic options or management decisions.Targeted therapy with brentuximab vedotin has been used in other CD30 positive malignancies and in HIV-related primary effusion lymphoma with good outcomes.We present the case of a non-HIV patient with primary effusion lymphoma who was successfully treated with brentuximab vedotin, which highlights the potential role of a new therapeutic approach in this subgroup of patients.

Primary spinal extramedullary diffuse large B-cell lymphoma presenting with initial spinal cord compression: a case report

Primary spinal extramedullary diffuse large B-cell lymphoma presenting with initial spinal cord compression: a case report

S2515 A Mysterious Case of a Failing Liver: Diffuse Large B-Cell Lymphoma Presenting as Acute Liver Failure

S2515 A Mysterious Case of a Failing Liver: Diffuse Large B-Cell Lymphoma Presenting as Acute Liver Failure

S2380 Diffuse Large B-Cell Lymphoma Presenting as Acute Liver Failure

S2380 Diffuse Large B-Cell Lymphoma Presenting as Acute Liver Failure

S2887 Diffuse Large B-Cell Lymphoma Presenting as Jejunal Diverticulitis on Imaging

INTRODUCTION: Small bowel tumors comprise of only 5% of all neoplasms in the gastrointestinal tract. The diagnosis of small bowel tumors is often difficult due to the rarity of these lesions and the non-specific and variable presenting signs and symptoms. This can lead to a delay in diagnosis and poor treatment outcome. Frequently, small bowel tumors are diagnosed on imaging and confirmed by endoscopy. We describe a case of jejunal diffuse large B-cell lymphoma which was initially read as jejunal diverticulitis on imaging. CASE DESCRIPTION/METHODS: Our patient is a 60-year-old male with poorly controlled diabetes, hypertension, hyperlipidemia, and COPD who presented with abdominal pain, nausea, and vomiting. Abdominal pain was dull in nature, located around the umbilical area, and had been going on for about a month. He had made multiple emergency department visits for similar symptoms in the prior weeks. Also, he lost about 20 pounds of weight and had decreased appetite over the last 3 months. CT scan of the abdomen showed inflammatory changes surrounding the proximal jejunum (Image 1) characterized as jejunal diverticulitis. He was given antibiotics without any improvement in symptoms. Eventually, a push enteroscopy was performed which showed a partially obstructing mass just distal to the duodenojejunal junction (Image 2). Tattoos were placed proximally and distally for marking. Biopsy was diagnostic of diffuse large B-cell lymphoma. PET scan was performed which showed localized disease with adjacent lymph node involvement. Patient underwent surgical resection of the tumor due to concern of bowel perforation followed by chemotherapy. DISCUSSION: Tumors in the small bowel are exceedingly rare and can easily be overlooked as their presenting symptoms are bizarre and non-specific. The most common symptoms are pain, obstruction, and bleeding while perforation can rarely occur as well. Abdominal imaging is usually the first line modality to figure out the etiology of these symptoms. Imaging usually shows some abnormalities in these cases but is not confirmatory and at times may lead to other diagnoses as was the case in our patient. Patient’s history should be considered when figuring out the diagnosis in these cases. If there are any alarming symptoms such as weight loss, decreased appetite, or no improvement after initial treatment then there should be a high index of suspicion for small bowel tumors and endoscopy should be performed as early detection is the most important prognostic factor in these cases.Figure 1.: Inflammatory changes around the jejunal area read as jejunal diverticulitis.Figure 2.: Partially obstructing mass seen on enteroscopy distal to duodenojejunal junction.

Primary Pancreatic Large B-Cell Lymphoma Presenting as Acute Pancreatitis

Primary pancreatic lymphoma (PPL) is an extremely rare form of extranodal malignant lymphoma. The most common histological subtype of PPL is diffuse large B-cell lymphoma (DLBCL). Clinical and imaging features of PPL may often overlap with pancreatic adenocarcinoma. Therefore, it is very important to obtain a preoperative cytohistology diagnosis of pancreatic tumors to avoid unnecessary surgeries in cases with a diagnosis of PPL.Herein, we report a 71-year-old male who was admitted to our hospital with a diagnosis of acute pancreatitis after he presented with complaints of nausea, vomiting, and epigastric abdominal pain. MRI of the abdomen revealed a pancreatic head mass, and histopathology and immunohistochemical assessment of the pancreatic lesion established the diagnosis of DLBCL. The patient achieved remission after six cycles of rituximab-cyclophosphamide, doxorubicin (hydroxydaunomycin), vincristine (oncovin), prednisolone (R-CHOP) chemotherapy.

Large B-cell lymphoma presenting primarily in bone marrow is frequently associated with haemophagocytic lymphohistiocytosis and has distinct cytogenetic features

The criteria for primary bone marrow large B-cell lymphoma (PBMLBCL) have not yet been clearly established. We aimed to investigate the clinicopathological features of PBMLBCLs (27 cases) and large B-cell lymphomas (LBCLs) with secondary marrow involvement (55 cases). PBMLBCL was defined as LBCLs presenting initially in bone marrow without lymphadenopathy, extramedullary tumour or localised bone tumour, and no evidence of transformation from low grade B-cell lymphoma. Compared with the patients in the secondary group, more patients in the primary group had haemophagocytic lymphohistiocytosis, cytogenetic aberrations, cytopenias, and atypical lymphocytes in peripheral blood. The most common chromosome abnormality in both groups was 6q deletion. The primary group had additional chromosome 10, 2, and 3 abnormalities. The acquired chromosome 10 aberration was associated with the risk of haemophagocytic lymphohistiocytosis. The 1-year survival rate was lower in the primary group than in the secondary group; however, the difference was not significant when the cases without chemotherapy plus rituximab were excluded. Moreover, multivariate analysis revealed that relatively high white blood cell count, not receiving chemotherapy plus rituximab, and cytogenetic aberrations were poor prognostic factors in the secondary group, but only not receiving chemotherapy plus rituximab was retained in the primary group. In conclusion, PBMLBCL is genetically and clinically distinct. Although patients with PBMLBCL generally have a poor outcome, the disease is treatable and some patients become long-term survivors.

A Huge Retroperitoneal Large B-Cell Lymphoma Presenting as Chronic Small Bowel Obstruction: A Case Report

A Huge Retroperitoneal Large B-Cell Lymphoma Presenting as Chronic Small Bowel Obstruction: A Case Report

RARE COMPLICATION OF A RARE DISEASE

SESSION TITLE: Pulmonary Pathology II SESSION TYPE: Med Student/Res Case Report PRESENTED ON: 10/21/2019 3:15 PM - 4:15 PM INTRODUCTION: Primary pulmonary lymphoma (PPL) comprises of only 1% of pulmonary malignancies and has been described with systemic autoimmune diseases. It may be associated with a fatal disease known as intravascular lymphoma which is extremely rare and can lead to a diagnostic dilemma. CASE PRESENTATION: 58 year old female with history of Sjögren’s syndrome presented to the pulmonology clinic with complaints of shortness of breath cough and low grade fever for 2 weeks. She was vitally stable with bronchial breath sounds at the right lower lung zone. Chest X-ray showed right middle lobe collapse. The CT scan chest after 2 weeks of conservative treatment showed soft tissue density in the bronchus intermedius (BI). Bronchoscopy revealed pinkish lesion in BI. The histopathology showed high grade B cell Non-Hodgkin's lymphoma. The patient was started on chemotherapy with R-CHOP (rituximab, cyclophosphamide, doxorubicin and prednisolone). After third cycle of chemotherapy she was admitted with fever and bodyaches. She became increasingly somnolent and dropped her GCS requiring intubation. The MRI brain showed diffusely scattered foci of signal dropout on SWI throughout the brain, predominantly in the corpus callosum and diffuse multifocal areas of diffusion restriction in periventricular and subcortical white matter. Lumbar puncture and EEG were negative. Brain biopsy was not attempted considering her clinical instability. She was treated with pulse steroids leading to improvement in GCS. A follow up MRI after pulse therapy showed interval improvement of the brain lesions. DISCUSSION: We believe that our case describes the presentation of a malignancy which progressed to develop a rare complication known as Intravascular lymphoma (IVL); it is a subtype of extranodal large B-cell lymphoma which spreads in angiotropic pattern to virtually any organ of the body, brain and skin being the most common sites. The gold standard of diagnosis is histological evidence of intravascular invasion but studies are being reported to identify noninvasive modalities of diagnosis of IVL (1). Recent literature reports various neuroimaging findings of IVL like multiple foci of high signal intensity in the deep white matter, infarct like changes and intracranial mass (2). Treatment of IVL is based on the RCHOP regimen, however prognosis is poor (3). The responsiveness to steroid therapy supports the diagnosis of IVL. CONCLUSIONS: A high index of suspicion is required to diagnose IVL in patients with Non-Hodgkins who present with neurological symptoms. An emerging evidence supports the use of neuroimaging in diagnosis of IVL in patients without tissue diagnosis. Reference #1: Shimada K, Kinoshita T, Naoe T, Nakamura S. Presentation and management of intravascular large B-cell lymphoma. The lancet oncology. 2009 Sep 1;10(9):895-902 Reference #2: Yamamoto A, Kikuchi Y, Homma K, O'uchi T, Furui S. Characteristics of intravascular large B-cell lymphoma on cerebral MR imaging. American Journal of Neuroradiology. 2012 Feb 1;33(2):292-6 Reference #3: Baehring JM, Longtine J, Hochberg FH. A new approach to the diagnosis and treatment of intravascular lymphoma. Journal of neuro-oncology. 2003 Feb 1;61(3):237-48 DISCLOSURES: no disclosure on file for Arsalan Ahmad; No relevant relationships by Hasaan Omar, source=Web Response No relevant relationships by Aqusa Zahid, source=Web Response No relevant relationships by Ali Zubairi, source=Web Response

1415 A Rare Presentation of Diffuse Large B-Cell Lymphoma as a Pancreatic Mass

INTRODUCTION: Diffuse Large B-Cell Lymphoma (DLBCL) of Pancreas is a fast-growing Non-Hodgkin lymphoma (NHL), which accounts for only 0.5% of all pancreatic tumors. In most cases, it presents as a single, metastatic mass or diffuse nodules in the pancreas. DLBCL should be considered in patients with a pancreatic mass, especially if: personal history of lymphoma, presence of an immunodeficiency syndrome, or prior infection with EBV. CASE DESCRIPTION/METHODS: A 60-year-old type II diabetic male presented to the ED with nausea, vomiting, diarrhea and 40 lb weight loss. Patient's mother had known pancreatic adenocarcinoma. Social history revealed multiple sexual partners of both sexes. On exam patient had epigastric tenderness, and a 1 cm non-tender supraclavicular lymph node. A CT abdomen/pelvis with contrast revealed a 4.8 × 7.5 × 4 cm mass in the head of the pancreas and retroperitoneal metastatic adenopathy. Endoscopic ultrasound characterized a “U” shaped parenchymal mass extending from the head to the tail of the pancreas encircling the splenic artery. Fine needle aspiration and biopsy both revealed DLBCL. Bone marrow biopsy and imaging studies were unremarkable, therefore the pancreas was determined to be the primary site. Additional testing found the patient to be HIV positive with a CD4 count of 119 and thus diagnosed with AIDS. He was started on antiretroviral therapy prior to initiation of R-CHOP (Rituximab, Cyclophosphamide, Doxorubicin, Vincristine and Prednisone). Following his first chemotherapy dose, he was readmitted to the hospital with fever and weakness. Patient continued to decompensate and expired 23 days from his initial diagnosis. DISCUSSION: Most common sites of extranodal involvement of NHL are the gastrointestinal tract, liver, lung, bone marrow, and the central nervous system. DLBCL can present with extra-nodal involvement in about 50% of cases, but only 0.2-2% involve the pancreas. Clinically, most cases of Primary Pancreatic Lymphoma (PPL) are misdiagnosed as pancreatic adenocarcinoma. PPL generally carries a better prognosis once treatment is initiated in an immunocompetent individual. In this rare case, the patient was concurrently diagnosed with AIDS and Stage IV DLBCL of the pancreas. This case highlights an unusual presentation of a primary pancreatic malignancy that typically presents as a metastatic lesion. Furthermore, this case shows the utility of endoscopic ultrasound to better identify and characterize pancreatic masses when compared to other diagnostic modalities.

2350 An Unlikely Presentation of Diffuse Large B-Cell Lymphoma Manifesting as Hepatic Failure

INTRODUCTION: Primary Hepatic Lymphoma (PHL) is a very rare subtype of Diffuse Large B-Cell Lymphoma (DLBCL), accounting for less than 1% of all cases. In rare instances, a patient can present with fulminant hepatic failure. The prognosis is grim with an average survival of 10.7 days from admission. The mainstay of diagnosis is liver biopsy, which must be performed as early as possible to prevent progression to acute liver failure. CASE DESCRIPTION/METHODS: A 55-year-old male with no pertinent medical history presented with a two week history of abdominal pain, fever, lethargy and mild jaundice. He was a former smoker and drinker who denied any alcohol use for the past 15 years. Upon presentation, the patient’s labs showed acute liver injury, anemia, thrombocytopenia and acute kidney injury. The patient’s model for end-stage liver disease (MELD) was 29. He was subsequently admitted to the medical intensive care unit (ICU) where emergent liver transplant evaluation was initiated. A full work up for the etiology of his liver failure was initially unrevealing so a liver biopsy was performed, which came back positive for DLBCL. The patient was then started on a chemotherapeutic regimen consisting of cyclophosphamide, vincristine, etoposide and high dose steroids. The patient’s condition further deteriorated during his ICU stay, leading to the need for mechanical ventilation, vasopressor therapy for circulatory shock, continuous renal replacement therapy for worsening renal failure and transfusion of blood products for worsening coagulopathy. Despite all of these aggressive measures, the patient’s clinical status only continued to worsen. The family decided to institute comfort measures and the patient died on ICU day 12. DISCUSSION: DLBCL predominantly affects Caucasian men over the age of 50. Some viruses, specifically EBV, HBV and HCV, have shown correlation with Non-Hodgkin Lymphoma (NHL); our patient had serologies indicative of past exposure to EBV and HBV. The only way to definitively diagnose DLBCL is via liver biopsy with immunohistochemical staining that reveals CD20, CD45 and BCL-6. The prevailing treatment modality is the use of Dose Adjusted Etoposide, Prednisone, Oncovin, Cyclophosphamide, Hydorxydauorubicin and Rituximab (DA-EPOCH R) Therapy. Due to its poor prognosis, early diagnosis and initiation of treatment for PHL is crucial. For this reason, it must be considered early in the differential when evaluating a patient with acute liver failure.

2642 Diffuse Large B-Cell Lymphoma Presenting as Partial Small Bowel Obstruction and a Fistula

INTRODUCTION: Non-Hodgkin lymphoma (NHL) is one of the most common cancers in the United States, accounting for 4% of all cancers. Diffuse Large B-Cell Lymphoma (DLBCL) the most common type of NHL. Gastrointestinal (GI) tract is a significant site of extranodal NHL and accounts for 30%–40% of all extranodal NHL. Out of this, 44 % are due to DLBCL. Ileocecal DLBCL accounts for 9.7% to 15% of total GI DLBCL. They lack specific symptoms and diagnosed when complications occur. We report a case of elderly male hospitalized for partial small bowel obstruction and a possible fistula due to DLBCL involving the ileocecal valve extending to the ileum. CASE DESCRIPTION/METHODS: A 75-year-old male presented with complaints of abdominal pain, nausea, and nonbilious vomiting for a day. He denied any fever, chills, sick contact, night sweat, or weight loss. On physical exam, he had moderate lower abdomen tenderness without palpable masses. CT scan of the abdomen and pelvis showed partial small bowel obstruction with a transition point at an ileocecal junction with amorphous soft tissue at the level of the terminal ileum and possible stricture or neoplastic involvement (Figure 1). Three days later, he had a colonoscopy which showed a large mass behind the ileocecal valve with a fistula (Figures 2 and 3). We were unable to intubate the ileocecal valve. Multiple biopsied taken from the mass that confirmed the diagnosis of DLBCL. PET scan showed cecal mass without any distal involvement. As recommended by surgery and oncology consultations, he had right hemicolectomy. DISCUSSION: Ileocecal region is a rare place for DLBCL occurrence. Majority of the cases are diagnosed incidentally or when complication like obstruction, perforation, or bleeding occurs like our patient who had bowel obstruction on presentation. We also found a fistula in cecum during colonoscopy. Clinically we suspect fistula as the patient was able to tolerate diet and complete bowel preparation easily in spite of having complete closure of ileocecal valve on colonoscopy. Due to the lack of oral contrast, it was not identified on the initial CT scan. Endoscopic features of DLBCL are nondiagnostic. The only way to confirm a diagnosis is, immunohistopathology staining specific for DLBCL. Majority of ileocecal DLBCL are at stage I or II diseases at the time of diagnosis. Surgical resection followed by chemotherapy had shown prolongation of survival. In conclusion, ileocecal DLBCL should be considered as a differential diagnosis for bowel obstruction or fistula.

2376 Diffuse Large B-Cell Lymphoma Presenting With Typical Features of HCC on Liver Imaging: A Diagnostic Conundrum

INTRODUCTION: Hepatocellular carcinoma (HCC) is the most common primary liver malignancy. HCC can be solely diagnosed on cross-sectional imaging (CT or MRI) if a lesion meets the diagnostic criteria according to the Liver Imaging Reporting and Data System (LI-RADS), which has above 90% specificity. HCC commonly metastasizes to lungs, regional lymph nodes, kidney, bone marrow and adrenals but metastases to the spleen are rare. We present a case of liver masses with typical HCC characteristics on liver MRI which was ultimately proven to be diffuse large B-cell lymphoma (DLBCL) on liver biopsy. CASE DESCRIPTION/METHODS: 38-year-old Vietnamese male with no past medical history was admitted with significant weight loss, fatigue and abdominal discomfort. He did not have a history of high risk behaviors or recent foreign travel. Physical exam revealed hepatomegaly. On labs, CBC was normal, T-bili 0.7, Alk Phos 147, AST 89, ALT 50, Albumin 3 g/dL, INR 1.1, creatinine 0.7. HBV serology was positive for HBsAg, anti-HBc and anti-HBe and was negative for HBeAg. HBV DNA was 497 IU/ml. HIV, HCV and HDV serology were negative. CT abdomen showed numerous liver lesions, largest of which was 10.4 cm and a single 8.1 cm splenic lesion. MRI showed several large, rounded and well-circumscribed liver lesions demonstrating arterial hyperenhancement, washout and pseudocapsule consistent with diagnosis of HCC (LI-RADS 5). MRI confirmed a single lesion on spleen (Figure 1), suspicious for metastasis. Tumor markers (AFP, CEA, CA 19-9) were within normal range. Lactate dehydrogenase (LDH) was 1200. Given elevated LDH and a spleen lesion, liver biopsy was done which showed high grade DLBCL (Figure 2). Systemic staging tests did not reveal any other tumor sites. Patient was started on tenofovir and chemotherapy with excellent response (Figure 3). DISCUSSION: Liver biopsy is rarely required to diagnose HCC if certain diagnostic criteria are met on cross sectional imaging, even without significantly elevated AFP. Extranodal lymphoma with liver and spleen involvement can present with lab and imaging abnormalities which can mimic HCC, as in our case. Markedly elevated LDH and spleen lesion raised suspicion for a different diagnosis. Undiagnosed or untreated advanced DLBCL can limit survival to a few months while hepatic involvement can also cause liver failure. In conclusion, a biopsy should be considered for liver lesions diagnosed as HCC on cross sectional imaging when atypical features, in our case elevated LDH and spleen lesion, are present.

A case of CD5-positive diffuse large B-cell lymphoma (DLBCL) presenting with the swelling of the mandibular gingiva as an initial symptom

A case of CD5-positive diffuse large B-cell lymphoma (DLBCL) presenting with the swelling of the mandibular gingiva as an initial symptom

MON-420 Diffuse Large B-Cell Lymphoma Presenting as Hypernatremia Secondary to Adipsic Central Diabetes Insipidus

Background: Central diabetes insipidus is usually characterized by polyuria and polydipsia secondary to deficiency in anti-diuretic hormone. In some cases, patients can have hypothalamic or thalamic involvement leading to an impaired thirst mechanism. Here we present a case of a primary central nervous system (CNS) diffuse large B-cell lymphoma which presented as hypernatremia secondary to adipsic central diabetes insipidus. Clinical Case: A 53-year-old female presented to the hospital with confusion and lethargy. Family noted increased urinary frequency. She had been hospitalized at a different facility three times prior for hypernatremia. On admission, she was found to have sodium elevated to 160 mmol/L (135-145). Urine studies were notable for initial urine osmolality 360 with repeat low-normal at 144 mOsm/kg (50-1400), random urine sodium 36 mmol/L, and urine specific gravity <1.005 (1.005-1.03). Further workup included hemoglobin A1C 6.5% (4-6), serum osmolality range 282-311 mOsm/kg (280-300), and normal TSH and free T4. ADH drawn when sodium was 150 mmol/L was undetectable. ACTH stimulation test was normal at 22.6 ug/dL (>18). Free water deficit was calculated at 8 liters. MRI brain showed a 4.1 x 3.5 x 2 cm mass in the right posterior pons extending to the right cerebral peduncle and thalamus with mass effect on the third ventricle. She was hydrated with intravenous D5W then with ½ normal saline. Her urine output was 3.5-5 liters/day. She was given 1 mcg/mL DDAVP injection with urine osmolality increasing from 145 mOsm/kg to 280 mOsm/kg with a greater than 50% increase consistent with central diabetes insipidus. She was started on oral DDAVP prior to discharge with improvement in mental status. She underwent stereotactic brain biopsy with pathology demonstrating primary diffuse large B-cell lymphoma. CT chest/abdomen/pelvis was negative for primary disease and bone marrow biopsy showed no evidence of lymphoma. She was started on chemotherapy with rituximab, methotrexate, procarbazine, and vincristine with CT brain two weeks later showing rapid decrease in the size of the thalamic and midbrain mass. Conclusions: Although pituitary involvement in lymphomas is rare, there are a few cases in the literature describing posterior pituitary involvement in the setting of a primary CNS lymphoma which should be considered in new-onset, non-traumatic central diabetes insipidus. In patients with impaired thirst mechanism, evaluation of the hypothalamus and thalamus should be pursued.

Diffuse large B-cell lymphoma presenting with masses in the pineal and adrenal glands.

Key Clinical MessageMagnetic resonance imaging (MRI) may offer several potential advantages in the evaluation of lymphoma with the additive value of H1‐MRS for differential diagnosis. Even though lymphoma has unique imaging findings on CT and multiparametric MRI, definite diagnosis must be thoroughly established by histopathological examination.

Diffuse large B-cell lymphoma presenting with gastrocolic fistula and successfully treated with R-CHOP chemotherapy

Diffuse large B-cell lymphoma presenting with gastrocolic fistula and successfully treated with R-CHOP chemotherapy

Massive Splenomegaly as Initial Presentation of Diffuse Large B-Cell Lymphoma

Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin's lymphoma in western countries and is characterized by aggressive clinical behavior. Primary splenic DLBCL is an extremely rare clinical condition. We present a case of successfully treated HCV who presented with acute abdominal pain and was found to have massive splenmogaly secondary to DLBCL. A 65-y.o. female presented with 1-week history of marked sharp left upper quadrant, non-radiating abdominal pain. She had poor appetite, nausea and 3 episodes of coffee-ground emesis over one day. She denied fever and review of systems was otherwise negative. Her history is significant for recently treated hepatitis C with sofosbuvir/velpatasvir a few months prior to this presentation. Physical exam was only positive for tender splenomegaly. CT abdomen showed massive splenomegaly with multiple new splenic infarcts (image 1). She was noted to have a 3-gram drop in hemoglobin in one month, so EGD was done (image 2,3). Her HCV RNA was undetectable by PCR. BCR/ABL and JAK2 mutations, as well as EBV and CMV serology were all negative. Peripheral blood showed mature B-cells. Lymph node biopsy and bone marrow biopsy were diagnostic for DLBCL. Patient was started on chemotherapy with RCHOP regimen with good response. Tumors of the spleen are rare and are classified into benign and malignant. Primary malignancies are extremely rare, with lymphoma being the most common splenic malignancy. Splenic lymphomas are heterogeneous. They may be primary, arising from the spleen, or secondary, involving the spleen as part of systemic dissemination of a lymphoma that arises elsewhere. As a general rule, isolated presentation with splenomegaly is more common in indolent lymphoma than in aggressive lymphoma. The association between hepatitis C virus (HCV) infection and malignant lymphoma is well documented. For patients with hepatitis C, who subsequently develop splenomegaly, it is important for clinicians to be suspicious for splenic DLBCL and not blame HCV as the only cause of splenomegaly especially if it develops after treating HCV. This case is unique as it presents a very rare initial presentation of DLBCL, which is splenomegaly due to splenic involvement without having any other symptoms or signs of systemic involvement. Physicians should be made aware of this rare presentation to avoid delay in diagnosis that can adversely affect patient morbidity and mortality.1925_A Figure 1. CT abdomen shows massive splenomegaly, with multiple infarcts1925_B Figure 2. EGD shows gastric polyp1925_C Figure 3. EGD shows non-bleeding angioectasia