A 56-year-old man with history of hypertension presented to our clinic for Crohn's disease evaluation. He initially presented to his gastroenterologist with complaints of abdominal cramping and anal discomfort. He had no complaints of fevers, chills, or weight loss. Upon review of his prior history, physical examination and colorectal screening 18 months prior revealed a normal perineum, digital rectal exam, and colonoscopy. His family history is significant for colitis and colon cancer in his mother (both types unknown to our patient). Physical exam at this presentation showed a rubbery textured rectal mass with fistulas on the right buttock. He had no evidence of gross hepatosplenomegaly or adenopathy. MR enterography showed mild hyperenhancement of the rectum without significant rectal wall thickening as well as prominent perirectal and retroperitoneal lymph nodes. This was thought to be mild proctitis without abscess. A repeat colonoscopy was done at which time a polypoid, nonobstructing non-circumferential mass was discovered in the distal rectum. Biopsy showed malignant T-cell lymphoma. Lymphoma of the gastrointestinal tract is the most common type of extranodal lymphoma. However, the etiology remains unclear. Potential risk factors include celiac disease, Helicobacter pylori infection, use of immunosuppressive agents, human immunodeficiency virus, Ebstein Barr virus and inflammatory bowel disease. Colorectal lymphomas are rare and predominantly of B-cell lineage. In our search we found 4 cases reported with primary rectal T-cell lymphoma, the most recent being a primary rectal T-cell lymphoma associated with tubulovillous adenoma. Other reports described rectal T-cell lymphoma in refractory ulcerative colitis, AIDS with Hepatitis C, and at the anastomosis site of adenocarcinoma resection. Common manifestation of colorectal lymphomas are abdominal pain, overt or occult bleeding, diarrhea, intussusception and rarely, bowel obstruction. Our investigation began with a rectal fistula, which is an extremely rare presentation of rectal T-cell lymphoma. This case may help increase awareness of this rare lymphoma and of its even rarer presentations, including rectal fistula.