A diagnostic dilemma in a patient with lymphoma
A 49-year-old man, with no significant co morbidities and no history of smoking or alcohol use, presented with upper abdominal pain and flatulence since 3 months. Upper GI scopy was suggestive of ulceroproliferative lesion in the gastric fundus and body. Lactate dehydrogenase (LDH) was elevated at 501 U/L. Gastric biopsy revealed lymphoma with LCA and CD20 positive. Thus, the patient was diagnosed with diffuse large B cell NHL (NHL – DLBCL) of the stomach stage I-EA. He received three cycles of cyclophosphamide, vincristine, epirubicin, and prednisolone (CEOP) chemotherapy. Following three cycles, upper GI endoscopy revealed an ulcerative lesion involving incisura and distal part of lesser curvature and part of antrum, indicative of progressive disease. He then received four cycles of salvage MINE (mitoxantrone, ifosfamide, and etoposide) following which he achieved complete remission. Patient declined further chemotherapy; therefore, he received consolidation radiation therapy with 45 GY/25# over 5 weeks to stomach and perigastric nodes.\nThe patient presented 2 months later with a 1-week history of malena. Examination was unremarkable. Stool occult blood was positive. Upper GI endoscopy revealed gastritis. Gastric biopsy showed chronic inflammation. Bone marrow aspiration and biopsy was normal. As there was no concrete evidence of recurrent disease, no further systemic therapy was given.\nPatient again presented 3 months later with 15-day history of persistent dull aching epigastric pain. Examination was normal. Abdominopelvic computed tomography (CT) scan showed pyloric wall thickness of 1.1 cm, wall thickening around lesser curvature up to 6 mm, tiny sized perigastric nodes, and enlarged left para-aortic nodes in retroperitoneum as well as mesentery. Upper GI scopy showed mucosal thickening in the distal body and antrum of stomach, extending till pyloric rim, with the differential diagnoses being post-treatment changes or residual disease []. Stomach biopsy showed gastric mucosa with acute and chronic inflammation accompanying S. stercoralis larvae [].\nThe patient was treated with ivermectin 10 mg (200 g/kg) daily on two consecutive days.\nAfter 1 month, the patient became asymptomatic. Follow-up upper GI scopy showed erosions in the distal body and antrum of stomach. Biopsy showed no organisms, parasites, or Helicobacter pylori, with no evidence of lymphoma.\nThe patient currently is disease free and asymptomatic over 2 years after completing treatment.