Title : Hidden within the blood: A case report on hematemesis from gastric ulcers as an atypical presentation of diffuse large B-Cell lymphoma
Abstract:
Background: Diffuse large B cell lymphoma (DLBCL) is the most prevalent subtype of Non Hodgkin Lymphoma (NHL), comprising around 25% of all NHLs.1 DLBCL typically presents with symptoms of nodal involvement but can have other various manifestations. Gastric DLBCL is uncommon, with an incidence of 7/100,000 and usually presents with epigastric pain, nausea, vomiting and unexplained weight loss, but it rarely presents as hematemesis. To our knowledge, there are only three other cases in English literature documenting upper gastrointestinal bleed as the initial presentation of DLBCL.
Case Presentation: This is a case of a 62-year-old female who came in due to hematemesis. Patient is hypertensive and diabetic with no significant family history. She was initially managed as a case of upper gastrointestinal bleeding probably secondary to bleeding peptic ulcer disease. Esophagogastroduodenoscopy revealed a wide-based ulcer with heaped-up regular borders and nonbleeding visible vessel at the center of the fundus and clean-based ulcers with heaped up regular borders at the proximal lesser curvature. There were no tortuous vessels seen in the esophagus. Samples were sent for histopathology revealing atypical lymphoid proliferation. Immunohistochemical staining were done which revealed to be positive for CD20, with 80-90% expression of BCL2 and ki-67 supporting the diagnosis of DLBCL. Patient was then started on chemotherapy with the R-CHOP regimen (Rituximab plus cyclophosphamide, vincristine, doxorubicin, and prednisone) and is now in complete remission.
Conclusion: This case emphasizes a rare presentation of DLBCL as upper gastrointestinal bleed without the typical manifestations of fever, weight loss, night sweats and lymphadenopathies. A high index of suspicion and knowledge of atypical presentation of DLBCL, such as in our case, may lead to early diagnosis and management, improving prognosis and patient outcomes.
