A 56-year-old woman was referred to our hospital with complaints of chronic diarrhea, weight loss, indigestion and abdominal pain lasting for 11 months. Before admission, the patient visited a private clinic and underwent gastroscopic and colonoscopic examinations. Gastroscopic examination showed small gastric ulcerations on the antrum and colonoscopic examination showed multiple punched-out ulcerations and erosions on the entire colon, including the sigmoid colon to the terminal ileum. Biopsy results were not diagnostic at that time. Under the clinical impression of intestinal tuberculosis, she received 2 months of antituberculosis medication without improvement of symptoms. The follow-up biopsy result of colonoscopic examination showed intestinal lymphoma of T-cell type. The patient was then referred for further evaluation. On admission, the patient looked pale, emaciated and dehydrated. An eleven kg weight loss was noted during the last 6 months (47kg--> 36kg). She denied fever or night sweating except complained of profuse watery diarrhea (5-6/day) and indigestion. She denied aggravation of diarrhea symptoms after wheat ingestion. No improvement of diarrhea was found by withdrawal of wheat intake. There was no palpable lymphadenopathy or hepatosplenomegaly. Diffuse abdominal tenderness on the whole abdomen was noted on abdominal physical examination. Initial laboratory findings were as follows: WBC 8,300/mm3, Hb 10.7 g/dL, Hct 32.6%, platelet 409,000/mm3, urine analysis was normal, stool occult blood was negative, serum total protein 5.2 mg/dL, albumin 2.3 mg/dL, serum LDH 128 IU, calcium 7.9 mg/dL, phosphorous 4.4 mg/dL, ALT/AST 12/13 U, cholesterol 101 mg/dL, BUN 13 mg/dL and creatinine 1.0 mg/dL. Chest X-ray was normal. Gastroscopic examination showed diffuse irregular nodular and depressed lesions on the angle and the lower body and multiple red spots on the antrum, suggesting erosive gastritis. But esophagus and stomach biopsies showed diffuse infiltration of lymphoma cells with epitheliotropic features (Figure 1, 2). Duodenal biopsy also revealed lymphoma cell infiltration, and villous atrophy and blunting were found. Colonoscopic findings were the same as noted previously (Figure 3) and the biopsy showed diffuse infiltration of small to medium-sized lymphoma cells (Figure 4). The infiltrated lymphoma cells were immunostained for UCHL-1 (+), CD 3 (+), MT-1 (+), L-26 (-) and MB-2 (-) (Figure 1.2.4). Small bowel series also showed chronic granulomatous lesions on the cecum and the distal ileum. Abdominal CT scan revealed diffuse wall thickening of the bowels, including the esophagus, the stomach and parts of the small bowel and colonic loop. There was no evidence of involvement of lymphoma on bilateral bone marrow biopsies. Finally, the patient was diagnosed as primary intestinal T-cell lymphoma involving the entire gastrointestinal tract (Ann Arbor Stage IVB) with malabsorption. She was treated with combination chemotherapy including cyclophosphamide, adriamycin, vincristine and prednisone (CHOP). Although after two cycles of chemotherapy the initially observed bowel wall thickening disappeared on follow-up abdominal CT scan and no definitive nodular or ulcerative lesions were noted, on follow-up gastro-and colonoscopic examinations lymphoma cells remained on the biopsy. Despite further treatment with 4 cycles of systemic chemotherapy, only a partial response was achieved.
The patient was readmitted to our hospital with complaints of hematochezia. Colonoscopic examination showed internal hemorrhoid and diffuse hyperemic mucosa and multiple ulcerations were noted throughout the rectum to cecal area, suggesting relapse of lymphoma. After two cycles of salvage chemotherapy with etoposide, dexamethasone, adriamycin and cisplatin (EDAP), the bowel lesions were slightly improved but lymphoma cells were still found, indicating refractory to chemotherapeutic agents, agten then, the patient was treated without a specific treatment except supportive care. Eventually, the patient died of spontaneous bowel perforation.