Rectal Bleeding in a 47-Year-Old Farmer Who Can't Pass Flatus

Sarah El-Nakeep, MD

Disclosures

September 12, 2022

The patient had generalized lymph node enlargement, including the para-aortic and mesenteric lymph nodes. Lymph node biopsy was taken from the cervical lymph nodes because of their accessibility and large size. The biopsy revealed a lymphomatous process.

Gastrointestinal lymphoma causes only 5% of gut malignancy. In general, inflammatory bowel diseases increase the risk of developing lymphoproliferative disorders. Epstein-Barr virus infection in immunosuppressed patients with inflammatory bowel disease can heighten this risk.[16] Immunosuppressive agents such as azathioprine and 6-mercaptopurine, although they are effective and have been used since the 1960s for maintenance of remission, are associated with a high rate of lymphoproliferative transformation.[17]

In the patient in this case, Hodgkin B-cell lymphoma with CD20 predominance was finally diagnosed through immunophenotyping and bone marrow trephine biopsy. Chemotherapy was planned using cycles of R-CHOP (anti-CD20 rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone). After the complete resolution of the patient's infection and three negative blood cultures, treatment was started. Chemotherapy was given in eight cycles 3 weeks apart.

The size of the patient's lymph nodes and splenic focal lesions decreased with chemotherapy, and he entered remission. Within 5 months, all signs of lymphoma disappeared. During chemotherapy, the ulcerative colitis regressed, and the patient later received maintenance therapy with methotrexate and oral mesalamine.

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