European Review for Medical and Pharmacological Sciences 2016; 20: 1707-1711 Ascites as the initial characteristic manifestation in a patient with primary gastric CD8-positive diffuse large B-cell lymphoma K.-X. ZHAO1, G.-Z. DAI1, J.-F. ZHU2 1Department of Gastroenterology, Wuxi Traditional Chinese Medicine Hospital, Jiangsu, China 2Department of Gastroenterology, Wuxi Traditional Chinese Medicine Hospital, Jiangsu, China Abstract. – CASE PRESENTATION: Diffuse Introduction large B-cell lymphoma (DLBCL) is the most com- mon lymphoid malignancy and the most common type of non-Hodgkin’s lymphomas, the stomach Gastric lymphoma accounts for 3%-5% of all is the most common extranodal site. Gastric DL- malignant tumors of the stomach1, which inclu- BCL is often characterized by epigastric pain and des primary tumor and disseminated lymphoma. vomiting. We report a case of a 78-year-old female Approximately 10% of non-Hodgkin’s lympho- patient with gastric diffuse large B-cell lympho- mas involve the gastrointestinal tract at the time ma (DLBCL) with high CD8 level which was initial- 2 ly manifested with ascites of unknown origin. The of initial evaluation . Primary gastrointestinal patient was admitted with a chief complaint of ab- lymphomas account for one-fourth of malignant dominal distension and scanty urine over the last lymphomas: the stomach and the small bowel are twenty days, while without anorexia and fatigue the most frequently involved sites. Gastric diffu- until 15 March. She had no history of viral hepati- se large B-cell lymphoma (DLBCL) is the most tis, tuberculosis, schistosomiasis. commonly high malignant type in primary ga- RESULTS: Laboratory data revealed normal aminotransferases and bilirubin levels, but se- stric lymphoma, yet the etiology for most cases of rum lactate dehydrogenase, CA125, ascitic fluid gastric lymphoma is unknown, although genetic lactate dehydrogenase, ascitic fluid lymphocytes and infections agent have been implicated. increased. The ascitic fluid was yellow-colored So far, CD8-positive has been previously de- with 98.5% lymphocytes. Stool occult blood test scribed in very few isolated case reports. Nogu- was positive. Upper gastrointestinal endosco- chi et al3 reported the case of gastric CD8+ DLBL py performed a few days later revealed multiple with HTLV-1, and Toyama et al4 reported the first gastric crateriform ulcers, and Helicobacter py- lori was detected in the biopsy specimen. Pe- case of primary splenic CD8-positive DLBL. Pri- ripheral blood CD8+ was increased by 51%. Pa- mary diffuse large B-cell lymphoma with ascites thology test showed lymphocytes with atypical is very rare. Zenda et al5 reported a DLBCL case hyperplasia, and immunohistochemistry test re- initially manifested as a form of effusion lympho- sulted CD20+, CD10-, CD79α+, κ+, bcl-6+, Ki-67+ ma with lymphoma cells detected in ascites but (approximately 95%), λ-, bcl-2-, CD3-, CD43-. Im- only minimum solid tumor component. Overall, munoglobulin gene (Ig) clonal rearrangement showed IgH: FR1 (+), FR2 (+), FR3(-), Igk: VJ(+), CD8-positive DLBCL with ascites as the initial Vkde (+) in lymphoma tissue. major characteristics is very rarely reported. CONCLUSIONS: The features of histopatholo- gy and immunohistochemistry of the tissue con- Case Presentation firmed diffuse large B-cell lymphoma (DLBL). A 78-year-old woman was admitted to Wuxi The patient received an uncompleted CHOP pro- Traditional Chinese Medicine Hospital on 15 gram combined with H. pylori eradication. How- March 2011 with complaints of abdominal disten- ever, the patient deceased due to disease devel- opment sixteen days later after the diagnosis. sion, scanty urine, fatigue, anorexia. She had no history of viral hepatitis, tuberculosis or schisto- Key Words: somiasis. On physical examination, there found Primary gastric diffuse large B-cell lymphoma, no enlarged superficial lymph nodes, abdominal CD8-positive, Initial characteristic manifestation, Ascites. tenderness or rebound tenderness, a palpable liver Corresponding Author: Kexue Zhao, MD; e-mail: [email protected] 1707 K.-X. Zhao, G.-Z. Dai, J.-F. Zhu and a palpable spleen. There was an exposure of kidneys and adrenal glands, little pleural effusion varication in the abdominal wall, in combination in the left lower thorax, small hemangioma in the with a distended abdomen with shifting dullness. left liver, gallbladder stones, cholecystitis massive Edema was found in the patient’s lower limbs, ascites, but no enlarged lymph nodes. Three sto- especially the left limb. The patient was afebrile, ol routine tests showed that the color was yellow, and cardiac pulse and blood pressure were wi- shape and properties was soft, yeasts were found thin normal range. Blood routine test showed that in the first stool sample, occult blood was negati- white blood cell (WBC) was 5.96x109/L (80.4% ve. After taking live combined Bifidobacterium neutrophil, 13% lymphocyte), red blood cell lactobacillus, and Enterococcus (420 mg, q8h) for (RBC) 3.30x1012/L, hemoglobin (Hb) 100 g/L, three days, yeasts were no longer found in the se- and platelet (PLT) 305x109/L. Prothrombin time cond stool sample, and occult blood was slightly was 16.5 s. Serologic studies for HIV and HCV positive. Occult blood turned negative without were negative, and HBeAb and HBcAb were acid inhibitors or hemostatic. Upper gastrointesti- positive. Liver function tests were: lactate dehy- nal endoscopy was performed on March 23, mul- drogenase 746 IU/L (normal 105-245 IU/L), cho- tiple gastric crateriform ulcers (fundus, body, and linesterase 4215 U/L (normal 4500-13000 U/L), antrum of the stomach, about 1.5x1.5 cm multiple total protein 53.5 g/L (60-85 g/L), albumin 29.3 ulcers, surrounding with elevated crater-like mu- g/L (35-55 g/L), prealbumin 0.102 g/L (0.20-0.40 cosa) were found (Figure 1). A biopsy was taken g/L). Other parameters were within normal range. from the border of the antrum and gastric fundus Renal function and electrolytes levels were nor- ulcers shew lymphocytes with atypical hyperpla- mal. Ascites was drained with abdominocentesis sia (Figure 2). H. pylori was detected from antral and tested: yellow-colored, turbid, tumor cell (-), biopsy specimens using urease testing. Immu- mesothelial cell (+), lymphocytes (+), Rivalta test nohistochemistry detected expression of CD20+, (+), white blood cell 18.75x109/L, red blood cell CD10-, CD79+, κ+, bcl-6+, Ki-67+ (approximately 3.5x109/L, neutrophil 1.5%, lymphocyte 98.5%, 95%), λ-, bcl-2-, MUM1-, CD3-, CD43- in lym- lactate dehydrogenase 4483 IU/L (normal 105- phoma tissue. The results of clonal rearrangement 245 U/L), adenosine deaminase 64.9 U/L (nor- of the immunoglobulin (Ig) gene in lymphoma mal 0-24 U/L), alpha fetal protein (AFP) (-), car- tissue were IgH: FR1 (+), FR2 (+), FR3 (-), Igk: cino-embryonic antigen (CEA) (-), carbohydrate VJ (+), Vkde (+). The results of pathology, im- antigen 19-9 (CA199) (-). Bacteria culture result munohistochemistry, gene rearrangements were of the ascites was negative. Serology tumor mar- consistent with diffusive large B-cell lymphoma. ker test results were: alpha fetal protein (AFP) The comprehensive analysis confirmed diagnose 2.54 ng/ml (normal 0-13.4 ng/ml), carcino-em- of diffusive large B-cell lymphoma. Furthermore, bryonic antigen (CEA) 0.789 ng/ml (normal 0-10 capsule endoscopy did not detect tumors, or an- ng/ml), carbohydrate antigen 153 (CA153) 13.41 giomas, ulcer or bleeding. Colonoscopy showed U/ml (normal 0-25 U/ml), carbohydrate antigen 19-9 (CA199) 5.59 U/ml (normal 0-27 U/ml), and carbohydrate antigen 72-4 (CA72.4) 0.534 U/ml (normal 0-6.9 U/ml), and an increased carbohy- drate antigen (CA125) 566.9 U/ml (normal 0-27 U/ml). The PPD (purified protein derivative) skin test and tubercle bacillus smear were negative, Doppler ultrasound showed that there was no thromboembolism in the limbs. Serum cellular immune function: CD16+: 27% (normal 12.5- 29.2%), CD3+: 68% (normal 60.7-77.2%), CD19+: 3% (normal 5-14.7%), CD4+: 16% (normal 27.3- 42.6%), Th/Ts: 0.31 (normal 0.9-2.2), CD8+: 51% (normal 19.2-30.5%). A current-generation multislice helical com- puted tomography (CT) scan using intravenous contrast material called compound meglumine in Figure 1. Panendoscopy: multiple crater-like gastric ulcers chest and abdomen showed a suspicion of ascen- observed under upper gastrointestinal endoscopy (1.5 cm x ding colon cancer which maybe metastasized to 1.5 cm) was suspected to be malignancy. 1708 Ascites as the initial characteristic manifestation in a patient with primary gastric CD8-positive DLBL numerous diverticula in the caecus, ulcer in the above causes were eliminated. Because of the ileocecal valve, and biopsy pathology of ileocecal increased serum lactate dehydrogenase, CA125, valve showed chronic inflammation with local dy- ascitic fluid lactate dehydrogenase, ascitic fluid splastic changes of local lymphocytes. lymphocytes and intermittent slight positive of After she had been admitted to the hospital, she occult blood, gastroscopy was performed. The received palliative and symptomatic treatments, endoscopy revealed multiple crateriform gastric including salt restriction and diuretics. On the fi- ulcers measuring 1.5 cm x 1.5 cm in the fun- fth day of admission, she had a moderate fever dus, body, and antrum of the stomach. H. pylo- (37.8○C), with no chills, rigors, abdominal pain or ri was also detected in antral biopsy specimens. cough. Blood routine test showed WBC 9.25x109/L The results of immunohistochemistry showed (neutrophil 88.41%, lymphocyte 7.02%), RBC CD20+, CD10-, CD79α+, κ+, bcl-6+, Ki-67+ (ap- 3.08x1012/L, Hb 92 g/L, PLT 363.0x109/L, and cul- proximately 95%) in the biopsy tissue. And the tures of blood were negative. Epstein-Barr virus immunoglobulin (Ig) gene clonal rearrangement detection was negative. The patient refused a sur- demonstrated IgH: FR1 (+), FR2 (+), Igk: VJ (+), gical treatment and a CHOP program at first.