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Abstract Number: 106 RARE COEXISTENCE OF SMALL BOWEL LYMPHOMA WITH TUBERCULOSIS IN A YOUNG PATIENT PATIENT HISTORY • 22 year old male came with history of colicky, non radiating abdominal pain which was progressive in nature for 1 year with loss of appetite and loss of weight. • Melena for 6 months, vomiting for 3 months and low grade fever for 3 days. ON EXAMINATION • A mass was palpable in the umbilical and epigastric region • Firm to hard in consistency • Well defined borders • Was less prominent on leg raising • Mass was dull on percussion LAB PARAMETERS • Hb-11.4 • TC-11800 • DC N-71 L-25 E-04 ESR-110 UREA -26 CREATININE-0.7 NA+=128 K+=4.20 RBS-98. ALBUMIN-3.7 GLOBULIN-2.3 A/G RATIO-1.6 • • • • SER LIPASE-40 DIR BILI-0.1 SER AMYLASE-80 TOT BILIRUBIN-0.5 INDIRECT BILI-0.4 ALP-123. TOT PROTIEN-6.0 ULTRASOUND ABDOMEN • Small bowel loop showed circumferential bowel wall thickening. • Dilated and thickened small bowel loop with luminal narrowing SCANOGRAM - ABDOMEN • Scanogram shows dilated small bowel loops. CECT ABDOMEN • Long segment bowel wall thickening involving ilieal loops in the infra umbilical region for a length of 20cms with maximal wall thickness of 20mm. • Dilatation of short segment of bowel loops proximal to the thickened bowel was seen. • Irregularly marginated soft tissue density lesion with necrotic areas and foci of air noted in the mesentery in the umbilical region abutting the thickened bowel wall. • Multiple mesenteric nodes, largest measuring ~12mm were noted adjacent to the thickened bowel. AXIAL CECT ABDOMEN CORONAL CECT ABDOMEN SAGITTAL CECT ABDOMEN DIFFERENTIAL DIAGNOSIS • Differential diagnosis of - Lymphoma - Carcinoid - Adenocarcinoma were considered according to CT/CECT findings. SURGICAL MANAGEMENT • Patient was taken up for surgery and intra-operatively a mass was noted in the distal ilieal mesentery compressing the ileum 15cm from the ileocaecal valve. • Adjacent bowel wall thickening was noted. • Post surgically, differential diagnosis of 1.Adenocarcinoma small bowel 2.TB small bowel. 3.Lymphoma small bowel. 4.Regional ileitis. were considered by the surgeons. SURGICAL MANAGEMENT HISTOPATHOLOGY • Histopathology turned out to be B cell NonHodgkins lymphoma along with tuberculosis. • Biopsy was confirmed by immuno histiochemistry with CD 20 and CD 45 positive. • Treatment for intestinal tuberculosis differs completely from that of small bowel lymphoma. TREATMENT • Patient was started on chemotherapy and antituberculous treatment (ATT) concurrently. • Treatment: - Chemotherapy is the primary modality of treatment as it spreads by hematogenous spread. - CHOP regimen. 1.Cyclophosphamide 2.Doxarubicin(H-hydroxy daunorubicin /doxorubicin) 3.Oncovin. 4.Prednisolone. DISCUSSION • Intestinal tuberculosis is a specific chronic intestinal disease caused by Mycobacterium tuberculosis. • The clinical manifestations of small bowel lymphoma are nonspecific, such as abdominal pain, vomiting, weight loss and intestinal perforation. • Small bowel is second most frequent site of gastrointestinal tract involvement by lymphoma. • Ileum is most common site of occurrence because it has most lymphoid tissue • The coexistence of Tuberculosis and small bowel lymphoma coincidental, or one disease process might have initiated the other. DISCUSSION • TB and various types of malignancies can mimic each other and have atypical clinical and radiological expressions. • Further research is required to determine whether TB infection, being similar to other chronic infections and inflammatory conditions, may facilitate carcinogenesis. • Although new radiological imaging studies such as combined positron emission tomography (PET) and computed tomography (CT) have enabled clinicians to make a more accurate diagnosis, the ability of these disorders to clinically mimic one another may present a serious challenge in the establishment of the diagnosis. CONCLUSION • Non Hodgkin’s lymphoma may be preceded by chronic inflammatory disease and related to immunodeficiency. • Tuberculosis on other hand is a chronic infectious disease whose presentation and reactivation is promoted by cell mediated immunodeficiency. • The coexistence of Non Hodgkin’s lymphoma and Tuberculosis in same organ is rare. REFERENCES 1. 2. 3. 4. Nikolaus S, Schreiber S. Diagnostics of inflammatory bowel disease. Gastroenterology. 2007;133:1670–1689 Epstein D, Watermeyer G, Kirsch R. Review article: the diagnosis and management of Crohn’s disease in populations with high-risk rates for tuberculosis. Aliment Pharmacol Ther. 2007;25:1373– 1388. Zhu QQ, Wu JT, Chen WX, Wang SA, Zheng J. [Differential diagnosis of intestinal tuberculosis and primary small intestinal lymphoma using computerized tomography] Zhonghua Weichang Waike Zazhi. 2012;15:1247–1251 Qing-Qiang Zhu, Wen-Rong Zhu, Jing-Tao Wu, Wen-Xin Chen, Shou-An Wang, World J Gastroenterology 2014 Apr;20(15):4446-52 REFERENCES 5. 6. 7. 8. 9. Cornes JS: Multiple primary cancers: primary malignant lymphomas and carcinomas of the intestinal tract in the same patient. J Clin Pathol 1960, 13:483-489. Jain BK, Chandra SS, Narasimhan R, Ananthakrishnan N, Mehta RB: Coexisting tuberculosis and carcinoma of the colon. Aust N Z J Surg 1991, 61:828-831 Falagas ME, Kouranos VD, Athanassa Z, Kopterides P: Tuberculosis and malignancy. QJM 2010, 103:461-487. Fanourgiakis, P.; Mylona, E.; Androulakis, I. I.; Eftychiou, C.; Vryonis, E.; Georgala, A.; Skoutelis, A.; Aoun, M.PUB. DATE. May 2008. SOURCE: Postgraduate Medical Journal;May2008, Costa LJM, Gallafrio CT, Franca FOS, del Giglio A. Simultaneous occurrence of Hodgkin disease and tuberculosis: report of three cases. South Med J 2004;97:696-8.