Human immunodeficiency virus (HIV)-associated duodenal lymphoma

A 68-year-old man was referred to our hospital for HIV treatment. He noticed melena on admission. Laboratory data showed anemia, with a hemoglobin level of 8.2 g/dL. The CD4 lymphocyte count was 101 cells/µL.

Esophagogastroduodenoscopy (EGD) showed two ulcerative lesions in the second part of the duodenum and in the inferior duodenal angulus ([Fig. 1]). These well-demarcated lesions consisted of an ulcer with a clean base and a regular elevated margin that had an auricle-like shape and many scattered tiny white spots. Histological examination of the biopsy specimens confirmed the diagnosis of diffuse large B-cell lymphoma (DLBCL). Immunochemical staining was positive for L-26 (CD20) ([Fig. 2]).

Fig. 1 Endoscopic images of the duodenum showing two ulcerative lesions: a second part of the duodenum; b inferior duodenal angulus.

Fig. 2 Photomicrographs of the biopsy specimen from the duodenal lesion (hematoxylin and eosin stain, × 20): a multiple atypical large lymphoid cells infiltrating the duodenal mucosa; b large lymphoid cells that are positive for L-26 (CD20).

Antiretroviral therapy (ART) was started for HIV treatment. After ART, the patient received six cycles of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone) chemotherapy. Follow-up EGD showed tumor regression.

Non-Hodgkin’s lymphoma is a common malignancy in HIV-positive individuals, and the gastrointestinal tract is one of the most common extranodal sites. However, HIV-associated duodenal lymphomas are very rare [1] [2] [3]. The endoscopic findings in AIDS-associated lymphoma are reported to be similar to those for gastrointestinal lymphomas in immunocompetent patients: polypoid, bulky lesions or well-defined ulcers are found in combination or as single lesions [4]. The most common HIV-associated lymphomas are Burkitt’s lymphoma and DLBCL. Although the incidence of follicular lymphoma in the duodenum is relatively higher than in other portions of the gastrointestinal tract [5], follicular lymphoma has not been reported in HIV-infected patients. Our patient was diagnosed with DLBCL and showed an excellent response to the R-CHOP chemotherapy administered after ART.

If unique duodenal ulcerative lesions are found, HIV-associated duodenal lymphoma should be considered as a rare differential diagnosis. Furthermore, accurately diagnosing DLBCLs by endoscopic biopsy is very important in such cases because HIV-associated lymphomas of the gastrointestinal tract have a poor prognosis [4] and require aggressive treatment.

Endoscopy_UCTN_Code_CCL_1AB_2AZ_3AB

References

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• 2 Corti M, Villafañe M F, Souto L et al. Burkitt’s lymphoma of the duodenum in a patient with AIDS.  Rev Soc Bras Med Trop. 2007;  40 338-340
• 3 Andhavarapu S, Tolentino A M, Jha C et al. Diffuse large B-cell lymphoma presenting as multiple lymphomatous polyposis of the gastrointestinal tract.  Clin Lymphoma Myeloma. 2008;  8 179-183
• 4 Heise W, Arastéh K, Mostertz P et al. Malignant gastrointestinal lymphomas in patients with AIDS.  Digestion. 1997;  58 218-224
• 5 Yoshino T, Miyake K, Ichimura K et al. Increased incidence of follicular lymphoma in the duodenum.  Am J Surg Pathol. 2000;  24 688-693