Case records of the Massachusetts General Hospital. Case 11-2013. A 4-year-old boy with fever and abdominal pain

Acute abdominal pain as the initial presenting symptom of pediatric Burkitt lymphoma: A case report and literature review

RATIONALE

Acute abdominal pain is a prevalent clinical symptom in pediatric patients, primarily attributed to pediatric acute abdomen. However, there are rare exceptional instances where neoplastic diseases may cause acute abdominal pain.

PATIENT CONCERNS

The present study encompasses a case of pediatric Burkitt lymphoma wherein acute abdominal pain manifested as the initial symptom, erroneously diagnosed as acute appendicitis.

DIAGNOSES

The immunohistochemistry results of laparoscopic biopsy revealed Burkitt lymphoma, characterized by positive expression of CD20, CD79a, CD10, BCL-6, MUM1, and strong positive expression of CD38, c-myc, cyclinD1, and Ki-67 positive index >90%+.

INTERVENTIONS

The child underwent regular chemotherapy according to the SCCCG-BL/DLBCL-2017 regimen.

OUTCOMES

During the 13-month follow-up period, the patient's obtained complete remission by Positron emission tomography-computed tomography scan.

LESSONS

The objective of this study is to enhance the awareness of clinical pediatricians regarding cases of acute abdominal pain caused by lymphoma.

Burkitt lymphoma

Burkitt lymphoma (BL) is an aggressive form of B cell lymphoma that can affect children and adults. The study of BL led to the identification of the first recurrent chromosomal aberration in lymphoma, t(8;14)(q24;q32), and subsequent discovery of the central role of MYC and Epstein-Barr virus (EBV) in tumorigenesis. Most patients with BL are cured with chemotherapy but those with relapsed or refractory disease usually die of lymphoma. Historically, endemic BL, non-endemic sporadic BL and the immunodeficiency-associated BL have been recognized, but differentiation of these epidemiological variants is confounded by the frequency of EBV positivity. Subtyping into EBV⁺ and EBV^- BL might better describe the biological heterogeneity of the disease. Phenotypically resembling germinal centre B cells, all types of BL are characterized by dysregulation of MYC due to enhancer activation via juxtaposition with one of the three immunoglobulin loci. Additional molecular changes commonly affect B cell receptor and sphingosine-1-phosphate signalling, proliferation, survival and SWI-SNF chromatin remodelling. BL is diagnosed on the basis of morphology and high expression of MYC. BL can be effectively treated in children and adolescents with short durations of high dose-intensity multiagent chemotherapy regimens. Adults are more susceptible to toxic effects but are effectively treated with chemotherapy, including modified versions of paediatric regimens. The outcomes in patients with BL are good in high-income countries with low mortality and few late effects, but in low-income and middle-income countries, BL is diagnosed late and is usually treated with less-effective regimens affecting the overall good outcomes in patients with this lymphoma.

Double-Expressor Appendiceal Burkitt’s Lymphoma: A Case Report and Literature Review

Background

Appendiceal lymphoma is a very rare entity accounting for 0.015% of all gastrointestinal lymphoma cases. Acute appendicitis is the most common presentation of primary appendix neoplasms. Burkitt's lymphoma presenting as an acute appendicitis is a rare entity with around 21% of the cases presenting as a lower iliac fossa mass. Case Presentation. A 23-year-old male was admitted to the surgical ward as a case of acute appendicitis with localized tenderness in the right iliac fossa, positive rebound tenderness, a positive Rovsing's sign, and ultrasound findings of suspected complicated appendicitis. Appendectomy was performed. Histopathological examination of the appendectomy specimen revealed a double-expressor non-Hodgkin diffuse large cell lymphoma with Burkitt's-like morphology. He was sent for chemotherapy treatment.

Conclusion

Only 34 cases of Burkitt's lymphoma have been reported to present as acute appendicitis. Histological examination following appendectomy for an apparent appendicitis is essential. Furthermore, complete blood count and a computed tomography scan aid the diagnosis of lymphoma. Double-expressor lymphoma has been shown to have poor outcomes. Therefore, prompt and aggressive treatment is vital.

Burkitt Leukemia Presenting as Acute Appendicitis: A Case Report and Literature Review

Patient: Female, 6-year-old

Final Diagnosis: Burkitt’s leukemia

Symptoms: Right iliac fossa pain

Medication: —

Clinical Procedure: Laparoscopic cecectomy

Specialty: Surgery

Mantle cell lymphoma presenting as acute appendicitis

•

Mantle cell lymphoma is an extremely rare form of lymphoma associated with appendicitis.

•

This is one of few reported cases of mantle cell lymphoma showing obstruction of appendiceal lumen.

•

Appendicitis associated with mantle cell lymphoma in this incident is unaffected by the effect of chemotherapy treatments.

INTRODUCTION

Most cases of appendicitis associated with lymphoma reported in literature are in patients with Burkitt's or large B-cell lymphoma. Mantle cell lymphoma only makes up 4% of all lymphoma cases in the U.S. We report a case of a patient with mantle cell lymphoma presenting with acute appendicitis.

PRESENTATION OF CASE

A 75 year old male with a history of left cervical lymphadenopathy biopsied to be mantle cell lymphoma presented with right lower abdomen pain for 3 days. An outpatient CT scan revealed acute appendicitis. Laparoscopic appendectomy was performed without any complication. The histologic examination showed mantle cell lymphoma occluding the lumen of appendix.

DISCUSSION

Typically, appendicitis is caused by obstruction of the lumen of appendix by fecalith or lymphoma. A previously reported case of a patient with mantle cell lymphoma who developed appendicitis received chemotherapy before appendectomy. The author could not determine how mantle cell lymphoma contributed to appendicitis because the lumen of appendix was not occluded by the lymphoma, likely from cytoreduction from chemotherapy. We have a patient with mantle cell lymphoma before the patient received chemotherapy who presented with appendicitis. The appendiceal specimen shows the lumen filled with mantle cell lymphoma.

CONCLUSION

This is a rare case of mantle cell lymphoma causing obstruction of appendiceal lumen and subsequently appendicitis, unaffected by chemotherapy.