Akhil Sood, MD1, Ravi B. Pavurala, MD2, Muhannad Al Hanayneh, MD3, Jose Aguirre, MD3, Maurice Willis, MD3, Sreeram Parupudi, MD1; 1University of Texas Medical Branch, Galveston, TX; 2UTMB, League City, TX; 3UTMB, Galveston, TX
Introduction: Gastrointestinal (GI) tract is the most common extranodal site of Non-Hodkin lymphoma (NHL) and constitutes about 4% of all GI malignancies. The most common sites of involvement in the GI tract are stomach followed by the small intestine. We report a case of primary colonic lymphoma manifesting with colovesical fistula in a patient with human immunodeficiency virus (HIV) infection.
Methods: A 50-year-old male with a history of HIV on antiretroviral therapy with undetectable viral load and a CD4 count of 260 cells/µL, presented with burning micturition, intermittent passage of air and feculent material in urine, on and off for one year. He has chronic nonbloody diarrhea and noticed thirty-pound weight loss over the past three months. At admission, he was afebrile, hypotensive, and had sinus tachycardia (114/min). Physical examination was significant for palpable, tender left lower quadrant mass but no hepatosplenomegaly, bowel distention, or peripheral lymphadenopathy. Laboratory data revealed anemia (HB 8.5 g/dl), leukocytosis (WBC 14000/µl), mildly elevated platelet count (422,000/µl), acute kidney injury (serum creatinine 2.50, baseline 0.81 mg/dL) and normal CEA level. Urine was brown, turbid with microscopy showing RBC and WBC ( >180/hpf).
CT scan of abdomen and pelvis with contrast revealed a large circumferential mass measuring 14.5 cm x 10 cm in sigmoid colon with a fistulous communication to the urinary bladder suggestive of colovesical fistula. Colonoscopy confirmed a partially obstructing, large circumferential, ulcerated mass within the proximal sigmoid colon. Pathology was consistent with diffuse large B-cell lymphoma (+BCL2, +MYC). PET-CT scan showed increased FDG uptake in the sigmoid colon along with adrenal gland and bone but no involvement of lymph nodes, liver, or spleen. A diverting colostomy was performed and subsequently, he was started on dose-adjusted R-EPOCH Regimen. The patient received 5 cycles of chemotherapy and a repeat PET-CT scan showed resolution of activity in the sigmoid colon, bone, and adrenal gland. Retroperitoneal ultrasound during chemotherapy showed persistence of colovesical fistula. Discussion: HIV-AIDS predisposes patients to different malignancies including NHL in about 10% of patients. Colonic involvement of primary NHL is exceedingly rare. High viral load and low CD4 counts (< 100) are risk factors for NHL in HIV patients. We describe here an unusual presentation of NHL manifesting as colovesical fistula, in a patient with HIV.
Computed tomographic scan of abdomen & pelvis in sagittal view showing large sigmoid mass (long arrow). Air-fluid level of orally administered contrast noted in the urinary bladder. (short arrow).
Colonoscopy shows a fungating, ulcerating mass in the sigmoid colon, nearly obstructing the lumen.
Initial PET tumor imaging whole body
Disclosures: Akhil Sood indicated no relevant financial relationships. Ravi Pavurala indicated no relevant financial relationships. Muhannad Al Hanayneh indicated no relevant financial relationships. Jose Aguirre indicated no relevant financial relationships. Maurice Willis indicated no relevant financial relationships. Sreeram Parupudi indicated no relevant financial relationships.