Largo Medical Center Saint Petersburg, FL, United States
Gilad Shapira, DO1, Itamar Shapira, 2, Ronald S. Jordan, MD3, Devendra Enjamuri, MD4, Meir Mizrahi, MD5 1Largo Medical Center, Huntsville, AL; 2University of Alabama at Birmingham School of Medicine, Birmingham, AL; 3University of South Alabama Health Systems, Mobile, AL; 4New York Methodist Hospital, Brooklyn, NY; 5HCA Largo Medical Center, Largo, FL
Introduction: Monomorphic epitheliotropic intestinal T-cell lymphoma (MEITL) is an aggressive lymphoma that arises from intestinal intraepithelial T lymphocytes. Typically, this rare lymphoma is most commonly seen in Asian, Hispanic, as well as indigenous populations that favors the jejunum and ileum. MEITL has not been directly related to celiac disease, though it was previously known as Type II enteropathy-associated T-cell lymphoma (EATL). Here we present a case of an elderly female with many comorbidities who has an unusual jejunal stricture.
Case Description/Methods: Our patient is a 71 F with a history of breast cancer and meningioma s/p radiation who presented to us for worsening epigastric abdominal pain with persistent nausea and vomiting. An initial EGD showed a large amount of fluid in stomach, though the patient had not consumed food for over 12 hours. A follow up small bowel follow through revealed a proximal jejunal small bowel obstruction. Thereafter a push enteroscopy was performed revealing severe stenosis in the proximal jejunum with ulceration. This stenosis was unable to be traversed and multiple biopsies were taken. The patient underwent laparoscopic assisted small bowel resection with jejunojejunostomy. Pathology from the specimen revealed lymphoid infiltrate composed of medium sized lymphocytes with round to irregular nuclei, moderate eosinophilic to clear cytoplasm, with frequent mitosis. Ki-67 showed increased proliferation rate (~70%). EBER in situ hybridization was negative. The findings were consistent with MEITL. The patient is currently undergoing chemotherapy with EPOCH followed by CHOP therapy.
Discussion: MEITL is a rare form of T-cell lymphoma that is aggressive and carries poor prognosis. Endoscopically MEITL presents as nodules or ulcerative masses. Microscopically, it appears as dense monomorphic, small/medium-sized lymphocytes, with pale cytoplasm, and hyperchromatic nuclei. Though similar histologically to EATL, MEITL has the differentiating factor of EBER (Epstein-Barr virus encoded small nuclear RNAs) negativity. Even with new development in the understanding of the pathogenesis there is still no efficient therapeutic intervention except for stem cell transplant. CHOP is the most frequently used chemotherapy with an anticipated 5-year survival rate of ~20%.
Figure: Jejunal stricture secondary to MEITL
Gilad Shapira indicated no relevant financial relationships.
Itamar Shapira indicated no relevant financial relationships.
Ronald Jordan indicated no relevant financial relationships.
Devendra Enjamuri indicated no relevant financial relationships.
Meir Mizrahi indicated no relevant financial relationships.
Gilad Shapira, DO1, Itamar Shapira, 2, Ronald S. Jordan, MD3, Devendra Enjamuri, MD4, Meir Mizrahi, MD5. P3055 - Heavy MEITL: Not the Sound of a Light Diagnosis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.