P1690 - Newly Diagnosed Advanced B-cell Lymphoma in the Setting of Crohn’s Disease on Chronic Azathioprine Management

William D. Davis, DO, Zaeema Zafar, DO, Camille H. Boustani, MD, Tenzin Choden, MD, Mark C. Mattar, MD
MedStar Georgetown University Hospital, Washington, DC

Introduction: Thiopurine medications, such as azathioprine for treatment of inflammatory bowel disease (IBD) is associated with an increased risk of lymphoma. This risk is greatest in patients older than 50 years, requiring increased awareness when prescribing this class of medications. This association returns to population baseline upon discontinuation of agent. We depict this relationship in a 72-year-old male with history of Cohn’s disease on azathioprine monotherapy.

Case Description/Methods: A 72-year-old male with past medical history of Parkinson’s disease and Crohn’s disease managed with azathioprine >5 years presented for left leg swelling along with abdominal pain for several weeks. Physical exam was pertinent for jaundice, hepatomegaly and left leg edema.

Laboratory data of his hospital course is summarized in table 1. On presentation, resuscitative fluids, calcitonin and bisphosphonate therapy were initiated for hypercalcemia. Azathioprine was held due to initial suspicion for drug-induced liver injury. Left lower extremity ultrasound (US) was negative for deep vein thrombosis. US abdomen Doppler demonstrated hepatomegaly with multiple echogenic solid lesions scattered throughout the liver parenchyma with non-visualization of left hepatic vein. Findings were consistent on computed tomography abdomen and pelvis with multiple large liver lesions occupying >50% of liver parenchyma with extensive, coalescent bulky lymphadenopathy of the retroperitoneal, porta hepatis and encasing the hepatic artery. MRCP and PET scans re-demonstrated large liver lesions and bulky lymphadenopathy, concerning for lymphoma (Fig A-C).

Liver and bone marrow biopsy demonstrated diffuse large B-cell lymphoma (Fig D-E). Treatment was discussed however due to elevated bilirubin levels, patient was not eligible. Biliary stent placement and steroids were considered for bilirubin reduction however, the disease burden was thought to be too extensive. Patient decided to pursue comfort care and was discharged to hospice.

Discussion: Thiopurines contribute to an approximately four-fold increase risk of lymphoma when treated for at least 1 year. The absolute risk is highest in male patients >50 years. In light of this patient’s advanced age and azathioprine use for over 1 year, a risk-benefit ratio for discontinuing azathioprine and consideration of alternative therapies should be considered. With alternative treatment regimens for IBD available, this discussion should be considered in all patients to prevent risk of lymphoma.




Disclosures:


William D. Davis, DO, Zaeema Zafar, DO, Camille H. Boustani, MD, Tenzin Choden, MD, Mark C. Mattar, MD. P1690 - Newly Diagnosed Advanced B-cell Lymphoma in the Setting of Crohn’s Disease on Chronic Azathioprine Management, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.