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Table of Contents
LETTER TO THE EDITOR
Year : 2013  |  Volume : 3  |  Issue : 1  |  Page : 91-92

Spontaneous ileal perforation in a critically ill adult with aggressive diffuse large B-cell lymphomas


1 Department of Hematology/Oncology, St. Michael's Medical Center, Newark, New Jersey, USA
2 Department of Internal Medicine, St. Michael's Medical Center, Newark, New Jersey, USA

Date of Web Publication22-Mar-2013

Correspondence Address:
Hamid S Shaaban
Department of Hematology/Oncology, St. Michael's Medical Center, 111 Central Avenue, Newark-07102, New Jersey
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5151.109431

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How to cite this article:
Shaaban HS, Johnson T, Guron G. Spontaneous ileal perforation in a critically ill adult with aggressive diffuse large B-cell lymphomas. Int J Crit Illn Inj Sci 2013;3:91-2

How to cite this URL:
Shaaban HS, Johnson T, Guron G. Spontaneous ileal perforation in a critically ill adult with aggressive diffuse large B-cell lymphomas. Int J Crit Illn Inj Sci [serial online] 2013 [cited 2019 Dec 12];3:91-2. Available from: http://www.ijciis.org/text.asp?2013/3/1/91/109431

Sir,

Spontaneous pneumoperitoneum is a rare but life-threatening complication of systemic chemotherapy for non-Hodgkin's lymphoma (NHL), and any part of the gastrointestinal (GI) tract may be affected. There is little data in the medical literature with regards to spontaneous GI perforation during chemotherapy in the absence of intestinal lymphoma involvement. [1] Poor prognostic markers include myeloid toxicity, immunosuppression, and protein malnutrition. [2] Diagnosis may be delayed because of masking effect of steroids on the localized and systemic inflammatory response. [3] We report herein a case of a 80-year-old Cuban male with chronic obstructive pulmonary disease, diabetes mellitus, and dilated cardiomyopathy that required defibrillator placement, and he complained of insidious onset of shortness of breath of 4 months' duration. Physical examination was unremarkable. Review of systems was significant for early fatigue, 10-pound weight loss, and night sweats. Computed tomography revealed a mediastinal mass, and the patient underwent a mediastinoscopy assisted biopsy of the mass. Histopathologically, the sample showed diffuse populations of pleomorphic lymphoid cells with immunohistochemical positivity for CD10, CD20, and CD79a with overexpression of lambda light chain. Bone marrow biopsy expressed large-cell lymphoma consisting of polyclonal B cells. Fluorescence in situ hybridization (FISH) detected a t(8,14), leading to an IgH/myc fusion protein, and the diagnosis of stage 4 diffuse large B-cell lymphoma (DLBCL), centroblastic variant was made.

He received one cycle of R-CHOP (rituximab, cyclophosphamide, hydroxydaunorubicin, vincristine, and prednisone) chemotherapy as well as oral allopurinol for acute tumor lysis syndrome (ATLS) prophylaxis. Two days after the first cycle of chemotherapy, laboratory results revealed a normal complete blood count (CBC) and the following: Creatinine 2.1 mg/dL, calcium 6.9 mg/dL, phosphorus 9.5 mg/dL, and uric acid 9.5 mg/dL.

The patient was diagnosed with ATLS and immediately started on aggressive intravenous hydration and continued on oral allopurinol. On day 4 post-chemotherapy, he experienced sudden severe abdominal pain. CT scan of the abdomen revealed pneumoperitoneum [Figure 1] and emergency surgical laparotomy revealed a perforation 2 feet from the ileocecal valve and sigmoid diverticulitis with purulent peritonitis. He had a Hartmann procedure with small bowel resection and primary anastomosis at the level of the ileum. Pathology revealed necrotizing inflammation with areas of granulation consisting predominately of mature lymphocytes, plasma cells, and macrophages. No definitive evidence of a lymphomatous or malignant process was identified. One day later, he developed post-operative hemorrhagic shock and was rushed to the operating room and about 1 L of blood was aspirated from the belly. He clinically improved after surgery, but a month later, he developed methicillin-resistant Staphylococcus aureus endocarditis-related complications and then expired.
Figure 1: CT scan revealing evidence of pneumoperitoneum

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There are few cases of spontaneous GI perforation secondary to systemic chemotherapy in the literature. [4] Lymphoma may involve the GI tract and when treated with chemotherapy can result in tumor necrosis and spontaneous perforation. [5] Intestinal involvement with lymphoma can contribute to this complication, but, in our patient, the pathology of the surgically resected bowel specimens rejected this notion since it was negative for lymphoma. The hypothesis may be that the combination of the drugs most likely results in ulcer perforation and the morbidity and mortality of pneumoperitoneum is high if a major medical illness exists concomitantly with the perforation. Diagnosis is often delayed because symptoms are blunted by high dose steroids and it may go unnoticed until septic shock presents. The time that elapses from the time of recognition of peritonitis to the time of surgical intervention can determine the survival outcome.

We recommend that patients with aggressive NHL who complain of abdominal pain during systemic chemotherapy and steroids get immediately evaluated for GI ulcers or even perforation and the clinical index of suspicion should be higher in patients with multiple co-morbidities.

 
   References Top

1.Jambhulkar MI, Joshi MA, Balsarkar D, Chandak M, Parab S. Perforation of jejunal non Hodgkin's lymphoma. Indian J Gastroenterol 2004;23:110-1.  Back to cited text no. 1
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2.Pine RW, Wertz MJ, Lennard ES, Dellinger EP, Carrico CJ, Minshew BH. Determinants of organ malfunction or death in patients with intra-abdominal sepsis. A discriminant analysis. Arch Surg 1983;118:242-9.  Back to cited text no. 2
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3.Sterioff S, Orringer MB, Cameron JL. Colon perforations associated with steroid therapy. Surgery 1974;75:56-8.  Back to cited text no. 3
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4.Torosian MH, Turnbull AD. Emergency laparotomy for spontaneous intestinal and colonic perforations in cancer patients receiving corticosteroids and chemotherapy. J Clin Oncol 1988;6:291-6.  Back to cited text no. 4
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5.Kobayashi T, Takizawa T, Yoshiyuki T, Suzuki H, Kikuchi T, Ide Y, et al. A case of malignant lymphoma with jejunal perforation. Geka 1995;57:359-61.  Back to cited text no. 5
    


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