Upper Digestive Tract Bleeding as Presentation of Diffuse Large B‐Cell Lymphoma

Abstract

A previously healthy 17-year-old teenager presented with new onset hematemesis and melena. He had no recent history of fever, fatigue, weight loss, or infection. Laboratory evaluation confirmed the presence of anemia. The patient underwent esophagogastroduodenoscopy (EGD) which identified 4 ulcerated lesions with erythematous, elevated margins on the gastric body, and erythematous areas in the gastric antrum (Fig. 1A, B). Due to the macroscopic appearance of the lesions, HIV, CMV, and HSV1-2 infections were ruled out. Intravenous pantoprazole was started, and he had a recurrent episode of melena on day 8. Upper endoscopy, which was repeated on day 10 to inform pantoprazole weaning, revealed almost complete resolution of the ulcers (Fig. 1C). Gastric biopsy specimens from the EGD showed a heterogenous proliferation of lymphocytes, plasmocytes, macrophages, and eosinophils; the immunocytochemical study suggested the diagnosis of gastric diffuse large B-cell lymphoma (DLBCL).Primary gastric lymphoma is very rare in childhood. According to SEER (Surveillance, Epidemiology, and End Results) data, the incidence of pediatric primary gastrointestinal lymphoma is 0.19/100.000. Most cases (47.6%) are located in the small intestine while only 10% arise in the stomach (1-3). Gastric DLBCL lesions may range in appearance from ulcers to erosions or polypoid masses, but multiple lesions are seen in a small percentage of cases (4,5). The authors aim to highlight the importance of obtaining multiple biopsy specimens, especially when lesions are seen in separate locations. Once the diagnosis was confirmed, the patient was referred to an oncological center for staging and treatment.