ClinicalRadiology(1992) 46, 350-351
Case Report: Lymphoma Causing Small Bowel Intussusception in a Patient With the Acquired Immune Deficiency Syndrome J. C. D A N I N , M. M c C A R T Y
a n d R. COKER*
Departments of Radiology and *Genitourinary Medicine, St Mary ~ Hospital, London We present the case of a patient with the acquired immune deficiency syndrome (AIDS) who developed an ileo-ileal intussusception due to lymphoma of the small bowel. The clinical and radiographic findings are described. D a n i n , J.C., M c C a r t y , M . & C o k e r , R. (1992). Clinical
Radiology 46, 3 5 0 - 3 5 1 . C a s e R e p o r t : L y m p h o m a C a u s i n g S m a l l B o w e l I n t u s s u s c e p t i o n in a P a t i e n t W i t h the A c q u i r e d I m m u n e D e f i c i e n c y S y n d r o m e
CASE REPORT A 30-year-old homosexual positive for HIV antibody presented with a 2 day history of colicky central abdominal pain and vomiting. Over the previous 3 weeks he had had fevers and night sweats, and had lost 6 kg in weight. Two weeks previously he had presented with a peritonsillar mass, biopsy of which revealed a B cell lymphoma. On examination of his abdomen there was visible peristalsis and an illdefined central abdominal mass. A supine plain abdominal radiograph showed a dilated small bowel loop, consistent with obstruction, and an absence of gas in the right iliac fossa suggesting a mass (Fig. 1). An
Fig. 2 - A section from the abdominal CT scan performed after injection of intravenous contrast. A small bowel loop in the right side of the abdomen contains a soft tissue mass (short arrow) together with mesenteric fat (long arrow) and a mesenteric vessel. abdominal CT scan was then performed. Appearances were typical of an intussusception (Fig. 2). There was a loop of bowel in the right iliac fossa containing within it a collapsed bowel loop together with mesenteric fat and vessels, conforming to a 'doughnut' appearance [1]. The proximal small bowel loops were dilated. A laparotomy was performed and a mid ileo-ileal intussusception was found. The lead point was formed by an intramural mass which on histological examination was shown to be B cell lymphoma, of similar cell type to the tonsillar lesion. Following surgery, chemotherapy was commenced but the patient died 4 months later of intracerebral lymphoma.
DISCUSSION
Fig. 1 - A plain supine abdominal radiograph showing a centrally located dilated loop of small bowel, and paucity of gas in the right iliac fossa. Correspondence to: Dr J. C. Danin, Department of Radiology, St Mary's Hospital, London W2.
G a s t r o i n t e s t i n a l s y m p t o m s a r e c o m m o n in A I D S p a t i e n t s ; m o s t will d e v e l o p a g a s t r o i n t e s t i n a l c o m p l i c a t i o n d u r i n g t h e c o u r s e o f their illness [2]. M o s t o f t e n the p r e s e n t i n g s y m p t o m is d i a r r h o e a , w h i c h is c o m m o n l y d u e to an i n f e c t i v e a g e n t a n d c a n be c a u s e d b y m a n y different organisms. I n f e c t i o n w i t h Giardia lamblia, Campylobacter a n d Strongyloides is c o m m o n in h o m o s e x u a l s . T h e s e p a t h o gens c a n be r e a d i l y t r e a t e d w i t h a n t i b i o t i c s a n d stool c u l t u r e to d e t e c t t h e s e o r g a n i s m s is e s s e n t i a l in a n y A I D S p a t i e n t p r e s e n t i n g w i t h d i a r r h o e a . C r y p t o s p o r i d i o s i s is a
INTUSSUSCEPTION IN AIDS
more serious in~fection; this causes a severe enteritis with debilitating diarrhoea and is difficult to treat. Gut infection with Cytomegalovirus most commonly presents as an enteritis, but occasionally it can be complicated by bowel perforation and peritonitis due to a necrotizing vasculitis [3]. However, abdominal complications that require surgery are rare. Wilson and co-workers [4] studied a large population of AIDS patients in 1989 reviewing all those requiring emergency laparotomy in eight southern Californian hospitals over 4 years. Only 35 patients (about 4%) came to surgery. In this series, the commonest indication for laparotomy was peritonitis; the majority of these cases had small bowel perforation due to cytomegalovirus infection. When patients presented with bowel obstruction, they were likely to have a neoplastic cause; either lymphoma or Kaposis sarcoma. AIDS patients are prone to develop aggressive B cell lymphomas with a high frequency of extranodal involvement. The gastrointestinal tract is one of the most commonly involved sites [5]. Our patient had already been diagnosed as having an oropharyngeal B cell lymphoma and when he presented with bowel obstruction, intestinal lymphoma was considered in the differential diagnosis. Although the plain films were suggestive of an intussusception, the CT scan was invaluable in preoperative assessment of the patient, as the classic features
351
of this condition were clearly demonstrated. Intussusce p tion in adults usually has an identifiable cause, making lymphomatous involvement of the small bowel even more likely. We emphasise that although infectious complications of AIDS causing diarrhoea are encountered frequently, bowel obstruction directly due to an AIDS-related disease is rare and a neoplastic cause should be sought.
REFERENCES 1 Lee JKT, Sagel SS, Stanley RJ. Computed body tomography with magnetic resonance imaging correlation, 2nd ed. New York: Raven Press, 1989:503 505. 2 Guerant RL, Bobak DA. Medical progress: bacterial and protozoal gastroenteritis. New England Journal of Medicine 1991;325:327-340. 3 Megibow A J, Balthazar E J, Hulnick DH. Radiology of nonneoplastic gastrointestinal disorders in Acquired Immune Deficiency Syndrome. Seminars in Roentgenology 1987;XXII:31-41. 4 Wilson SE, Robinson G, Williams RA, Stabile BE, Cone L, Sarfeh I J, Miller DR, Passaro E. Acquired Immune Deficiency Syndrome (AIDS) indications for abdominal surgery, pathology and outcome. Annals of Surgery 1989;210:428 434. 5 Knowles DM, Chamulak GA, Subar M, Burke JS, Sugan M, Wernz J, Slywotzky C, Pelicci P-G, Dalla-Favera R, Raphael B. Lymphoid neoplasia associated with the Acquired Immune Deficiency Syndrome (AIDS). Annals of lnternal Medicine 1988;108:744-753.
Case Report: Lymphoma Causing Small Bowel Intussusception in a Patient With the Acquired Immune Deficiency Syndrome J. C. D A N I N , M. M c C A R T Y
a n d R. COKER*
Departments of Radiology and *Genitourinary Medicine, St Mary ~ Hospital, London We present the case of a patient with the acquired immune deficiency syndrome (AIDS) who developed an ileo-ileal intussusception due to lymphoma of the small bowel. The clinical and radiographic findings are described. D a n i n , J.C., M c C a r t y , M . & C o k e r , R. (1992). Clinical
Radiology 46, 3 5 0 - 3 5 1 . C a s e R e p o r t : L y m p h o m a C a u s i n g S m a l l B o w e l I n t u s s u s c e p t i o n in a P a t i e n t W i t h the A c q u i r e d I m m u n e D e f i c i e n c y S y n d r o m e
CASE REPORT A 30-year-old homosexual positive for HIV antibody presented with a 2 day history of colicky central abdominal pain and vomiting. Over the previous 3 weeks he had had fevers and night sweats, and had lost 6 kg in weight. Two weeks previously he had presented with a peritonsillar mass, biopsy of which revealed a B cell lymphoma. On examination of his abdomen there was visible peristalsis and an illdefined central abdominal mass. A supine plain abdominal radiograph showed a dilated small bowel loop, consistent with obstruction, and an absence of gas in the right iliac fossa suggesting a mass (Fig. 1). An
Fig. 2 - A section from the abdominal CT scan performed after injection of intravenous contrast. A small bowel loop in the right side of the abdomen contains a soft tissue mass (short arrow) together with mesenteric fat (long arrow) and a mesenteric vessel. abdominal CT scan was then performed. Appearances were typical of an intussusception (Fig. 2). There was a loop of bowel in the right iliac fossa containing within it a collapsed bowel loop together with mesenteric fat and vessels, conforming to a 'doughnut' appearance [1]. The proximal small bowel loops were dilated. A laparotomy was performed and a mid ileo-ileal intussusception was found. The lead point was formed by an intramural mass which on histological examination was shown to be B cell lymphoma, of similar cell type to the tonsillar lesion. Following surgery, chemotherapy was commenced but the patient died 4 months later of intracerebral lymphoma.
DISCUSSION
Fig. 1 - A plain supine abdominal radiograph showing a centrally located dilated loop of small bowel, and paucity of gas in the right iliac fossa. Correspondence to: Dr J. C. Danin, Department of Radiology, St Mary's Hospital, London W2.
G a s t r o i n t e s t i n a l s y m p t o m s a r e c o m m o n in A I D S p a t i e n t s ; m o s t will d e v e l o p a g a s t r o i n t e s t i n a l c o m p l i c a t i o n d u r i n g t h e c o u r s e o f their illness [2]. M o s t o f t e n the p r e s e n t i n g s y m p t o m is d i a r r h o e a , w h i c h is c o m m o n l y d u e to an i n f e c t i v e a g e n t a n d c a n be c a u s e d b y m a n y different organisms. I n f e c t i o n w i t h Giardia lamblia, Campylobacter a n d Strongyloides is c o m m o n in h o m o s e x u a l s . T h e s e p a t h o gens c a n be r e a d i l y t r e a t e d w i t h a n t i b i o t i c s a n d stool c u l t u r e to d e t e c t t h e s e o r g a n i s m s is e s s e n t i a l in a n y A I D S p a t i e n t p r e s e n t i n g w i t h d i a r r h o e a . C r y p t o s p o r i d i o s i s is a
INTUSSUSCEPTION IN AIDS
more serious in~fection; this causes a severe enteritis with debilitating diarrhoea and is difficult to treat. Gut infection with Cytomegalovirus most commonly presents as an enteritis, but occasionally it can be complicated by bowel perforation and peritonitis due to a necrotizing vasculitis [3]. However, abdominal complications that require surgery are rare. Wilson and co-workers [4] studied a large population of AIDS patients in 1989 reviewing all those requiring emergency laparotomy in eight southern Californian hospitals over 4 years. Only 35 patients (about 4%) came to surgery. In this series, the commonest indication for laparotomy was peritonitis; the majority of these cases had small bowel perforation due to cytomegalovirus infection. When patients presented with bowel obstruction, they were likely to have a neoplastic cause; either lymphoma or Kaposis sarcoma. AIDS patients are prone to develop aggressive B cell lymphomas with a high frequency of extranodal involvement. The gastrointestinal tract is one of the most commonly involved sites [5]. Our patient had already been diagnosed as having an oropharyngeal B cell lymphoma and when he presented with bowel obstruction, intestinal lymphoma was considered in the differential diagnosis. Although the plain films were suggestive of an intussusception, the CT scan was invaluable in preoperative assessment of the patient, as the classic features
351
of this condition were clearly demonstrated. Intussusce p tion in adults usually has an identifiable cause, making lymphomatous involvement of the small bowel even more likely. We emphasise that although infectious complications of AIDS causing diarrhoea are encountered frequently, bowel obstruction directly due to an AIDS-related disease is rare and a neoplastic cause should be sought.
REFERENCES 1 Lee JKT, Sagel SS, Stanley RJ. Computed body tomography with magnetic resonance imaging correlation, 2nd ed. New York: Raven Press, 1989:503 505. 2 Guerant RL, Bobak DA. Medical progress: bacterial and protozoal gastroenteritis. New England Journal of Medicine 1991;325:327-340. 3 Megibow A J, Balthazar E J, Hulnick DH. Radiology of nonneoplastic gastrointestinal disorders in Acquired Immune Deficiency Syndrome. Seminars in Roentgenology 1987;XXII:31-41. 4 Wilson SE, Robinson G, Williams RA, Stabile BE, Cone L, Sarfeh I J, Miller DR, Passaro E. Acquired Immune Deficiency Syndrome (AIDS) indications for abdominal surgery, pathology and outcome. Annals of Surgery 1989;210:428 434. 5 Knowles DM, Chamulak GA, Subar M, Burke JS, Sugan M, Wernz J, Slywotzky C, Pelicci P-G, Dalla-Favera R, Raphael B. Lymphoid neoplasia associated with the Acquired Immune Deficiency Syndrome (AIDS). Annals of lnternal Medicine 1988;108:744-753.
