Rectal Epstein-Barr virus-positive Hodgkin's lymphoma in a patient with Crohn's disease: case report and review of the literature

Transition From Epstein-Barr Virus (EBV)-Positive Rectal Hodgkin Lymphoma to Diffuse Large B-Cell Lymphoma in the Lung

We report a distinctive case of sequential lymphomas in a 72-year-old male, initially diagnosed with Epstein-Barr virus (EBV)-positive rectal classic Hodgkin lymphoma (cHL), followed by the development of diffuse large B cell lymphoma (DLBCL) in the lung. This rare progression underscores the complexity of lymphomas associated with EBV infection and their unpredictable clinical courses. The patient's journey began with symptoms of intractable diarrhea, low appetite, and significant weight loss, leading to the diagnosis of stage 4B cHL, managed initially with brentuximab/doxorubicin, vinblastine, dacarbazine (AVD) chemotherapy. Despite a partial response, surveillance identified a transition to DLBCL, marked by new pulmonary lesions. This case highlights the clinical and diagnostic challenges in managing sequential lymphomas, emphasizing the role of EBV in lymphomagenesis and the potential for clonal evolution from a common precursor cell. The therapeutic approach evolved from targeted chemotherapy to consideration of advanced treatments such as autologous stem cell transplant and chimeric antigen receptor (CAR) T-cell therapy, reflecting the aggressive nature and poor prognosis of the disease. This case contributes to our understanding of the EBV's impact on lymphoma progression and underscores the need for vigilant monitoring and adaptive treatment strategies in similar clinical scenarios.

A Rare Case of Primary Anorectal Hodgkin Lymphoma in an HIV-Positive Patient: A Case Report and Literature Review

Lymphoma is a well-known complication related to HIV infection; of these, non-Hodgkin lymphoma (NHL) is the most common subtype with Hodgkin lymphoma (HL) occurring less frequently. We present a rare case of a 35-year-old male with a history of HIV/AIDS well-controlled on antiretroviral therapy (ART) with an atypical HL presentation. He arrived at the emergency department with rectal bleeding, 30-pound unintentional weight loss, and subjective fever. CT scan of the abdomen and pelvis showed a circumferential mass extending from the mid-rectum to the anus, with extensive local lymphadenopathy. He underwent multiple biopsies of the mass and adjacent lymph nodes. The pathology report showed EBV-positive lymphoma with features of classical Hodgkin lymphoma (cHL) (positive for EBV-EBER by in-situ hybridization). He was started on A+AVD (brentuximab plus doxorubicin, vinblastine and dacarbazine). The patient tolerated the chemotherapy well without significant complications. We want to encourage physicians and providers to include anorectal HL in their differential diagnosis for HIV/AIDS patients with atypical rectal malignancy presentations and subsequent reporting of these cases.

Impact of Epstein-Barr virus infection in patients with inflammatory bowel disease

A high prevalence of Epstein-Barr virus (EBV) infection in patients with inflammatory bowel disease (IBD) has been reported in many case reports and studies; thus, the association between EBV and IBD has gained increasing attention. Patients with IBD are at an increased risk of opportunistic EBV infection owing to the common use of immunomodulators. EBV infection in IBD patients can cause various complications, including superimposed viral colitis, which is associated with chronicity, exacerbation, and poor prognosis of refractory IBD, and can induce progression to lymphoproliferative disorders, such as EBV-positive mucocutaneous ulcer (EBVMCU), lymphomatoid granulomatosis (LYG), hemophagocytic lymphohistiocytosis (HLH) and diffuse large B-cell lymphoma (DLBCL). It has been suggested to screen for EBV before initiating immunosuppressive therapy and monitor the status of EBV infection in patients with IBD, especially those who are EBV-seronegative and have a risk of primary EBV infection. Clinicians should also be careful of misdiagnosing IBD and EBV-associated lymphoproliferative diseases due to similarities in both clinical symptoms and endoscopic manifestations. Withdrawal of immunosuppressants has been shown to be an effective strategy to achieve remission of disease at the time of EBV diagnosis, but antiviral therapy remains controversial. The present review aims to describe the characteristics of the complications caused by EBV infection and generalize the recent research progress on and challenges caused by EBV infection in IBD patients. The literature for writing this review was collected from 'PubMed' research engine. The keywords 'inflammatory bowel disease and Epstein-Barr virus' or 'ulcerative colitis and Epstein-Barr virus' or 'Crohn's disease and Epstein-Barr virus' were used to collect the literature and relevant papers were collected to help writing this review.

Iatrogenic immunodeficiency-associated lymphoproliferative disorders of B-cell type that develop in patients receiving immunosuppressive drugs other than in the post-transplant setting

In the current revised 4th edition of the World Health Organization (WHO) classification, ‘other iatrogenic immunodeficiency-associated lymphoproliferative disorders (Oii-LPDs)’ is listed in the last section in the chapter on immunodeficiency-associated lymphoproliferative disorders. Oii-LPDs cover a broad spectrum from benign lesions to lymphoma, and correspond to one of the subtypes in the WHO classification for immunocompetent patients.

The WHO classification does not clearly indicate the histological subtype of this disease category; however, the framework of subtype classification is similar to the classification of post-transplant lymphoproliferative disorders, and recent studies have attempted to subcategorize Oii-LPDs that fit this unique disease type. In this review, we provide an overview of B-cell-type Oii-LPDs regarding their histopathology and immunophenotype, genetics and clinical behaviors.

A review on co-existent Epstein-Barr virus-induced complications in inflammatory bowel disease

There have been growing reports regarding the presence of Epstein-Barr virus (EBV) in the intestine portions of patients suffering from ulcerative colitis and Crohn's disease, collectively termed as inflammatory bowel disease (IBD). Indeed, the prevalence of EBV infection increases in IBD patients due to prolonged employment of immunosuppressive drugs including azathioprine and infliximab. In turn, coinfection with EBV increases the propensity of development of lymphoproliferative disorders in the gastrointestinal tract including Hodgkin lymphoma, non-Hodgkin lymphomas, and lymphoepithelioma-like cholangiocarcinoma. Therefore, it is recommended that IBD patients on prolonged immunomodulator therapy should be monitored for the presence of primary intestinal lymphoproliferative diseases. Moreover, coinfection of EBV complicates the clinical course of IBD by increasing the severity, chronicity, inducing refractoriness and increasing relapse incidences. Therefore, it is recommended that antiviral drugs should be added in the conventional IBD therapy in the suspected cases of EBV infection. Research has also revealed that EBV-induced colitis is very similar to IBD and there are chances of misdiagnosis of IBD in the presence of EBV colitis. The proper diagnosis of EBV infection along with its timely treatment is necessary to avoid the severe complications in patients of IBD. The present review discusses the role of EBV coinfection in increasing the clinical complications of IBD patients.

Epstein-Barr virus (EBV) status in colorectal cancer: a mini review

Epstein-Barr virus (EBV) is a well-characterized oncovirus, associated with several malignancies. The complex and heterogeneous nature of colorectal cancer (CRC) has led to many epidemiological causal associations with CRC. However, a direct causal link between microbial infections and CRC has not been established yet. Our review indicates that the current evidence for the presence and role in EBV in CRC is insufficient and contradictory. The design of the analyzed studies, sample size as well as methodology used for EBV detection varied markedly and consequently may not lead to meaningful conclusions. The presence of EBV in other colorectal tumors (lymphomas, smooth muscle tumors) is in line with their status at other anatomic locations and may have therapeutic implications with EBV-specific vaccines. On the other hand, studies exploring EBV in colorectal adenoma-carcinoma sequence and its molecular genetic characteristics are largely missing and may significantly contribute to a better understanding of the role of EBV in CRC.

Lymphoproliferative disorders in inflammatory bowel disease patients on immunosuppression: Lessons from other inflammatory disorders

Immunosuppressive agents, such as thiopurines, methotrexate, and biologics, have revolutionized the treatment of inflammatory bowel disease (IBD). However, a number of case reports, case control studies and retrospective studies over the last decade have identified a concerning link between immunosuppression and lymphoproliferative disorders (LPDs), the oncological phenomenon whereby lymphocytes divide uncontrollably. These LPDs have been associated with Epstein-Barr virus (EBV) infection in which the virus provides the impetus for malignant transformation while immunosuppression hampers the immune system’s ability to detect and clear these malignant cells. As such, the use of immunosuppressive agents may come at the cost of increased risk of developing LPD. While little is known about the LPD risk in IBD, more is known about immunosuppression in the post-transplantation setting and the development of EBV associated post-transplantation lymphoproliferative disorders (PTLD). In review of the PTLD literature, evidence is available to demonstrate that certain immune suppressants such as cyclosporine and T-lymphocyte modulators in particular are associated with an increased risk of PTLD development. As well, high doses of immunosuppressive agents and multiple immunosuppressive agent use are also linked to increased PTLD development. Here, we discuss these findings in context of IBD and what future studies can be taken to understand and reduce the risk of EBV-associated LPD development from immunosuppression use in IBD.

Recent advances in intestinal lymphomas

A large variety of lymphoma types may develop as primary intestinal neoplasms in the small intestines or, less often, in the colorectum. Among these are a few entities such as enteropathy-associated T-cell lymphoma or immunoproliferative small intestinal disease that, essentially, do not arise elsewhere than in the gastrointestinal tract. In most instances the primary intestinal lymphomas belong to entities that also occur in lymph nodes or other mucosal sites, and may show some peculiar features. In the case of follicular lymphoma, important differences exist between the classical nodal cases and the intestinal cases, considered as a variant of the disease. It is likely that the local intestinal mucosal microenvironment is a determinant in influencing the pathobiological features of the disease. In this review we will present an update on the clinical, pathological and molecular features of the lymphoid neoplasms that most commonly involve the intestines, incorporating recent developments with respect to their pathobiology and classification. We will emphasize and discuss the major differential diagnostic problems encountered in practice, including the benign reactive or atypical lymphoid hyperplasias, indolent lymphoproliferative disorders of T or natural killer (NK) cells, and Epstein-Barr virus (EBV)-related lymphoproliferations.

Two rare cases of Epstein-Barr virus-associated lymphoproliferative disorders in inflammatory bowel disease patients on thiopurines and other immunosuppressive medications

The setting of chronic immunosuppression in inflammatory bowel disease (IBD) may promote the proliferation of Epstein-Barr virus-positive neoplastic clones. We report two rare cases of Epstein-Barr virus-associated lymphoproliferative disorder in IBD patients: one resembled lymphomatoid granulomatosis, and the other was a lymphoma resembling Hodgkin lymphoma. There are currently no guidelines for the prevention of lymphoproliferative disorder in IBD patients on immunosuppressive therapy.

Incidence, clinical characteristics, and natural history of pediatric IBD in Wisconsin: a population-based epidemiological study

BACKGROUND

Epidemiological studies of pediatric inflammatory bowel diseases (IBD) are needed to generate etiological hypotheses and inform public policy; yet, rigorous population-based studies of the incidence and natural history of Crohn's disease (CD) and ulcerative colitis (UC) in the United States are limited.

METHODS

We developed a field-tested prospective system for identifying all new cases of IBD among Wisconsin children over an 8-year period (2000-2007). Subsequently, at the end of the study period, we retrospectively reconfirmed each case and characterized the clinical course of this incident cohort.

RESULTS

The annual incidence of IBD among Wisconsin children was 9.5 per 100,000 (6.6 per 100,000 for CD and 2.4 per 100,000 for UC). Approximately 19% of incident cases occurred in the first decade of life. Over the 8-year study period, the incidence of both CD and UC remained relatively stable. Additionally, (1) childhood IBD affected all racial groups equally, (2) over a follow-up of 4 years, 17% of patients with CD and 13% of patients with patients with UC required surgery, and (3) 85% and 40% of children with CD were treated with immunosuppressives and biologics, respectively, compared with 62% and 30% of patients with UC.

CONCLUSIONS

As in other North American populations, these data confirm a high incidence of pediatric-onset IBD. Importantly, in this Midwestern U.S. population, the incidence of CD and UC seems to be relatively stable over the last decade. The proportions of children requiring surgery and undergoing treatment with immunosuppressive and biological medications underscore the burden of these conditions.

Sources of information on lymphoma associated with anti-tumour necrosis factor agents: comparison of published case reports and cases reported to the French pharmacovigilance system

BACKGROUND

Anti-tumour necrosis factor (TNF) agents, through their intense immunoregulatory effect, have been suspected to increase the risk of malignant lymphoma. However, the classical epidemiological approaches conducted over about the last 10 years have not totally succeeded in addressing the question of a causal or artifactual association. Therefore, the analysis of a substantial set of case reports, although usually considered as poorly generalizable to the general population, could be particularly informative. Two main sources of case reports in postmarketing settings are available; publications in medical journals and reports to pharmacovigilance systems.

OBJECTIVE

The aim of the study was to compare the characteristics of case reports from both these sources in order to understand whether they provided the same information for the investigation of the causal link between lymphoma and anti-TNF agents.

METHODS

All case reports of malignant lymphoma in patients treated with an anti-TNF agent published in MEDLINE and all reports to the French pharmacovigilance system up to 1 February 2010 were identified. Cases of malignant lymphoma identified in postmarketing surveillance from both sources were compared regarding the following variables: age, sex, anti-TNF agent involved, indication for use, type of lymphoma, prior or concomitant immunosuppressive drugs and time to onset of lymphoma.

RESULTS

A total of 81 published case reports and 61 cases reported to the French pharmacovigilance system were compared. In published reports, patients were younger (p = 0.03) and more frequently receiving a first anti-TNF treatment (p = 0.03), particularly infliximab (p = 0.03). Conversely, in the pharmacovigilance system reports, a succession of different anti-TNFs (p = 0.03) and adalimumab (p < 0.0001) were more frequently reported. Lymphomas in patients treated with anti-TNF agents for Crohn's disease were more prevalent in published cases than in pharmacovigilance reports (p < 0.0001), and in particular involved hepatosplenic T-cell lymphoma. Conversely, rheumatoid arthritis was the main indication for anti-TNF agents in pharmacovigilance reports (p = 0.01). Time to onset was markedly shorter in published cases (median 12 months) than in pharmacovigilance reports (median 30 months; p = 0.0001).

CONCLUSIONS

Characteristics of published cases and those reported to the French pharmacovigilance system differed markedly for all characteristics tested, except sex and the use of prior or concomitant immunosuppressive drugs. Published case reports favoured convincing arguments for drug causation whereas cases reported to the pharmacovigilance system were more disparate but could describe more accurately the reality of lymphoma occurrence in this particular population. These results argue for the use of the pharmacovigilance reports when case reports are used to investigate the causal link between lymphoma and anti-TNF agents at the population level. Data from cases notified to the French pharmacovigilance system did not indicate an increased risk of lymphoma during the early phase of anti-TNF treatment. To confirm this hypothesis, a study combining pharmacovigilance reports from several countries, or, if feasible, a cohort study both with a large sample size and a long duration of follow-up would be required.

Cancer in inflammatory bowel disease 15 years after diagnosis in a population-based European Collaborative follow-up study

AIM OF THE STUDY

To determine the occurrence of intestinal and extraintestinal cancers in the 1993-2009 prospective European Collaborative Inflammatory Bowel Disease (EC-IBD) Study Group cohort.

PATIENTS-METHODS

A physician per patient form was completed for 681 inflammatory bowel disease patients (445UC/236CD) from 9 centers (7 countries) derived from the original EC-IBD cohort. For the 15-year follow up period, rates of detection of intestinal and extraintestinal cancers were computed.

RESULTS

Patient follow-up time was fifteen years. In total 62/681 patients (9.1%) [41 with ulcerative colitis/21 with Crohn's disease, 36 males/26 females] were diagnosed with sixty-six cancers (four patients with double cancers). Colorectal cancer was diagnosed in 9/681 patients [1.3%] (1 Crohn's disease and 8 ulcerative colitis). The remaining 53 cancers were extraintestinal. There was a higher prevalence of intestinal cancer in the Northern centers compared to Southern centers [p=NS]. Southern centers had more cases of extraintestinal cancer compared to Northern centers [p=NS]. The frequency of all observed types of cancers in Northern and in Southern centers did not differ compared to the expected one in the background population.

CONCLUSIONS

In the fifteen-year follow up of the EC-IBD Study Group cohort the prevalence of cancer was 9.1% with most patients having a single neoplasm and an extraintestinal neoplasm. In Northern centers there were more intestinal cancers while in Southern centers there were more extraintestinal cancers compared to Northern centers. In this IBD cohort the frequency of observed cancers was not different from that expected in the background population.

A Burkitt's Lymphoma Case Mimicking Crohn's Disease: A Case Report

Lymphomas are solid tumors that arise from lymphoid tissue and present themselves as Hodgkin's or non-Hodgkin's lymphoma. Particularly gastrointestinal lymphomas can be clinically confused with other gastrointestinal tumors as well as with diffuse and inflammatory bowel disease. Early diagnosis and treatment bear vital importance in the management of lymphomas due to their high proliferation rates. In this report, we are presenting a case which initially displayed clinical and radiological signs of Crohn's disease, but was eventually diagnosed as Burkitt's lymphoma by laparotomy, and also we aim to underscore the importance of differential diagnosis.

Regression of Hodgkin lymphoma after discontinuation of a tumor necrosis factor inhibitor for Crohn's disease: a case report and review of the literature

Lymphoma is an increasingly recognized complication of tumor necrosis factor (TNF) inhibition for the treatment of autoimmune and inflammatory disease; the majority of these cases are non-Hodgkin lymphomas (NHL). The impact of withdrawing TNF inhibition therapy in cases of lymphoma is not well described. A woman with Crohn's disease (CD) was diagnosed with Hodgkin lymphoma (HL) and subsequently went into remission with standard chemotherapy. Her CD later worsened, requiring initiation of adalimumab, a TNF inhibitor. Ten months later, she was found to have recurrence of HL. When she opted against additional treatment for the lymphoma, the TNF inhibitor was discontinued. Three months later, the measurable sites of disease had completely regressed. It can be concluded that HL is a potential complication of treatment with TNF inhibitors. Withdrawal of immunosuppression may be a consideration for patients treated for lymphoproliferative disorders including HL. Maintenance of an intact immune system may be important for prevention of lymphoma relapse. Further understanding of this complex interaction will help clinicians determine in which patients these agents have a favorable risk-benefit ratio.

A decade of infliximab: The Austrian evidence based consensus on the safe use of infliximab in inflammatory bowel disease

Infliximab (IFX) has tremendously enriched the therapy of inflammatory bowel diseases (IBD) and other immune mediated diseases. Although the efficacy of IFX was undoubtedly proven during the last decade numerous publications have also caused various safety concerns. To summarize the immense information concerning adverse events and safety issues the Austrian Society of Gastroenterology and Hepatology launched this evidence based consensus on the safe use of IFX which covers the following topics: infusion reactions and immunogenicity, skin reactions, opportunistic infections (including tuberculosis), non-opportunistic infections (bacterial and viral), vaccination, neurological complications, hepatotoxicity, congestive heart failure, haematological side effects, intestinal strictures, stenosis and bowel obstruction (SSO), concomitant medication, malignancy and lymphoma, IFX in the elderly and the young, mortality, fertility, pregnancy and breast feeding. To make the vast amount of information practicable for routine application the consensus was finally condensed into a checklist for a safe use of IFX which consists of two parts: issues to be addressed prior to anti-TNF therapy and issues to be addressed during maintenance. Both parts are further divided into obligatory and facultative items.

A new subtype of Hodgkin's lymphoma, syncytial nodular sclerosing: first case report of primary small bowel lymphoma

INTRODUCTION

Gastrointestinal lymphomas may arise as a component of systemic disease with GI involvement or primary neoplasm. The diagnosis of primary GI lymphoma requires the lack of peripheral or mediastinal lymphadenopathy, normal white blood cell count, and differential on the peripheral blood smear; tumor involvement must be predominantly in the GI tract, and no evidence of liver or spleen involvement. The small bowel accounts for approximately 9% of the GI lymphomas.

CASE REPORT

We describe a first case of primary small bowel Hodgkin's lymphoma syncytial variant nodular sclerosing type. A 28-year-old man with history of long-term use of immuno-suppressive agent and steroid presents with partial obstructing abdominal-mass-causing anemia and lower gastrointestinal bleeding. The patient underwent colonoscopy because of progressive microcytic anemia. Colonoscopy revealed non-specific polyps that were non-bleeding. The patient continued to have symptoms of abdominal cramping and twitching sensation that led to serial of small bowel radiology studies which showed multiple filling defects and a partial small bowel obstruction. The patient underwent small bowel resection, which showed Hodgkin's lymphoma syncytial variant type of nodular sclerosing.

CONCLUSION

This presentation is uncommon and, so far, there are less than ten cases reported with syncytial variant (SV) type of nodular sclerosing Hodgkin's lymphoma (NSHD). All of which have presentation above the diaphragm and, to our knowledge, this represents the first case that primary SV type of NSHD originated from the small intestine.

Contribution of the 2-[18F]-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography to the diagnosis of primary osseous Hodgkin lymphoma

Hodgkin lymphoma typically presents as a nodal lesion and infrequently involves extra nodal sites. Although cases of primary extra-nodal Hodgkin lymphoma have been reported previously, the reality of the primitive nature of the disease was difficult to authenticate with traditional high resolution imaging techniques, such as computed tomography or magnetic resonance imaging, because they cannot evaluate the spread of the disease throughout the whole body. We report here a case of primary osseous Hodgkin lymphoma, regarded as stage I extranodal IE thanks to the important contribution of a new imaging technique, the 2-[18F]-fluoro-2-deoxy-d-glucose positron emission tomography/ computed tomography (18F-FDG-PET/CT). PET enables systemic Hodgkin lymphoma with secondary bone invasion to be distinguished from primitive osseous Hodgkin lymphoma. This technique is highly specific in demonstrating the isolated osseous localisation of the tumour and should be recommended in all patients with putative osseous lymphoma.

An unusual case of Crohn's disease with unresponsive pleural exudates. Is Crohn's disease finally a systemic immunological disorder?

Crohn's disease has been infrequently associated with various respiratory manifestations. Reports of pleural effusions in Crohn's disease are even sparser, but differential diagnosis is rich, with causes either associated with the disease or being independent. Processes directly or indirectly related to therapy, entities overlapping with Crohn's disease in pathogenesis and common causes of effusions should all be considered, under the guidance of laboratory testing and imaging. We report here an unusual case of bilateral pleural effusions unresponsive so far to medical therapy, in a patient with long-standing Crohn's disease and several features of autoimmunity. A short review of the literature is presented, the differential diagnosis is outlined and the systemic immunological profile of Crohn's disease is discussed.