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Tsujii H, Nakayama R, Funakoshi S, Tsuji S, Haga H, Ono K. Polymorphic lymphoproliferative disorder arising in a rheumatoid arthritis patient, presenting as fibrin-associated large B-cell lymphoma-like lesions in aortic and mitral valves. Pathol Int 2024; 74:285-291. [PMID: 38563592 DOI: 10.1111/pin.13424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 03/01/2024] [Accepted: 03/19/2024] [Indexed: 04/04/2024]
Abstract
We herein report a case of methotrexate-associated lymphoproliferative disorder (MTX-LPD) showing fibrin-associated large B-cell lymphoma-like heart valve lesions, and Epstein-Barr virus (EBV)-positive mucocutaneous ulcer-like cutaneous and oral mucosal lesions. MTX-LPD is a critical complication that can occur in RA patients who are treated with MTX. EBV also plays a defining or important role in LPDs. Among the sites of MTX-LPD, 40-50% occur in extranodal sites, including the gastrointestinal tract, skin, liver, lung, and kidney. There are few reports of MTX-LPDs involving the heart valves, and to the best of our knowledge, this is the first case to be reported in the English literature. The possibility of EBV-positive LPD should be considered in RA patients, even in patients with an atypical site, as in this case.
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Affiliation(s)
- Hideaki Tsujii
- Department of Diagnostic Pathology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
- Department of Diagnostic Pathology, Kyoto University Hospital, Sakyo-ku, Kyoto, Japan
| | - Ryuko Nakayama
- Department of Diagnostic Pathology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Sohei Funakoshi
- Department of Rheumatology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Shuhei Tsuji
- Department of Cardiovascular Medicine, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Hironori Haga
- Department of Diagnostic Pathology, Kyoto University Hospital, Sakyo-ku, Kyoto, Japan
| | - Kazuo Ono
- Department of Diagnostic Pathology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
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2
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Kitagawa K, Oyama M, Asada S, Sato S, Nakatani T, Nishimura N, Mui Y, Hanatani J, Takeda M, Yoshiji H. Methotrexate-associated lymphoproliferative disorder: A rare pancreatic tumor diagnosed via endoscopic ultrasound-guided fine-needle biopsy. DEN OPEN 2024; 4:e346. [PMID: 38444882 PMCID: PMC10914123 DOI: 10.1002/deo2.346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/07/2024] [Accepted: 02/10/2024] [Indexed: 03/07/2024]
Abstract
A 73-year-old woman with a history of rheumatoid arthritis treated with methotrexate (MTX) for the last 10 years was referred to our hospital for a pancreatic tumor examination. Contrast-enhanced abdominal computed tomography revealed a 20-mm-diameter hypovascular tumor in the pancreatic tail. A hypoechoic mass with heterogeneous internal echo was found on an endoscopic ultrasound (EUS). An EUS-guided fine-needle biopsy (EUS-FNB) was performed with a 22-gauge Franseen-tip needle. Histologic examination of EUS-FNB specimens from the pancreatic tumor revealed the proliferation of atypical spindle cells. Immunohistochemical staining for CD20 and Ki-67 was positive in the atypical cells. Immunohistochemical staining for CD3 was partially positive in the atypical cells. Epstein-Barr virus-encoded RNA in situ hybridization showed positive staining. MTX-related lymphoproliferative disorder (MTX-LPD) with Epstein-Barr virus infection was diagnosed. MTX treatment was immediately discontinued, and treatment was initiated by a hematologist. However, her condition rapidly deteriorated, and she died of multiple organ failure 4 weeks after diagnosis. MTX-LPD can complicate gastrointestinal lesions. However, most lesions are localized in the stomach and rarely complicate pancreatic lesions. MTX-LPD is classified as an "iatrogenic" LPD. Therefore, immediate action, such as MTX discontinuation, is necessary. In conclusion, endoscopists should be aware that MTX-LPD lesions can occur in the pancreas and gastrointestinal tract. Moreover, EUS-FNB can be useful in the diagnosis of this rare pancreatic tumor.
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Affiliation(s)
- Koh Kitagawa
- Department of GastroenterologyNara Medical UniversityNaraJapan
| | - Masafumi Oyama
- Department of GastroenterologyNara Medical UniversityNaraJapan
| | - Shohei Asada
- Department of GastroenterologyNara Medical UniversityNaraJapan
| | - Shinya Sato
- Department of GastroenterologyNara Medical UniversityNaraJapan
| | | | - Naoki Nishimura
- Department of GastroenterologyNara Medical UniversityNaraJapan
| | - Yuka Mui
- Department of GastroenterologyNara Medical UniversityNaraJapan
| | | | - Maiko Takeda
- Department of Diagnostic PathologyNara Medical UniversityNaraJapan
| | - Hitoshi Yoshiji
- Department of GastroenterologyNara Medical UniversityNaraJapan
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Saraiva RO, Saunders C, Varela dos Santos M, Carvalho D, Loureiro R, Ramos J. Refractory Hidradenitis Suppurativa: A Diagnosis to Consider. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2024; 31:60-64. [PMID: 38476303 PMCID: PMC10928865 DOI: 10.1159/000528432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 11/04/2022] [Indexed: 03/14/2024]
Abstract
Hidradenitis suppurativa is a chronic inflammatory disease associated with multiple comorbidities, and its association with lymphoma has recently been a topic of debate. However, it is still controversial whether this risk can be attributed to the disease itself or whether it has any relationship with immunosuppressive treatment. Here, we describe the case of a patient with severe perianal hidradenitis suppurativa treated with methotrexate and infliximab, whose exacerbation with persistence of severe symptoms refractory to adequate treatment led to the diagnosis of diffuse large non-Hodgkin B-cell lymphoma. It was decided to perform a colostomy to improve perianal sepsis, and immunochemotherapy was proposed.
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Affiliation(s)
- Rita Ornelas Saraiva
- Department of Gastroenterology, Hospital Universitário de Lisboa Central, Lisbon, Portugal
| | - Christopher Saunders
- Department of Hematology, Hospital Universitário de Lisboa Central, Lisbon, Portugal
| | | | - Diana Carvalho
- Department of Gastroenterology, Hospital Universitário de Lisboa Central, Lisbon, Portugal
| | - Rafaela Loureiro
- Department of Gastroenterology, Hospital Universitário de Lisboa Central, Lisbon, Portugal
| | - Jaime Ramos
- Department of Gastroenterology, Hospital Universitário de Lisboa Central, Lisbon, Portugal
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Sato D, Takami H, Takayanagi S, Taoka K, Tanaka M, Matsuura R, Tanaka S, Saito N. Lymphoproliferative disorder during temozolomide therapy; a representative case of a formidable complication and management challenges. BMC Neurol 2023; 23:224. [PMID: 37296412 DOI: 10.1186/s12883-023-03274-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 06/03/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Lymphoproliferative disorder represents a heterogeneous clinicopathological spectrum characterized by uncontrolled proliferation of lymphocytes. Immunodeficiency is a major trigger of its development. While induction of immunodeficiency is a well-known adverse effect of temozolomide therapy, development of lymphoproliferative disorder following temozolomide therapy has not previously been described. CASE PRESENTATION A patient with brainstem glioma developed constitutional symptoms, pancytopenia, splenomegaly and generalized lymphadenopathy during the 2nd cycle of maintenance therapy following induction therapy with temozolomide. Epstein-Barr virus-infected lymphocytes were observed histopathologically and "other iatrogenic immunodeficiency-associated lymphoproliferative disorder" (OIIA-LPD) was diagnosed. Although discontinuation of temozolomide led to rapid remission, relapse was observed 4 months later. CHOP chemotherapy was induced, resulting in secondary remission. Vigilant follow-up for another 14 months showed radiologically stable brainstem glioma and no further recurrence of OIIA-LPD. CONCLUSIONS This is the first report documenting OIIA-LPD during temozolomide administration. Timely diagnosis of the disease and discontinuation of the causative agent were considered to be the management of choice. Close monitoring for relapse should be continued. Finding a balance between glioma management and controlling the remission of OIIA-LPD remains to be clarified.
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Affiliation(s)
- Daisuke Sato
- Department of Neurosurgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Hirokazu Takami
- Department of Neurosurgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan.
| | - Shunsaku Takayanagi
- Department of Neurosurgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Kazuki Taoka
- Department of Hematology and Oncology, The University of Tokyo Hospital, Tokyo, Japan
| | - Mariko Tanaka
- Department of Pathology, The University of Tokyo Hospital, Tokyo, Japan
| | - Reiko Matsuura
- Department of Neurosurgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Shota Tanaka
- Department of Neurosurgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Nobuhito Saito
- Department of Neurosurgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
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Afonso C, Roque A, Almeida C, Pimentão MB, Julião MJ, Silva R, Geraldes C, Gomes M. Methotrexate-Associated Lymphoproliferative Disorder in a Patient with Psoriasis: A Case Report and Review of the Literature. Case Rep Hematol 2022; 2022:7178065. [PMID: 35535243 PMCID: PMC9078817 DOI: 10.1155/2022/7178065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 03/14/2022] [Indexed: 12/25/2022] Open
Abstract
Iatrogenic immunodeficiency-associated lymphoproliferative disorders (LPDs) are heterogeneous clinicopathological entities developing in patients receiving immunosuppression. Outside the posttransplant setting, methotrexate (MTX), a drug commonly used for the treatment of autoimmune diseases, is an immunosuppressive agent frequently reported to be associated with LPD. MTX-associated LPD (MTX-LPD) includes a spectrum of lymphocytic proliferations, ranging from polyclonal hyperplasia to malignant lymphoma. MTX-LPD diagnosis can be challenging, as signs and symptoms are often nonspecific and may overlap with those of several other conditions, including exacerbation of the underlying autoimmune disease. Spontaneous regression of LPD after MTX discontinuation is characteristic of MTX-LPD, therefore avoiding chemotherapeutic intervention in a significant proportion of patients. Other cases, however, should receive chemotherapy.
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Affiliation(s)
- Carolina Afonso
- Hematology Unit, Hospitais da Universidade de Coimbra, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Adriana Roque
- Hematology Unit, Hospitais da Universidade de Coimbra, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Cátia Almeida
- Hematology Unit, Hospitais da Universidade de Coimbra, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Maria Beatriz Pimentão
- Pathology Unit, Hospitais da Universidade de Coimbra, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Maria José Julião
- Pathology Unit, Hospitais da Universidade de Coimbra, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Rodolfo Silva
- Nuclear Medicine Unit, Hospitais da Universidade de Coimbra, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Catarina Geraldes
- Hematology Unit, Hospitais da Universidade de Coimbra, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Marília Gomes
- Hematology Unit, Hospitais da Universidade de Coimbra, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
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Hojo Y, Takatsuna M, Ikarashi S, Kamimura H, Kimura R, Mito M, Watanabe Y, Tani Y, Yokoyama J, Terai S. Methotrexate‐associated proliferative disorder in the lower esophagus extending to the gastroesophageal junction: A case report. DEN OPEN 2022; 2:e14. [PMID: 35310712 PMCID: PMC8828178 DOI: 10.1002/deo2.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 03/18/2021] [Accepted: 03/28/2021] [Indexed: 11/11/2022]
Abstract
A 64‐year‐old woman was receiving oral methotrexate (MTX) for rheumatoid arthritis (RA) for 15 years. She underwent esophagogastroduodenoscopy because of discomfort in the chest. Endoscopic findings revealed an ulcer in the lower esophagus extending to the gastroesophageal junction (EGJ). The ulcer occupied half of the esophageal lumen and had a sharp and clear margin. Magnifying narrow‐band imaging endoscopy revealed the deposition of white plaque, and there were few microvessels in the edge and bottom of the ulcer. Histologic examination of the biopsy specimens from the oral edge of the lesion revealed proliferation of atypical lymphoid cells (immunophenotype results: CD20 [+], CD3 [partially +], CD5 [−], and BCL‐2 [−]]. The patient was diagnosed with methotrexate‐associated lymphoproliferative disorder (MTX‐LPD) and was advised to stop MTX intake. After 2 months of stopping MTX, the ulcer was found to be almost regressed and showed signs of healing. MTX‐LPD in the lower esophagus extending to the EGJ is extremely rare. This case can help in expanding the understanding of esophageal MTX‐LPD.
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Affiliation(s)
- Yuki Hojo
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences Niigata University Niigata Japan
| | - Masafumi Takatsuna
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences Niigata University Niigata Japan
| | - Satoshi Ikarashi
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences Niigata University Niigata Japan
| | - Hiroteru Kamimura
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences Niigata University Niigata Japan
| | - Rika Kimura
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences Niigata University Niigata Japan
| | - Masaki Mito
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences Niigata University Niigata Japan
| | - Yusuke Watanabe
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences Niigata University Niigata Japan
| | - Yusuke Tani
- Division of Molecular and Diagnostic Pathology, Graduate School of Medical and Dental Sciences Niigata University Niigata Japan
| | - Junji Yokoyama
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences Niigata University Niigata Japan
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences Niigata University Niigata Japan
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Osaki Y, Kawaratani H, Kachi H, Matsuura K, Tsuji Y, Ozutsumi T, Takagi H, Furukawa M, Sawada Y, Mitoro A, Yamao J, Yoshiji H. Small intestinal follicular lymphoma induced by methotrexate: a case report. BMC Gastroenterol 2021; 21:280. [PMID: 34238226 PMCID: PMC8268449 DOI: 10.1186/s12876-021-01849-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 06/21/2021] [Indexed: 02/07/2023] Open
Abstract
Background Methotrexate-associated lymphoproliferative disorder (MTX-LPD) is a rare but critical complication that develops in patients treated with MTX. Although MTX-LPD has been recently reported, the incidence of follicular lymphoma in the intestine is very low. Case presentation A 73-year-old woman who had been receiving MTX for over 10 years visited our hospital complaining of postprandial abdominal pain and nausea. Upper and lower digestive tract endoscopies did not show any abnormal findings. A patency capsule was stagnated at the proximal part of the ileum with a mild dilation on the oral side. An oral balloon endoscopy revealed shallow ulcerative lesions in the jejunum. She was diagnosed with MTX-LPD based on histopathological findings. The symptoms did not improve with the discontinuation of MTX, and the patient required partial resection of the small intestine. The test result for Epstein-Barr virus-encoded small RNA was negative. She was diagnosed with follicular lymphoma based on the histology findings of a surgical specimen. Postoperative positron emission tomography-computed tomography and bone marrow aspiration did not show any findings of lymphoma. On follow-up, no recurrence was noted four years after the surgery. Conclusions Herein, we report the first case of follicular lymphoma that occurred in the small intestine, negative for Epstein-Barr virus-encoded small RNA. If intestinal symptoms occur during MTX administration, it is important to directly observe by endoscopy and perform histological examination.
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Affiliation(s)
- Yui Osaki
- The Department of Gastroenterology and Metabolism, Nara Medical University, Kashihara, Nara, 634-8522, Japan
| | - Hideto Kawaratani
- The Department of Gastroenterology and Metabolism, Nara Medical University, Kashihara, Nara, 634-8522, Japan.
| | - Hiroki Kachi
- The Department of Gastroenterology and Metabolism, Nara Medical University, Kashihara, Nara, 634-8522, Japan
| | - Kyohei Matsuura
- The Department of Gastroenterology and Metabolism, Nara Medical University, Kashihara, Nara, 634-8522, Japan
| | - Yuki Tsuji
- The Department of Gastroenterology and Metabolism, Nara Medical University, Kashihara, Nara, 634-8522, Japan
| | - Takahiro Ozutsumi
- The Department of Gastroenterology and Metabolism, Nara Medical University, Kashihara, Nara, 634-8522, Japan
| | - Hirotetsu Takagi
- The Department of Gastroenterology and Metabolism, Nara Medical University, Kashihara, Nara, 634-8522, Japan
| | - Masanori Furukawa
- The Department of Gastroenterology and Metabolism, Nara Medical University, Kashihara, Nara, 634-8522, Japan
| | - Yasuhiko Sawada
- The Department of Gastroenterology and Metabolism, Nara Medical University, Kashihara, Nara, 634-8522, Japan
| | - Akira Mitoro
- The Department of Gastroenterology and Metabolism, Nara Medical University, Kashihara, Nara, 634-8522, Japan
| | - Junichi Yamao
- The Department of Gastroenterology and Metabolism, Nara Medical University, Kashihara, Nara, 634-8522, Japan
| | - Hitoshi Yoshiji
- The Department of Gastroenterology and Metabolism, Nara Medical University, Kashihara, Nara, 634-8522, Japan
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