Clinical presentation of gastric Burkitt lymphoma presenting with paraplegia and acute pancreatitis: A case report

Abstract

Background: The incidence of gastric Burkitt lymphoma (BL), presenting as paraplegia and acute pancreatitis, is extremely low. BL is a great masquerader that presents in varied forms and in atypical locations, and it is prone to misdiagnosis and missed diagnosis. The prognosis of BL remains poor because of the difficulty in early diagnosis and the limited advances in chemotherapy.

Case summary: A 53-year-old man was referred to our hospital from the local county hospital due to abdominal pain for two weeks and weakness in the lower extremities for one day. Magnetic resonance imaging of the abdomen and lumbar spine showed a swollen pancreas and gallbladder, with peripancreatic exudation and liquid collection, indicating acute pancreatitis and acute cholecystitis. Additionally, we observed abnormally thickened lesions of the gastric wall, multiple enlarged retroperitoneal lymph nodes and a well-demarcated, posterolateral extradural mass lesion between T9 and T12, with extension through the spinal foramen and definite bony destruction, suggesting metastasis in gastric malignancy. Subsequent whole-body positron emission tomography/computed tomography examination showed multifocal malignant lesions in the stomach, pancreas, gallbladder, bone, bilateral supraclavicular fossa, anterior mediastinum, bilateral axillary and retroperitoneal lymph nodes. Gastroduodenal endoscopy revealed primary BL with massive involvement of the gastric body and duodenum. The patient refused chemotherapeutic treatment and died one week later due to upper gastrointestinal hemorrhage. Afterward, we reviewed the characteristics of 11 patients with BL involving the stomach, pancreas or spinal cord.

Conclusion: Clinicians should be aware that BL can be the potential cause of acute pancreatitis or a rapidly progressive spinal tumor with accompanying paraplegia. For gastric BL, gastroscopy biopsies and pathology are necessary for a definite diagnosis.

Keywords: Acute pancreatitis; Burkitt lymphoma; Case report; Paraplegia.

Figure 1

Magnetic resonance imaging of the abdomen at diagnosis. A: Axial T2-weighted magnetic resonance imaging (MRI) demonstrates homogeneous, hyperintense lesion in the whole pancreas and a markedly swollen gallbladder (arrows); B: Diffusion-weighted MRI shows abnormal hyperintensity in gall bladder wall and pancreas; C: Axial contrast-enhanced T1-weighted MRI shows the abnormal thickened lesions of the gastric wall (arrows), which display contrast enhancement in a × homogeneous fashion; D: Axial contrast-enhanced T1-weighted MRI shows the swollen gallbladder and multiple enlarged retroperitoneal lymph nodes (arrows), which display contrast enhancement in a homogeneous fashion.

Figure 2

Magnetic resonance imaging of the thoracic and lumbar vertebrae at diagnosis. A: Sagittal T2-weighted magnetic resonance imaging (MRI) shows epidural mass at the centrum and left posterolateral aspect of the spinal cord at the T9 to T12 levels, resulting in severe cord compression; B: Sagittal contrast-enhanced T1-weighted MRI shows the lesions displaying contrast enhancement in a heterogeneous fashion; C: Axial T2-weighted MRI shows that epidural mass involves the centrum and left posterolateral aspect of the spinal cord; D: Axial contrast-enhanced T1-weighted MRI shows the lesions displaying contrast enhancement in a heterogeneous fashion.

Figure 3

Positron emission tomography-computed tomography of the whole body at diagnosis. A: Coronal images; B: Sagittal images.

Figure 4

Gastric endoscopy. A: Multiple large (2 to 3 cm in diameter) raised ulcerated tumors involving both the greater and smaller curvatures of the gastric body; B: Numerous smaller tumors involving the anterior wall of the duodenal bulb and the second part of duodenum.

Figure 5

Histology and immunohistochemistry of gastric biopsies (× 200). A: Haematoxylin and eosin staining showed a characteristic “starry sky” appearance; B: Immunohistochemical staining was positive for CD20; C: Immunohistochemical staining was positive for CD10; D: Immunohistochemical staining was positive for Ki-67 (> 90% +); E: Immunohistochemical staining was positive for BCL-6; F: Immunohistochemical staining was negative for BCL-2.