Ascites as First Atypical and Only Clinical Manifestation of De Novo Follicular Lymphoma

Abstract

Follicular lymphoma is the most common indolent non-Hodgkin's lymphoma and is usually initially detected in lymph nodes. Primary extranodal NHL is most commonly primarily localized in the gastrointestinal tract. We present one unusual case of ileum FL with ascites as the first clinical sign. The 73-year-old female patient was presented to the emergency department for evaluation of mild abdominal pain and abdominal swelling that had been going on for three days followed by bloating and occasional pain in the spine. The abdominal contrast-enhanced CT revealed the contrast stagnation in the distal part of the ileum. The ileum wall about 11 cm in length was thickened up to 2.9 cm and the tumor mass infiltrated all layers of ileum mesenteric lymphadenopathy up to 2 cm in diameter and significant ascites. On the upper ileum wall, the vegetative mass was described 3 cm in diameter. The patient had an emergent laparotomy with the ileocolic resection and latero-lateral ileocolic anastomosis. The microscopy finding of terminal ileum and the regional lymph nodes showed domination of cleaved cells with irregular nuclei which correspond to centrocytes. There were 0-15 large non-cleaved cells corresponding to centroblast in the microscopy high-power field. The final diagnosis was follicular lymphoma, the clinical stage 2E and histological grade by Berard and Mann criteria 1-2.

Keywords: ascites; follicular lymphoma; gastrointestinal lymphoma.

Figure 1

The tumor mass infiltrated all layers of the ileum wall (A). The vegetative mass about 3 cm in dimeter on the upper ileum wall (B). On all three images, ascites is present (C).

Figure 2

Macroscopic finding.

Figure 3

Resected ileum tissue showed centrocyte and centroblast (A). Cells were positive on CD20, CD79a, CD10, bcl-2, bcl-6 (B).