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He felt all the time fatigued !

Clinical scenario:  
        A 54 yr old male was admitted with history of fatigue and generalized malaise of 3 weeks duration . He also complained of postprandial fullness and an episode of non bilious vomiting .Patient denied history of fever , night sweats but had weight loss of 3 kgms over this period.
      Prior to this presentation he was admitted in a different hospital one month ago with history of epigastric pain of 3 days duration and was managed as acute pancreatitis based on high levels of Amylase and lipase and an ultrasound evidence of gall stones at that time .After necessary treatment his pain had settled and was  discharged home with an advice for follow up. Patient has been known case of Diabetes mellitus for last 5 years on oral hypoglycemic agents.

Clinical Examination : 
 On examination  he was conscious , oriented in time place and person with stable vitals . There was no icterus , pallor or lymphadenopathy Systemic examination was normal.
Investigations : 
The blood  tests revealed Hemoglobin of 11gm/dl WBC 9500 normal platelets  . Bilirubin levels of 2.3mg .ALP 230 KA units   ALT/AST 65/57. Kidney functions and electrolytes were normal . Serum Amylase and Lipase were normal too. HIV serology was negative .
Hospital course:  
        Patient underwent Upper GI examination which revealed thick whitish patches in esophagus suggestive of candidiasis and brush  biopsy later confirmed . The stomach showed diffuse thickening of stomach folds and multiple biopsies were taken . D1 was normal and D2 showed diffuse thickening extended to Peri-ampullary area Explaining his episode of pancreatitis few weeks prior to current presentation 

Fig 1 Esophgus showing candidiasis  

Fig 2 Diffuse thickening in the  stomach wall,

Patient underwent CT scan abdomen which showed diffuse thickening in antral area (red arrow) Note was made of  abdominal lymphadenopathy .
Fig 3 CT scan stomach showing diffuse thickening near antrum and body of stomach.

The biopsy from stomach showed Aggressive Non Hodgkin B cell Lymphoma consistent with Burkitt's Lymphoma . Immunostains CD20++ ,CD79a++, CD 43+Ki-67++ Bcl-2 AlK1-+. Quick stain for H pylori was negative.
The bone marrow biopsy was done to stage the disease .It showed hypercellularity due to infiltration of  lymphocytes blue cytoplasm and vacculations (stary sky appearance ) around 35% Reduced erthrpoises . The biopsy was consistent with stage 4  Lymphoma
The patient was  planned for chemotherpay 
Fig 4 Microscopy showing features of NHL 

Burkitt lymphoma is a substantially aggressive mature B cell neoplasm mainly in children and young adults. This entity has three recognized clinical variants: endemic form which is usually associated with EBV infection, sporadic variant where only about 30% of the cases are related to EBV infection, and immunodeficiency associated BL . Extra nodal disease is frequently observed but GI tract involvement varies among the three clinical subtypes, with the sporadic variant usually presenting as an abdominal mass, commonly in the terminal ileum . Rare cases of gastric as the index case  and cecal  BL have also been described.

Further reading : Gastrointestinal Lymphomas

This case was Contributed by 
Dr Ali Al Ahmari  M.D
Head of dept. Gastroenterology
 Al Hada Military  Hospital Taif Saudi Arabia