An Unusual Cause of a Common Duodenal Pathology

A 50-year-old man presented with 10 days of intractable nausea, vomiting, and abdominal pain accompanied by a 20-pound weight loss and night sweats without fever. Physical examination was notable for a soft abdomen with tenderness in the epigastric region and markedly reduced right hand grip strength and hypothenar atrophy. Admission investigations including complete blood count, electrolytes, renal function, and liver enzymes were within normal limits. Computed tomography of the abdomen revealed irregular inflammatory changes in the third portion of the duodenum with periduodenal lymphadenopathy. Urgent gastroscopy demonstrated a shallow, large antimesenteric ulcer in the second part of the duodenum (Figure A). The appearance of the ulcer was irregular and biopsies were taken. The ulcer was reminiscent of human immunodeficiency virus gastrointestinal inflammation and serology was performed. CD4 count was 150 cells/μL. Human immunodeficiency virus viral load was 56,396 copies/mL. On retrospective inquiries, the patient admitted to prior unprotected sexual relationships with men. Pathology revealed an aggressive diffuse large B-cell lymphoma associated with elevated Ki-67 expression and presence of Epstein-Barr virus (Figures B and C). MYC protein was overexpressed, associated with an MYC gene amplification (Figure D). The patient was transferred under the care of the malignant hematology service and was started on R-CHOP chemotherapy with rapid improvement in his symptoms.