Burkitt's lymphoma causing acute pancreatitis in a child

Muhammed Ak?l, Avni Kaya, M.Sel?uk Bekta?, Fesih Aktar, Sinan Akbayram, Salim Bilici, Mehmet Beyazal

1Yüzüncü Y?l University, Faculty of Medicine, Departments of Pediatrics Van, Turkey

2Van Women’s and Children’s Hospital, Van, Turkey

3Yüzüncü Y?l University, Faculty of Medicine, Departments of Pediatric Surgery Van, Turkey

4Yüzüncü Y?l University, Faculty of Medicine, Department of Radiology, Van, Turkey

Burkitt's lymphoma causing acute pancreatitis in a child

Muhammed Ak?l1, Avni Kaya2*, M.Sel?uk Bekta?2, Fesih Aktar1, Sinan Akbayram1, Salim Bilici3, Mehmet Beyazal4

1Yüzüncü Y?l University, Faculty of Medicine, Departments of Pediatrics Van, Turkey

2Van Women’s and Children’s Hospital, Van, Turkey

3Yüzüncü Y?l University, Faculty of Medicine, Departments of Pediatric Surgery Van, Turkey

4Yüzüncü Y?l University, Faculty of Medicine, Department of Radiology, Van, Turkey

A 8-year-old boy admitted with abdominal pain, fever and vomiting for the previous 10 days. Sensitivity was detected in the epigastric area. There was not defense and rebond. Aspartate aminotransferase was 106 U/L, alanine aminotransferase 25 U/L, alkaline phosphatase 311 U/L, blood amylase level 748 U/L, blood lipase level 391 U/L. In thoracic CT, soft tissue with smooth contours measuring 32 mm×28 mm was identified in the posterior mediastinum. Bone marrow aspiration biopsy was normal. A mass specimen obtained from the duodenum endoscopic biopsy. This specimen was diffuse staining by leukocyte common antigen, CD10 and CD20. The patient was diagnosed with acute pancreatitis associated with stage 3 duodenal Burkitt's lymphoma. Modified LMB-98 was initiated. Burkitt's lymphoma may rarely cause acute pancreatitis.

1. Introduction

Burkitt’s lymphomas or their variants (approximately 40% of non-Hodgkin lymphomas) seen in child age. Sporadic Burkitt’s lymphoma is most common involvement in the abdomen. Approximately 25%-30% of children are develop acute abdomen due to the right lower quadrant mass or ileo-cecal invagination. The initial presentation of disease occurs are abdominal pain, nausea, vomiting, gastrointestinal bleeding or perforation[1,2]. Non-Hodgkin’s lymphoma can begin acute pancreatitis rarely[3].

We reported 8-year-old boy who developed acute pancreatitis due to duodenal involvement with Burkitt’s lymphoma.

2. Case report

A 8-year-old boy admitted with abdominal pain, fever andvomiting for the previous 10 days. His personal and family history was unremarkable. The general situation moderate and he was conscious his physical examination. Sensitivity was detected in the epigastric area. There was not defense and rebond. There was not organomegaly and peripheral lymphadenopathy. In the laboratory examination, white blood cell count was 7 800 mm3, hemoglobin 13.8 g/dL and thrombocyte count 428 mm3. Aspartate aminotransferase was 106 U/L, alanine aminotransferase 25 U/L, alkaline phosphatase 311 U/L, blood amylase level 748 U/L, blood lipase level 391 U/L. Serum albumin, glucose, urea, creatinine, and electrolyt values were normal limits. Sedimentation was 20 mm/h and C-reactive protein was 3 mg/dL. In the abdominal ultrasonography, the pancreas was enlarged and fluid in a rim pattern was identified. Pancreatic duct was apparent. Multiple lymphadenopathy was determined in the mesenteric area (Figure 1). The thickest part of the duodenum was measured at 15 mm in the abdominal computed tomography (CT). The pancreatic duct was remarkable and measured 3.5 mm. Diffuse wall thickening and perihepatic fluid were observed (Figure 2). There was not periduodenal lymphadenopathy and peripancreatic lymphadenopathy. In thoracic CT, softtissue with smooth contours measuring 32 mm × 28 mm was identified in the posterior mediastinum. Brain CT was normal. Bone marrow aspiration biopsy was normal. A mass specimen obtained from the duodenum endoscopic biopsy. This specimen was diffuse staining by leukocyte common antigen, CD10 and CD20. The patient was diagnosed with acute pancreatitis associated with stage 3 duodenal Burkitt’s lymphoma. Modified LMB-98 was initiated. Blood amylase and lipase levels of the patient were arrived normal limits in the past of the one week chemotherapy. Unfortunately, the patient was lost in the initial month of chemotherapy due to febrile neutropenic sepsis.

Figure 1. Transverse sonogram of the epigastrium demonstrates diffuse enlarged hypoechoic pancreas, dilatation of biliary (black arrow) and pancreatic duct (arrow head), distension of the gall bladder (thin arrow), hypoechoic mass (thick arrow) surrounding the lumen of the duodenum.

Figure 2. Post-contrast axial abdominal CT image shows diffusely enlarged pancreas (white arrow), dilatation of biliary and pancreatic duct (black arrows).

3. Discussion

Burkitt’s lymphomas are fairly aggressive B-cell tumors characterized with chromosome 8 translocation and C-myc gene[4]. Abdominal involvement can develop in the duodenum, cecum, between ascending colon and jejunum, and within the pelvis. Primary lymphoid lymphoma which constitutes less than 5% of all small bowel lymphomas is a rarely encountered condition developing due to lack of duodenal lymphoid tissue. Nonspecific indications may sometimes persist for years prior to diagnosis[5]. In our patient appeared abdominal pain, fever and vomiting. There was not weight loss, edema, obstructive symptoms and gastrointestinal bleeding.

Considering the low incidence of Burkitt’s lymphoma, it is rare for it to manifest itself as acute pancreatitis on admission[6]. Acute pancreatitis developing due to pancreatic involvement has been rarely reported in Burkitt’s lymphoma[3,7]. Moreover, a case presentation of acute pancreatitis developed due to solitary hepatic Burkitt’s lymphoma[8]. Glória et al[9] reported a duodenal infiltrative Burkitt’s lymphoma by ultrasonography, CT and endoscopy followed-up with diagnoses of acute pancreatitis, pleural effusion and acid in a 13-year-old boy. They were full remission with chemotherapy in their patient.

We associated the increase in blood amylase and lipase levels with the acute pancreatitis related to the rapid growth of Burkitt’s lymphoma. No cholestasis was detected. Following chemotherapy for Burkitt’s lymphoma, it was observed that the clinical and laboratory course of acute pancreatitis improved completely at the initial week. We lost the patient in the initial month of chemotherapy due to febrile neutropenic sepsis.

In conclusion; Burkitt’s lymphoma may rarely cause acute pancreatitis.

Conflict of interest statement

We declare that we have no conflict of interest.

[1] Link MP, Weinstein HJ. Malignant non-Hodgkin lymphomas in children. In: Pizzo PA, Poplack DG (eds). Principles and practice of pediatric oncology. Philadelphia: Lippincott Williams and Wilkins; 2006, p. 728-747.

[2] Magrath I. B-cell lymphoma/Burkitt lymphoma. In: Weinstein HJ. Hudson MM, Link PM (eds). Pediatric lymphomas. New-York: Springer; 2007, p. 142-168.

[3] Amodio J, Brodsky JE. Pediatric Burkitt lymphoma presenting as acute pancreatitis: MRI characteristics. Pediatr Radiol 2010; 40: 770-772.

[4] Toma P, Granata C, Rossi A, Garaventa A. Multimodality imaging of Hodgkin disease and non-Hodgkin lymphomas in children. Radiographics 2007; 27: 1335-1354.

[5] Smith C, Kubicka RA, Thomas CR Jr. Non-Hodgkin lymphoma of the gastrointestinal tract. Radiographics 1992; 12: 887-899.

[6] Benifla M, Weizman Z. Acute pancreatitis in childhood: analysis of literature data. J Clin Gastroenterol 2003; 37: 169.

[7] Francis IR, Glazer GM. Burkitt’s lymphoma of the pancreas presenting as acute pancreatitis. J Comput Assist Tomogr 1982; 6: 395-397.

[8] Wan YL, Chen WJ, Huang SC, Lee TY, Tsai CC. Solitary hepatic Burkitt lymphoma presenting as acute pancreatitis. Pediatr Radiol 1988; 18: 160.

[9] Glória Silva F, Paiva M, Tavares A, Lacerda A, Pereira G, Marques A, et al. Paediatric Burkitt lymphoma presenting as acute pancreatitis. Acta Med Port 2008; 21: 515-520.

10 January 2013

*Corresponding author: Dr. Avni Kaya, Pediatrist, MD, Van Women’s and Children’s Hospital, Van, Turkey.

Office: +904322171983

Mobil: +905052677045

Fax: +904322150479

E-mail: avnikaya@gmail.com

ARTICLE INFO

Article history:

Received in revised form 15 January 2013

Accepted 15 March 2013

Available online 20 June 2013

Abdominal pain

Child

Duodenum