Digestive Diseases and Sciences, Vol. 50, No. 12 (December 2005), pp. 2359–2361 ( C  2005) DOI: 10.1007/s10620-005-3063-1 Intestinal B Cell Lymphoma Associated with Chronic Hepatitis C and Celiac Disease S ¸ AHIN C ¸ OBAN, MD,* MURAT PALABIYIKO ˘ GLU, MD,* ARZU ENSARI, MD,† RAMAZAN IDILMAN, MD,* SEYFETTIN K ¨ OKL ¨ U, MD,‡ ¨ OMER FARUK YOLCU, MD,‡ and NECATI ¨ ORMECI, MD* KEY WORDS: celiac disease; hepatitis C virus; B cell lymphoma. Celiac disease (CD) is a condition characterized by dif- fuse damage of proximal small intestinal mucosa induced by gluten, leading to malabsorption of many nutrients. Al- though it usually presents in infancy, the onset of initial clinical signs and symptoms may be observed between the second and the fourth decades or even later. The under- lying mechanism of the damage has not yet been clearly defined. Identifying CD patients with few or no symptoms is of critical value in the follow-up of the disease, which has a high mortality rate due to malignant complications. A notable complication of CD is the development of ma- lignancies such as T cell lymphoma, which constitutes 50% of all malignancies in individuals with CD (1, 2). B cell intestinal lymphoma associated with CD has rarely been reported (3–6). The prevalence of hepatitis C virus (HCV) infection in patients with B cell non-Hodkin’s lymphoma (NHL) is quite variable, ranging from 1 to 30% (7–12). On the other hand, nearly 60% of patients with chronic hepatitis C develop B cell clonal expansion (10). The following is a case report of a patient with CD and hepatitis C who developed intestinal diffuse large B cell lymphoma. Focusing on this rare complication, we dis- cuss the possible mechanisms in the light of the pertinent literature. CASE REPORT A 73-year-old male was admitted to our hospital with com- plaints of severe abdominal pain for 3–4 hr. In the history, he had Manuscript received June 8, 2004; accepted November 3, 2004. From the Departments of *Gastroenterology and †Pathology, Ankara University Medical School, and ‡Department of Gastroenterology, T¨ urkiye Y ¨ uksek Ihtisas Hospital, Ankara, Turkey. Address for reprint requests: S ¸ahin C ¸ oban, MD, 39 Cd. Pembe K¨ o¸ sk Apt. 1/4, 06520, C ¸ ukurambar Mh., Balgat, Ankara, Turkey; scoban72@yahoo.com. presented at the hospital with complaints of diarrhea, malaise, and peripheral edema lasting for 4 weeks 13 years previously. Laboratory investigations had revealed iron deficiency anemia and hypoalbuminemia. Serological markers of CD were positive (Table 1). In radiologic examination, slight dilatation of the small intestinal loops and thickening of the villi had been observed. Small intestinal biopsy had showed villous atrophy, increased in- traepithelial lymphocytes, crypt hypertrophy, and lymphoplas- mocytic infiltration in lamina propria. Hence, the patient had been diagnosed with CD and followed up at our hospital since then. He had no complaints while he was on a gluten-free diet (GFD). During follow-up, the patient had been hospitalized a few times because of flare-ups following cessation of GFD. Once he had begun the GFD, his symptoms had disappeared gradu- ally. Thus, no medication had been administered for flare-ups of the CD. Four years ago, he was diagnosed with HCV-related chronic active hepatitis and was given interferon-α (3 MU/day 3 times/week) and ribavirin (1200 mg/day) for a year. HCV RNA was positive 6 months after the end of treatment. On follow-up, a biochemical response was achieved, however, HCV RNA was positive (Table 1). On admission, physical examination revealed abdominal ten- derness and rebound on palpation. The patient was tachycardic (112 beats/min) and tachypneic (21/min). His blood pressure was 120/70 mm Hg and his body temperature was 38,1 ◦ C. He also had peripheral edema. Laboratory investigations were as fallows: WBC, 15,600 mm 3 ; Hb, 13.5 g/dL; platelets, 234,000/mm 3 ; and sedimentation rate, 62/hr. Biochemical tests were within normal ranges except LDH and albumin. Anti-HCV and HCV RNA were positive (Table 1). Abdominal x-ray showed air-fluid levels and free air beneath the right diaphragm. Abdominal computerized tomography confirmed intra-abdominal perfo- ration with segmental thickening of ileum without abdominal lymphadenopathies. The patient underwent surgery with the diagnosis of acute abdomen. Intestinal perforation and a mass approximately 5 cm in diameter were observed in the ileum wall intraoperatively. Thus small intestinal resection and end-to-end anastomosis were performed. Gross examination of the surgical specimen showed a large mass in the bowel wall with ulcerated mucosa. On microscopy, an aggressive large cell lymphoma was observed infiltrating the wall, with no infiltration in surgical resection margins (Figure 1). Immunohistochemical examination revealed Digestive Diseases and Sciences, Vol. 50, No. 12 (December 2005) 2359 0163-2116/05/1200-2359/0 C  2005 Springer Science+Business Media, Inc.