Cytomegalovirus gastritis after treatment with rituximab

We present a case of gastric ulcer with bleeding following chemotherapy with rituximab for non-Hodgkin’s lymphoma (NHL).

A 68-year-old woman presented with hematemesis and melena. One year ago she had been diagnosed as having diffuse large B-cell NHL (stage IE) of the nasal root. She was treated with three courses of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) followed by radiation therapy at a dose of 40 Gy, resulting in complete remission of the NHL. However, the patient had a relapse, with evidence of NHL in the thyroid gland and the mediastinal lymph nodes. Two weeks before the patient had hematemesis, she had been administered the first cycle of a second course of R-CHOP. At presentation, her hemoglobin level was 5.2 g/dL, which was lower than 2 days earlier (7.9 mg/dL). An esophagogastroduodenoscopy revealed multiple, irregular-shaped ulcers, with clearly demarcated borders, in the body of the stomach ([Fig. 1 a]).

Fig. 1 Esophagogastroduodenoscopy showing: a multiple ulcers with sharply defined borders; and b blood vessels at the base.

One ulcer had vessels visible at the base ([Fig. 1 b]), and a hemoclip was placed endoscopically. Histological examination of the biopsy specimens showed nuclear inclusions in the epithelial cells ([Fig. 2 a]) with positive immunostaining for cytomegalovirus (CMV) ([Fig. 2 b]).

Fig. 2 Histological image showing: a epithelial cells containing nuclear inclusions; and b positive immunostaining for cytomegalovirus.

Rituximab is a mouse/human chimeric monoclonal antibody that targets the CD20 antigen found on the surface of malignant and normal cells of B-cell lineage and has been proved to be effective in the treatment of B-cell NHL [1] [2]. However, the use of rituximab is associated with the development of certain severe viral infections [3] [4] [5]. Cytomegalovirus gastritis should be considered in the differential diagnosis in patients with gastric ulcers who are receiving rituximab treatment.

Endoscopy_UCTN_Code_CCL_1AB_2AD_3AC

References

• 1 Feugier P, Van Hoof A, Sebban C. et al . Long-term results of the R-CHOP study in the treatment of elderly patients with diffuse large B-cell lymphoma: a study by the Groupe d’Etude des Lymphomes de l’Adulte.  J Clin Oncol. 2005;  23 4117-4126
• 2 Persky D O, Unger J M, Spier C M. et al . Phase II study of rituximab plus three cycles of CHOP and involved-field radiotherapy for patients with limited-stage aggressive B-cell lymphoma: Southwest Oncology Group study 0014.  J Clin Oncol. 2008;  26 2258-2263
• 3 Aksoy S, Harputluoglu H, Kilickap S. et al . Rituximab-related viral infections in lymphoma patients.  Leuk Lymphoma. 2007;  48 1307-1312
• 4 Lee M Y, Chiou T J, Hsiao L T. et al . Rituximab therapy increased post-transplant cytomegalovirus complications in Non-Hodgkin’s lymphoma patients receiving autologous hematopoietic stem cell transplantation.  Ann Hematol. 2008;  87 285-289
• 5 Vallet S, Tempescul A, Tran A. et al . Cytomegalovirus-associated meningoradiculoneuritis after treatment of mantle cell lymphoma with a combination of chemotherapy and rituximab.  Ann Hematol. 2005;  84 545-547