Case Presentation: A 73-year-old man presented to his PCP after noticing new onset jaundice. He endorsed 6 weeks of decreased appetite, intermittent abdominal pain and 7-pound weight loss. Lab analysis demonstrated a cholestatic pattern of liver injury and elevated CA 19-9. CT abdomen revealed an infiltrative soft tissue mass originating from the head of the pancreas with extension into the mesentery and correlating bile duct occlusion. Adjacent retroperitoneal, portocaval, and gastrohepatic lymphadenopathy was also present. The patient was informed he likely had pancreatic cancer and was referred to surgery for resection. However, his mass was deemed unresectable, and he was referred to GI for ERCP and EUS with biopsy to confirm diagnosis and plan subsequent neo-adjuvant chemotherapy. During his ERCP, the bile duct was unable to be canulated. EUS revealed a conglomeration of lymph nodes at the pancreatic head rather than a mass resulting in lymph node biopsy. During the procedure he developed atrial flutter with rapid ventricular response and dyspnea requiring transfer to the ED for evaluation. There he was found to have right axillary lymph nodes on CTPA. Following admission, he underwent percutaneous transhepatic biliary drainage with improvement in his LFTs. Pathology results from the biopsy showed benign pancreatic cells and necrotic tissue from the lymph nodes. This in combination with, isolated axillary metastasis, and EUS findings raised the question of an alternative diagnosis. Simultaneous right axillary lymph node biopsy and repeat EUS ultimately revealed diffuse large B cell lymphoma and no evidence of metastatic carcinoma. Bone marrow biopsy and imaging confirmed stage III disease. Chemotherapy was initiated with rituximab, prednisone, cyclophosphamide, and doxorubicin. He was discharged with plans to initiate polatuzumab as an outpatient.
Discussion: Diffuse large B cell lymphoma (DLBCL) is commonly associated with lymphadenopathy, fever, night sweats, and unexplained weight loss (B symptoms) as its usual clinical presentation. However, the diagnosis may be delayed depending on the location of the lymphadenopathy and other accompanying symptoms.This case highlights the importance of considering a broad range of possibilities in the differential diagnosis when presented with unusual or atypical clinical presentations. It is also a reminder that relying solely on a single diagnostic test or marker (CA 19-9) can be misleading and may lead to the incorrect diagnosis. In similar cases, utilizing a multidisciplinary team can expediate accurate diagnosis and guided treatment decisions.
Conclusions: It is crucial to maintain a high level of suspicion for lymphoma when evaluating patients with gastrointestinal symptoms, even in the absence of palpable lymphadenopathy or classic B symptoms. Timely diagnosis and treatment can have a significant impact on patient outcomes, and early recognition of the potential for lymphoma can help avoid unnecessary procedures and treatments.