P0474 - A Rare Case of Diffuse Nodular Lymphoid Hyperplasia With Rectal Involvement

James R. Pellegrini, MD¹, Shino Prasandhan, MD², Jose R. Russe-Russe, MD², Michael Baldino, DO², Pranay Srivastava, MD², Bobby Jacob, MD³, Charudatta Wankhade, MD², Paul Mustacchia, MD, MBA^2
1Nassau University Medical Center, Great River, NY; ²Nassau University Medical Center, East Meadow, NY; ³Nassau University Medical Center, Lake Grove, NY

Introduction: Nodular lymphoid hyperplasia (NLH) is characterized by the growth of multiple discrete small submucosal nodules specifically confined to the lamina propria and superficial submucosa layers of the intestinal wall.These nodules typically range from 2 to 10mm in diameter. When these mucosal lymphoid aggregates in the small and large bowel it is known as diffuse lymphoid hyperplasia, which is a more common finding and relatively benign. Gastric and rectal involvement of NLH is exceedingly rare. To date, few case reports have described diffuse nodular lymphoid hyperplasia presenting with multiple submucosal lymphomatous polyposis occurring in the rectum.

Case Description/Methods: Our patient is 39 year old morbidly obese hispanic female who presents to the gastroenterology clinic complaining of intermittent hematochezia for the past 6 months. The patient associated her hematochezia with straining on defecation, the sensation of incomplete voiding, and small caliber stools. The rest of the review of systems were unremarkable. Colonoscopy showed diffuse nodularity in the sigmoid colon and rectal mucosa, extending 20 cm from the rectal verge (Figure 1). Rectal biopsies revealed moderate active chronic inflammation predominantly of lymphoplasmacytic cells with areas of lymphoid hyperplasia and focal surface ulceration. Immunohistochemistry stains revealed reactive lymphoid hyperplasia (RLH).

Discussion: NLH is a remarkably rare disorder and rectal involvement is even more scarce. NLH is a risk factor for extraintestinal and intestinal lymphomas. Thus, when encountering lymphoid hyperplasias, the possibility of malignancy must always be considered. Lymphoid hyperplasias are difficult to classify as benign or malignant. Classification is distinguished by the poly-morphology of the infiltrates, the cytologic atypia, and the reactive lesions within the follicles. Immunohistochemistry is the gold standard for definitive diagnosis. A study of 781 non-protruding colorectal neoplasms (adenomas and early carcinomas) suggested an association between these neoplasms and colonic lymphoid nodules. The concept of RLH seems to be a spectrum ranging from lesions of completely benign lymphoid hyperplasia to malignant lymphomas, but in many cases are often classified as pre-lymphomas. It is crucial to monitor patients with NLH via capsule endoscopies, small bowel series, and colonoscopy for surveillance of new lesions in light of the potential for malignancy.


Figure: Colonoscopy revealing diffuse nodularity in the rectum


Disclosures:
James Pellegrini indicated no relevant financial relationships.
Shino Prasandhan indicated no relevant financial relationships.
Jose Russe-Russe indicated no relevant financial relationships.
Michael Baldino indicated no relevant financial relationships.
Pranay Srivastava indicated no relevant financial relationships.
Bobby Jacob indicated no relevant financial relationships.
Charudatta Wankhade indicated no relevant financial relationships.
Paul Mustacchia indicated no relevant financial relationships.


James R. Pellegrini, MD¹, Shino Prasandhan, MD², Jose R. Russe-Russe, MD², Michael Baldino, DO², Pranay Srivastava, MD², Bobby Jacob, MD³, Charudatta Wankhade, MD², Paul Mustacchia, MD, MBA². P0474 - A Rare Case of Diffuse Nodular Lymphoid Hyperplasia With Rectal Involvement, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.