Epstein-Barr Virus (EBV) Lymphoproliferative Disorder Mimicking Watermelon Stomach (GAVE, Gastric Antral Vascular Ectasias)

Epstein Barr Virus (EBV) Lymphoproliferative Disorder Mimicking Watermelon Stomach (GAVE, Gastric Antral Vascular Ectasias)

by Klaus Mönkemüller, MD, PhD, FASGE, FJGES

Department of Gastroenterology, Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA

Figure 1. Epstein Barr Virus (EBV) Lymphoproliferative Disorder Mimicking Watermelon Stomach (GAVE, Gastric Antral Vascular Ectasias). A. Notice the multiple submucosal erythematous patches and prominent antral mucosal folds. B. The mucosa is obviously edematous. Panel C shows NBI.

The biopsy showed gastric mucosa with a dense lymphoid infiltrate with intermixed plasma cells, eosinophils, and histiocytes with a significant amount of edema, replacing and pushing the gastric mucosa. A significant portion of the lymphoid cells were CD79a positive with the same cells positive for EBV on an EBER in situ hybridization ancillary study. There were small aggregates of CD20 positive B-cells CD3 and CD5 and CD43 marked a select number of background T-cells. Immunohistochemistry for H. pylori negative. In sum, the histologic and ancillary studies support an unusual EBV positive B-cell lymphoproliferative disorder, with EBV positive B-cell lymphoma favored.

Epstein-Barr virus (EBV) has been linked to the development of a variety of human malignancies, including Burkitt's lymphoma, Hodgkin's disease, nasopharyngeal carcinoma, some T cell lymphomas (e.. g. NK/T), post-transplant lymphoproliferative disease, and more recently, certain cancers of the stomach, breast and smooth muscle (1-3). The oncogenic potential of EBV is related to its ability to infect and transform B lymphocytes into continuously growing lymphoblastoid cell lines (2). EBV encodes a series of products mimicking several growth, transcription and anti-apoptotic factors, to usurp control of the pathways that regulate diverse homeostatic cellular functions (2).

EBV-lymphoproliferative disorder may mimic inflammatory bowel disease (4, 5). Our case is unusual for two main reasons. First, the EBV-lymphoproliferative disorder mimicked GAVE. And second, there are very few reports in the literature of gastric EBV. It is important to keep EBV in mind as etiologic for a variety of neoplasias, including EBV-lymphoproliferative disorder

References

Baumforth KR, Young LS, Flavell KJ, Constandinou C, Murray PG. The Epstein-Barr virus and its association with human cancers. Mol Pathol. 1999 Dec;52(6):307-22. doi: 10.1136/mp.52.6.307. PMID: 10748864; PMCID: PMC395716.Hematemesis due to prolapse gastropathy: an emetogenic injury. Byfield F, Ligresti R, Green PHR, Finegold J, Garcia-Carrasquillo RJ. Gastrointest Endosc. 1998;45:527–529.

Grywalska E, Markowicz J, Grabarczyk P, Pasiarski M, Roliński J. Epstein-Barr virus-associated lymphoproliferative disorders. Postepy Hig Med Dosw (Online). 2013 May 24;67:481-90. doi: 10.5604/17322693.1050999. PMID: 23752600.

Martínez-Alcalá A, Gutierrez JP, Mönkemüller K. Endoscopic repair of complex pyloroduodenal stenosis resulting from post-transplant lymphoproliferative disorder. Endoscopy. 2016;48 Suppl 1 UCTN:E90-1. doi: 10.1055/s-0042-102961. Epub 2016 Mar 7. PMID: 26951477.

Abdul-Ghafar J, Kim JW, Park KH, Cho MY. Fulminant Epstein-Barr virus-associated T-cell lymphoproliferative disorder in an immunocompetent middle-aged man presenting with chronic diarrhea and gastrointestinal bleeding. J Korean Med Sci. 2011 Aug;26(8):1103-7. doi: 10.3346/jkms.2011.26.8.1103. Epub 2011 Jul 28. PMID: 21860564; PMCID: PMC3154349.

Zheng X, Xie J, Zhou X. Epstein-Barr virus associated T-cell lymphoproliferative disease misdiagnosed as ulcerative colitis: a case report. Int J Clin Exp Pathol. 2015 Jul 1;8(7):8598-602. PMID: 26339440; PMCID: PMC4555768.