it can also be caused by prior surgery , foreign bodies , pancreatitis , diverticulitis , and malignancy.1 - 4 small bowel tumors account for 1% to 3% of all gastrointestinal neoplasms.5 malignant lymphoma accounts for up to 20% of all primary malignant tumors of the small bowel,6 and most primary small intestine lymphomas are of b - cell origin . lymphomas originating from t - cells are rare.6,7 in japan , only 24 cases of t - cell malignant lymphoma of the small intestine have been reported and primary intestinal peripheral t - cell lymphoma ( ptcl ) is especially rare.8 intestinal fistula is known to be a late complication of primary intestinal lymphoma , and so is rarely encountered . this report describes a case - to our knowledge this is first reported case in korean population - of primary intestinal ptcl causing jejunocolic fistula and perforation . a 56-year - old man presented with an acute diarrheal illness that had begun 14 days prior to first hospital visit . the patient had intermittent fevers , chills , night sweat 1 month previously and a 9 kg loss of body weight in the previous 3 months . the patient was cachectic and pale , but appeared nontoxic on physical examination with a soft and flat abdomen , normoactive bowel sounds and no tenderness or palpable lymphadenopathy . the past medical history was significant for pulmonary tuberculosis in the third decade of life and chronic hepatitis b carrier state . initial laboratory tests revealed the following results : leukocyte counts 7.210/l ( neutrophile 75.5% ) , hemoglobin 11 g / dl , platelets 40710/l , total protein 6.6 g / dl , albumin 3.9 g / dl , total bilirubin 1.0 mg / dl , ast 73 iu / l , alt 65 iu / l , alkaline phosphatase 193 iu / l , ldh 212 iu / l , bun 12.3 mg / dl , creatinine 0.96 mg / dl , sodium 129 mmol / l , potassium 3.3 mmol / l , cl 93 mmol / l , plasma cea 0.2 ng / ml , with a normal blood cell morphology . contrast enhanced computed tomography ( ct ) of the abdomen showed focal wall thickening in the distal transverse colon with enlarged regional lymph nodes ( fig . a fistula opening communicating with a small bowel was identified at the distal transverse colon , and a circumferential ulcer was detected in the small bowel side through the fistula opening ( figs 2 and 3 ) . biopsies from the circumferential ulcer of small bowel side showed an aggregation of atypical lymphoid cells suggestive of lymphoma . however , biopsies from the margin of the colonic fistula opening showed chronic inflammation only . patient refused to admit and further evaluation until histologic diagnosis of the lesion is determined . therefore , the further studies including ct enterography and follow - up colonoscopy for additional biopsy were delayed . two weeks after the colonoscopy , at his 3rd visit to outpatient clinic for admission , the patient presented with acute abdominal distress . an emergency laparotomy was performed , which revealed a large inflammatory mass - like lesion covered with omentum . an extended right hemicolectomy and segmental jejunectomy were performed with dissection of regional mesenteric lymph nodes . pathology revealed a 7.05.5 cm - sized ulcerated fistula tract between the jejunum and the distal transverse colon ( fig . light microscopy examination of the involved small intestinal mucosa showed diffuse infiltration of predominantly medium - sized atypical lymphoid cells in the lamina propria ( h&e stain , 400 ) , but findings of normal small bowel mucosa showed normal villi without atrophic change . immunohistochemical staining was positive for leukocyte common antigen , cd30 , cd3 , and galectin-3 ; weakly positive for cd4 ; and negative for cd56 , anaplastic lymphoma kinase , and cd8 ( fig . after surgery , the patient 's condition continued to deteriorate and he died 2 months after surgery due to peritonitis and sepsis . gastrointestinal lymphomas represent 1% to 10% of all gastrointestinal malignancies,9,10 up to 20% of all small bowel malignancies5,6 and only 0.2% to 0.4% of large bowel malignancies.11 most primary small intestine lymphomas originate from b - cells , with t - cell origin being rare.6,7 the most common location of ptcl is the jejunum12 and common symptoms include abdominal pain , nausea , vomiting , diarrhea , fatigue , weight loss and fever . therefore , the diagnosis of lymphoma of the small intestine is often made after complications such as hemorrhage , obstruction or perforation develop.6,13 enterocolic fistula is a rare complication in patients with intestinal lymphoma . it has been noted that most gastrointestinal malignant fistulas arise in the presence of locally invading adenocarcinoma.14 in the natural course of ptcl , enterocolic fistula is likely to represent a late complication and suggests an advanced disease.15 to the best of our knowledge , only six cases enterocolic fistula associated with lymphoma have previously reported in the english literatures . of these , four were b - cell lymphoma15 - 18 and two cases were t - cell lymphoma.9,19 in all six cases , diarrhea was an initial symptom . there has been no other case of intestinal lymphoma causing alimentary tract fistula reported in korea . although the patient already had intestinal adhesion and enterocolic fistula at the time of the first hospital visit , physical examination revealed no abdominal tenderness or palpable abdominal mass . fever , night sweat and extensive weight loss were the only clues to suspect a malignant disease . the patient 's diarrhea may be explained by short bowel syndrome and small bowel bacterial overgrowth syndrome caused by refluxed colonic bacteria.20,21 in summary of the symptoms above , fever and extensive weight loss were clinical clues to the diagnosis of malignant disease . subacute diarrhea that was intractable with the conventional antidiarrheal agent and negative stool studies were clues to presume an intestinal fistula . barium studies , endoscopy and ct enterography are useful tools for demonstrating a fistulous tract . resection of tumor and regional lymph nodes constitutes the initial treatment of small bowel lymphoma . after surgery , combination chemotherapy is the preferred option.22 in comparison with b - cell lymphoma , ptcl is a heterogeneous group of neoplasms presenting as advanced disease , and is characterized by widespread dissemination , aggressive behavior and a very poor outcome.23 the therapeutic outcome of ptcl is usually worse than that of diffuse large b - cell lymphoma.24 in conclusion , we report a male patient with primary intestinal ptcl complicated with enterocolic fistula and small bowel peforation . although intestinal ptcl is an extremely rare disease , particular attention should be paid its nonspecific clinical manifestation for early diagnosis and treatment of this aggressive disease .
malignant fistula of the small bowel to the colon is rare and is most often due to adenocarcinoma . 
 small bowel lymphoma is unusual , representing less than 1 percent of all gastrointestinal malignancies . 
 we report a case of intestinal lymphoma presenting with diarrhea and abdominal pain . a jejunocolic fistula was discovered during colonoscopy . 
 celiotomy revealed a large , ulcerated fistula tract between the jejunum and distal transverse colon , and pathology was consistent with peripheral t - cell lymphoma . 
 this is a rare entity in a nonimmunocompromised individual and has not been previously described in korea .