A 22-year-old male patient was admitted in the surgery ward with symptoms of bowel obstruction. He had a history of vomiting and abdominal distention since 10 days. The patient had experienced similar complaints on and off for the past year. On examination, the patient's abdomen was distended and a vague swelling was noted in the umbilical region. The baseline investigations were normal with only a rise noted in the patient's erythrocyte sedimentation rate which was 70 mm at 30 minutes and 118 mm at the end of 1hour. His Mantoux tested negative. An X-ray abdomen showed multiple fluid levels and a contrast-enhanced CT scan revealed ileal wall thickening and mesenteric nodes. The surgeon proceeded with a laparotomy and resected a segment of ileum with omental adhesions and sent for histopathological examination.\nThe cut open small intestinal segment measured 34 × 6 cm. A polyp of 1.5 cm diameter was noted 18 cm from the proximal end. Two ulcers were identified, the first measuring 2 × 2.5 cm was 14 cm from the proximal end and the second, measuring 2 × 1.5 cm was 20cm from the proximal end. Both ulcers were shallow, situated along the horizontal plane, with undermined edges and a fibrotic base. A stricture was present 9cm from the distal end with dilatation of the proximal segment. The serosa showed large lymph nodes measuring 4 × 5 cm, whose cut section was whitish and creamy in consistency. The areas adjacent to the ulcers showed diffuse thickening of the wall and on cut section revealed a whitish mass extending from the submucosa upto the serosa. Representative sections from each of the grossly abnormal areas and the resected margins were submitted for processing.\nSections from the polyp showed a polypoidal mass with a core containing smooth muscle fibers and was identified as a Peutz-Jeghers polyp. Sections from the ulcerated areas showed edematous lamina propria with a dense infiltration of eosinophils and lymphocytes with congested blood vessels in the submucosa and a dense lymphocytic infiltration in the muscularis propria [] and serosa. Sections from the lymph node showed partial loss of architecture, areas of necrosis and fibrosis with epithelioid cell aggregates but no definite granuloma was made out. Multiple sections from the thickened areas showed diffuse sheets of lymphocytes ulcerating the mucosa and infiltrating transmurally upto the serosa and periserosal fat. Rest of the mucosa showed focal erosions, increased eosinophilic and lymphocytic infiltrates in the lamina propria and increased intra-epithelial lymphocytes with focal shortening of villi. In view of the high suspicion of tuberculosis and lymphoma, further diagnostic modalities were sought after such as acid fast staining, polymerase chain reaction (PCR) and immunohistochemistry.\nZiehl–Neilson acid fast staining revealed numerous acid fast bacilli. The PCR was positive for tubercle bacilli. A lymphoma panel of immunohistochemical markers showed CD 45 and CD 20 positivity [] with weak positivity for Bcl2. The rest of the IHC markers such as cytokeratin, chromogranin, CD 3 and CD 10 were negative.\nThus, a final diagnosis of primary small intestinal B-cell lymphoma, tuberculosis and Peutz-Jeghers polyp was made.
In 2003, a 40-year-old woman consulted a doctor because of feeling a palpable mass in the right breast and bleeding discharge from both breasts. Mammography was taken and revealed bilateral mass with infiltrating margins. Excisional biopsy was performed on both breasts. In histopatholgical examination, grossly; the right side showed a nonencapsulated mass with 5.0 × 4.0 × 1.0 cm size as well as relatively dense consistency and the left one showed the same mass with 6.0 × 3.0 × 2.0 cm size. In microscopic examination it was showed carcinoma in atypical sclerosing papilloma of both breasts [].\nOne month later bilateral modified radical mastectomy and axillary lymph nodes dissection were performed. In microscopic examination there was no residual of primary tumor and the only abnormality is atypical ductal hyperplasia. Lymph-nodes, skin, and nipple were free. Three months later a colonoscopy was performed and multiple polyps were found in the large bowel. Biopsy was taken and the result was hamartomatous polyp [].\nTwo years later in 2005, she was referred to the hospital again because of abnormal uterine bleeding (menometrorrhagia). Pelvic ultrasound showed increased endometrial thickness with normal adnexal regions. Bilateral salpingo-oophorectomy was performed. In histopathological examination, grossly, the uterus was measured 10.0 × 8.0 × 3.0 cm. The right ovary was measured 4.0 × 2.0 × 1.0 cm and the left one 4.0 × 3.0 × 1.0 cm. The cut surface of both ovaries showed nonhomogenous appearance with no obvious lesion. In microscopic examination, both ovaries showed sharply circumscribed rounded epithelial nests composed of ring-shaped tubules encircling the hyalinized basement membrane-like material. The nests have two basic patterns: The simple pattern is that of a single tubule encircling a central rounded hyaline mass, and the complex pattern is characterized by communicating tubules encircling multiple hyaline masses. These features are compatible with sex cord tumor with annular tubules that are usually associated with Peutz–Jeghers syndrome []. Except simple hyperplasia of endometrium; no any pathologic feature was found in the endometrium.