Ratuapli et al. Journal of Medical Case Reports 2011, 5:5 http://www.jmedicalcasereports.com/content/5/1/5 bladder fossa in the absence of the gall bladder, and an inflamed appendix was found elevated due to the trans- planted kidney in the right lower quadrant. Laparoscopic appendectomy was performed and the tissue underwent pathological examination. He was discharged after an uneventful post-operative course. Pathology of his appendix by immunostaining revealed anaplastic cells strongly positive for CD3, CD56 together with strong focal EBV-encoded RNA (EBER) staining (Figures 1, 2, 3 and 4). The malignant cells were nega- tive for CD20, CD30, CD45, CD5, Alk-1 and TCK. The tissue was found to be positive for the T-cell receptor (TCR) by gamma gene rearrangement studies by PCR analysis (Figure 5). Immunoglobulin heavy chain rear- rangement (IgH) by PCR analysis did not detect a clonal B-cell population, thereby confirming T-cell lymphoma. A bone marrow examination revealed no involvement with negative flow cytometry and showed normal male karyotype (46, XY). A staging positron emission tomo- graphy (PET) scan showed increased radiotracer uptake in the right cervical and left groin lymph nodes along Page 2 of 8 with the 3.3 cm liver mass. Non-specific uptake in the stomach was also observed. The patient was re-admitted to the hospital 10 days later, with increasing abdominal pain, symptoms of gas- tric outlet obstruction, weight loss, headaches and fever. A lumbar puncture was negative for infection or lym- phoma. Cranial imaging with a computed tomography (CT) scan was also negative. An esophagogastroduode- noscopy (EGD) was performed revealing multiple ulcer- ated nodular masses in the stomach and duodenum (Figures 6 and 7). A stomach biopsy gave similar results as the appendix with large anaplastic cells with irregular nuclei. Immunostaining of the gastric specimen con- firmed T-cell lymphoma as well as positive EBER staining. Initial treatment management involved reducing the dose of the patient’s immunosuppressive agents and starting chemotherapy. Administration of azathioprine, prednisone and tacrolimus was stopped and low dose sirolimus at 1 mg was given daily. The first cycle of chemotherapy (PEGS) included cisplatin 25 mg/m2, Figure 1 Appendix biopsy showing large, pleomorphic lymphocytes with irregular nuclear contours and large nucleoli. (400 X).