CASE REPORT

A 32 year-old female patient was admitted to our department due to diarrhoea without blood or mucus, abdominal pain and severe weigh lost. These clinical features began after a major surgery for excision of a supposed mesenteric tumour, requiring resection of the sigmoid and a long segment of the jejunum. Histopathology examination revealed an inflammatory mass apparently secondary to a sigmoid diverticulum perforation. The patient had also a history of preeclampsia with stillbirth and a miscarriage caused by antiphospholipid syndrome. The physical examination showed a good general condition and a large right inguinal adenopathy.

The analytical profile revealed an elevation in inflammatory parameters (C-reactive protein, sedimentation rate, leukocytosis, thrombocytosis). Tumour, autoimmune and viral markers (including serology of syphilis and HIV) were negative. Tuberculin skin test revealed a 10 mm induration.

Patient had an abdominal computed tomography describing multiple mesenteric lymphadenopathies, a peripancreatic mass with 5.7 cm x 3.7 cm and two abdominal collections with 15.0 cm and 7.0 cm (Figure 1).

Figure 1: Abdominal CT showing peripancreatic lymphadenopathies

A transvaginal ultrasound was performed and showed alterations consistent with a complicated process of endometriosis, chronic pelvic peritonitis or ovary cancer (Figure 2).

Figure 2: Transvaginal ultrasound revealing an ovarian of heterogeneous cystic aspect

Abdominal MRI showed several perihepatic nodular lesions and multiple mesenteric adenopathies with central necrosis, which may correspond to disseminate ovarian cancer and pelvic MRI revealed an inguinal lymphadenopathy (Figure 3).

Figure 3: Pelvic MRI revealing an inguinal lymphadenopathy

Chest X-ray was normal. Given this diagnostic uncertainty it was decided to perform an endoscopic ultrasound with fine needle aspiration of a lymphadenopathy (Figure 4 and Video 1).

Figure 4 A-C: EUS showing peripancreatic lymphadenopathies with fine needle aspiration of one of the lesions

Cytology revealed a necrotizing adenitis with epithelioid granulomas. The inguinal adenopathy was also excised. The direct microbiological examination and culture revealed the presence of Mycobacterium tuberculosis (Figure 5).

Figure 5: Epithelioid granuloma on FNA

Subsequent chest computed tomography described multiple lymphadenopathy and parenchymal abnormalities compatible with pulmonary tuberculosis. However, bronchial lavage was negative for mycobacteria. The patient started anti-tuberculosis therapy with increased weight while maintaining diarrheal stools.

Commentary

Tuberculous lymphadenitis is amongst the most common presentations of extrapulmonary tuberculosis. The peak age of onset in developed countries has changed from childhood to 20 to 40 years. Typical presentation is an isolated chronic nontender lymphadenopathy without systemic symptoms. Tuberculous peritoneal lymphadenopathy generally includes lymph nodes in the periportal region, followed by peripancreatic and mesenteric lymph nodes. The volume increase of intra-abdominal lymph nodes leads to compression of segments of the gastro-intestinal tract. The differential diagnosis of unique peripheral lymphadenopathy is wide-ranging and includes malignancy (lymphoma) and other infections (nontuberculous mycobacteria, cat scratch disease, fungal infection, sarcoidosis and bacterial adenitis). Since the diagnosis of tuberculous lymphadenitis is established by histopathology examination along with acid-fast bacilli smear and culture of lymph node material, this case shows the crucial role of EUS-FNA for establishing the clinical diagnosis.

Authors

Oliveira A.¹, Almeida N.¹, Fernandes A.¹, Giestas S.¹, Ferreira AM.¹, Portela F.¹, Tomé L.¹, Romãozinho J.M.¹, Martins R.², Abrantes C.³, Silva N.⁴, Sofia C.¹

1. Serviço de Gastrenterologia, Centro Hospitalar e Universitário de Coimbra

2. Serviço de Cirurgia, Centro Hospitalar e Universitário de Coimbra

3. Serviço de Anatomia Patológica,Centro Hospitalar e Universitário de Coimbra

4. Serviço de Patologia Clínica, Centro Hospitalar e Universitário de Coimbra