Ultrasonographic aspiration of mesenteric lymph node: lifeline to be redeemed in ileocaecal growth

Manuscript type : Brief Report | Article Date : 2015/02/20

  • Autors

    1. Sureshwara Ghalige Hemanth
    2. Karthik K
    3. Bhabatosh Das
    4. Sandesh O
    5. Chandra Singh Th Sudhir
  • Abstract

    Tuberculosis (TB) being a disease predominantly occurring in developing countries presents variedly and the occurrence of extra-pulmonary TB without primary pulmonary is a challenge even in the present era. Here we report a case of an 18 year old female presenting with symptoms of diffuse dull aching pain abdomen for 2 to 3 months with poor appetite who had history of significant weight loss with irregular bowel habits. Though CT of abdomen showed polypoidal growth in right colon with mesenteric lymphadenopathy, colonoscopy and guided biopsy failed to give histological diagnosis. Ultrasonography (USG) guided FNAC from mesenteric lymph node showed acid fast bacilli thus helping diagnosis and preventing radical procedures. Thus authors feel the need to share their experience to sensitize clinicians about the usefulness of USG guided aspiration to diagnose such cases of ileocaecal growth.
  • Description

    BRIEF REPORT

    Gastro-intestinal tuberculosis (GITB), being misdi-agnosed is often reported in literature. Either treat-ment in lines of Crohn’s with immunosuppressants and steroids or in lines of malignancy with radical resection will have adverse outcomes in these de-bilitated patients. Tuberculosis (TB) being a disease predominantly occurring in developing countries, we take our responsibility to think of something novel in the diagnostic workup in cases of ileocecal growth. An 18-year-old female presented with symptoms of diffuse dull aching pain abdomen for 2 to 3 months with poor appetite. Patient’s had history of significant weight loss with irregular bowel habits. She was pre-viously treated in lines of peptic ulcer disease without much relief. There was no past history of prolonged fever, TB or contact with TB patients. On examination patient was afebrile weighing 32kg with severe pallor and cervical lymphadenopathy. Multiple lumps in the right hypochondrium, right lumbar and right iliac fossa of abdomen were noted. Patient’s haemoglobin was 6gm %, elevated lymphocyte count (55%), ESR was 45 mm. at I hour. Liver profile was normal except for hypoproteinemia (4gm %). Serum lactate dehydrogenase (LDH) was raised, Serum ADA was equivocal. Sputum examination was negative for acid fast bacilli (AFB) and chest x-ray did not show features of pulmonary TB. On imaging with Ultrasonography (USG) and CECT of abdomen showed polypoidal growth in right colon with mesenteric lymphadenopathy, favouring gastro intestinal lymphoma. Colonoscopy was performed showing multiple elevated mucosal thickening ex-tending from ileocecal junction to ascending colon (hepatic flexure) which bled on touch. Colonoscopy guided biopsy was inconclusive. Upper gastrointes-tinal endoscopic biopsy showed nonspecific duode-nitis. Fine needle aspiration cytology (FNAC) of cervical lymph nodes showed nonspecific inflammatory changes. USG guided FNAC from mesenteric lymph node showed AFB and diagnosis of abdominal tuberculosis was made. Patient was started on first line antituberculosis (ATT) drugs rifampicin(R), isoniazid (H), pyrazinamide (Z), ethambutol (E) and streptomycin (S). Patient’s appe-tite improved after one month of ATT with increase in weight to 36 kg. Patient was followed up monthly till one year after which advised to take HRE regimen for next 1 year. Subsequent follow-up showed complete recovery from symptoms and 14 kilograms weight gain. Abdominal TB as rightly said doesn’t have any spe-cific clinical, radiological, laboratory findings and poses a diagnostic challenge till date to the treating surgeons. Only 20% of the abdominal TB patients had associated active pulmonary TB.1 Our case also had no pulmonary involvement. Tripathi et al. observed that pain abdomen was the most common presentation (82.7%) followed by fever (58.2%) and significant weight loss (52.6%).2 Absence of fever and presence of generalized lymphadenopathy in our case pointed clinically more towards malignant etiology. Tripathi et al also documented that there was no sexual predilection and the patients belonged to 21- 40 years age group.2 Our patient was a 15 year old emaciated female. In lines with clinical findings and haematological workup none of the imaging modalities (Ultrasonography, Barium studies, CT) are specific for abdominal TB. The protocol of CT scan (non-diagnostic in present case) followed by colonos-copy and guided biopsy did not yield any histological diagnosis to guide our treatment. Similar results were reported by Batikian et al.3 Keeping in mind the available literature right hemi-colectomy was given a thought as a mode of treatment. Uygur et al has already shown that 60.8% of abdominal TB are confirmed by histopathology, 16% microbiologically only and the rest 23.2% solely based on positive response to ATT trial.4 As a last resort USG guided aspiration from mesenteric lymph node was done and was positive for AFB. Authors are also aware of the synchronous occurrence of abdominal TB and colonic cancer as reported by Shashirekha et al.5 Mesenteric lymph node aspirations from such cases might serve a dual purpose of confirming TB and extent of malignancy. Conclusion Considering myriad causes of mesenteric lymphadenopathy in cases of ileocecal growth, we propose aspiration from mesenteric lymph node as a routine in the diagnostic workup of such cases either to diagnose TB or stage the malignancy.

  • Reference

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