SONOWORLD : Abdominal adenopathy due to tuberculosis infection in an AIDS patient

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Abdomen » Gastrointestinal

Abdominal adenopathy due to tuberculosis infection in an AIDS patient

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Author(s) :

Pamela T. Johnson, MD

Presentation This 23 year old man presented with fever.

Caption: Sagittal image of the right mid abdomen.

Description: The right kidney is diffusely echogenic, an appearance classically associated with AIDS nephropathy. Increased echogenicity of the kidneys is also seen with other forms of renal parenchymal disease.

Caption: Sagittal sonogram of the right upper quadrant.

Description: A heterogeneous, hypoechoic mass is seen adjacent to the liver. Further imaging confirmed that it was separate from kidney, pancreas, liver or bowel. This is enlarged periportal adenopathy.

Final Diagnosis Abdominal adenopathy due to tuberculosis in a man with AIDS.

Discussion This case demonstrates a patient with a chronic condition, AIDS and a superimposed acute process, tuberculosis (TB) involving the abdomen. The echogenicity of the kidney is nonspecific, but can be seen in the setting of AIDS nephropathy. In this clinical setting, the enlarged nodes could be due to an infectious or neoplastic process. Considerations include TB MAI, lymphoma, or metastases from pancreas, liver, biliary tree or gastrointestinal cancer.

In non-AIDS patients, such metastatic disease would also be a consideration, as well as sarcoidosis and Whipple's disease, which can cause abdominal adenopathy.

While AIDS patients may develop diffuse adenopathy, enlarged nodes greater than 1.5 cm in diameter are concerning for infection or neoplasm. TB nodes are often hypoechoic; however, the appearance of the nodes with ultrasound can not be used to definitively determine the etiology. Nonetheless, the presence of caseation or calcification suggest TB as an etiology. Caseation may be evident on CT or MRI as decreased attenuation or intensity centrally, with peripheral rim enhancement after contrast infusion. The peripancreatic and mesenteric nodes are most commonly enlarged in abdominal TB.

Although abdominal TB most commonly manifests as enlarged nodes, additional abdominal findings are often present. Ascites, frequently loculated with septations, is common. Peritoneal and mesenteric masses may be seen. On CT or MRI, the peritoneum may enhance with contrast. Bowel wall thickening is identified in 80-90%, particularly ileocolic. Micronodular (miliary) or macronodular lesions can be seen in the liver and/or spleen.

In the retroperitoneum, enlarged nodes may be identified, as well as adrenal enlargement and psoas muscle abscesses. In the kidneys, the pelvicalyceal system may be involved and papillary necrosis can occur. TB can result in "autonephrectomy".

Ultrasound can be used to guide aspiration of the ascites for diagnosis or to perform percutaneous biopsy of adenopathy, peritoneal masses, or other focal lesions in the abdominal or retroperitoneal organs.

Case References 1. Engin G et al. Imaging of extrapulmonary tuberculosis. Radiographics 2000;20:471-88.

2. Monill-Serra JM et al. Abdominal US findings of disseminated tuberculosis in AIDS. J Clin US 25(1): 1-6, 1997.

3. Sheikh M et al. Ultrasonographic diagnosis in abdominal tuberculosis. Australasian Radiology.43(2): 175-9, 1999.

4. Pombo F et al. Periportal-peripancreatic tuberculosis adenitis: US and CT findings. ROFO 152(2): 142-6, 1990.