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Abdomen » Peritoneal Cavity
Tuberculous mesenteric mass
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Author(s) :
Chaitali Shah, FRCR
 
Presentation A 23 year old male presents with abdominal mass, low grade fever and weight loss. His symptoms have been of one month duration.
 
 
 
Caption: Transverse scan of the abdomen
Description: A large heterogeneous, predominantly hypoechoic mass is seen in the abdomen.
 
 
 
Caption: Scan of the mass at a different level
Description: The heterogeneous mass shows a few cystic appearing areas. The entire mass shows evidence of increased through transmission of sound.
 
 
 
Caption: Transverse scan of the abdomen
Description: This image shows that the mass is predominantly in the mesenteric location.
 
 
 
Caption: Sagittal color Doppler image of the mass
Description: The mass shows areas of increased vascularity and also appears to encase the superior mesenteric vessels.
 
 
 
Caption: Spectral waveform analysis of the encased vessel
Description: The encased vessel is the superior mesenteric vein and appears patent. A few areas showing no color flow at all are also visualized in this image.
 
 
 
Caption: Spectral waveform analysis of encased vessel
Description: The second encased vessel is the patent superior mesenteric artery.
 
 
 
Caption: Sagittal scan of the mass during biopsy
Description: An ultrasound guided biopsy was performed and the tip of the needle can be seen within the mass.
 
 
 
Caption: Axial CT scan
Description: This CT image shows the mesenteric location of the mass and its close proximity to the anterior abdominal wall.
 
Differential Diagnosis Tuberculous mesenteric mass, lymphomatous mass
 
Final Diagnosis Tuberculous mesenteric mass caused by mycobacterial avium intracellulare complex
 
Discussion The increasing resurgence of tuberculosis as an opportunistic infection in HIV infected individuals is a cause of major concern. Abdominal tuberculosis can have various manifestations and can involve the GI tract, the peritoneum, the solid viscera or the lymph nodes. Tuberculosis superinfection in HIV- infected individuals results in significant mortality.

According to many studies of patients with visceral tuberculosis, intra-abdominal adenopathy and visceral lesions were more common in HIV infected patients while non-HIV infected patients more frequently had omental thickening and ascites. The lymph nodes can significantly enlarge and encase the adjacent mesenteric vessels. The enlarged tuberculous nodes have a predilection for the mesenteric, peripancreatic and periportal locations as compared to retro-peritoneal location.  The closest differential for such enlarged nodes in a HIV infected individual would be lymphoma [Non-Hodgkin’s]. The other common secondary disease processes seen in AIDS are Kaposi’s sarcoma and cytomegalovirus infection.

Ultrasound appearance:
1.Enlarged conglomerate nodal mass which is heterogeneous and predominantly hypoechoic.
2.Increased sound through transmission by the abdominal nodal mass suggests caseating necrosis and is highly suggestive, though not specific for tubercular lymphadenitis.
3.Calcifications may also be noted in the lymph nodes.
4.The other features associated with abdominal tuberculosis include bowel wall thickening [especially in the ileo-cecal junction], peritoneal nodules, mesenteric thickening and clear or complex ascites. Visceral involvement may be seen as organomegaly or as multiple small abscesses in the organs.
5.Ultrasound guided fine needle aspirate is useful in arriving at a diagnosis by obtaining tubercular organisms that can be cultured.

Take home pearl of this case:
In an HIV infected patient with abdominal adenopathy, rule out opportunistic infections, especially atypical mycobacterial infection. The other closest differential to be considered is lymphoma.
 
Case References 1. Radin R. HIV infection: analysis in 259 consecutive patients with abnormal abdominal CT findings. Radiology. 1995 Dec; 197(3):712-22.
2. Fee MJ, et al. Abdominal tuberculosis in patients infected with the human immunodeficiency virus. Clin Infect Dis. 1995 Apr; 20(4):938-44.
3. Mehta JB, Morris F. Impact of HIV infection on mycobacterial disease. Am Fam Physician. 1992 May; 45(5):2203-11.
4. Hochedez P, et al. Lymph-node tuberculosis in patients infected or not with HIV. Pathol Biol (Paris). 2003 Oct; 51(8-9):496-502.
5. Ghazinoor S, et al. Increased through-transmission in abdominal tuberculous lymphadenitis. JUM. 2004 Jun; 23(6):837-41.
6. Malik A, Saxena NC. Ultrasound in abdominal tuberculosis. Abdom Imaging. 2003 Jul-Aug; 28(4):574-9.
7. Jain R, et al. Diagnosis of abdominal tuberculosis: sonographic findings in patients with early disease. AJR. 1995 Dec; 165(6):1391-5.
 
Follow Up This patient was HIV positive and the biopsy results from the mesenteric mass were positive for mycobacterium avium intracellulare organism. The patient was started on anti-tuberculous treatment.
 
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