Presentation
Progressive loss of weight for the last 2 months. Lab tests revealed normal CBC, mildly elevated liver enzymes, increased ESR and CRP.
Patient Data
The parotid glands bilaterally are enlarged with lobulated appearance, diffuse hypoechoic texture and thickening of interlobular septae as well as increased vascularity. No stones or ductal dilatation.
Multiple enlarged cervical lymph nodes are noted with heterogeneous hypoechoic texture, largest are both jugulodigastric nodes, the right one measures 3.7 x 0.9 cm, in keeping with cervical lymphadenopathies.
On presentation (first stack):
- the liver is mildly enlarged measuring 18.5 cm in MCL with homogeneous echo-pattern and smooth borders
- the spleen is mildly enlarged measuring 17 cm in bipolar diameter with normal echo-pattern. No focal lesions
- multiple porta-hepatis lymph nodes, laregst averages 3 x 2.2 cm
Six months later (second stack):
- progressive hepatomegaly measuring 21.2 cm in MCL
- progressive splenomegaly measuring 18.3 cm in bipolar diameter
- porta hepatis lymph nodes are still present
Multiple enlarged mediastinal and bilateral hilar lymph nodes are noted. They are attenuating and partially encasing main stem bronchi and pulmonary arteries with preserved patency of their lumen.
Multiple pulmonary parenchymal and subpleural nodules, some shows irregular outline with perilesional fibrotic bands and centrilobular nodules, the largest is seen at the apico-posterior segment of the left lower lung lobe.
Scans through the upper abdomen revealed multiple para-aortic, aortocaval, celiac and porta hepatis enlarged lymph nodes.
Pathology report
Specimen:
Video-assisted thoracoscopic surgery (VATS) biopsy from hilar and mediastinal lymph nodes, composed of multiple well-encapsulated lymph nodes, the largest is 2 x 2 x 1 cm and lung biopsy composed of wedge-shaped soft tissue specimen measuring 1 x 0.5 x 0.3 cm.
Microscopy:
Examination of all nodes reveals nodal tissue showing complete effacement of nodal architecture. The nodal tissue is replaced by multiple granulomas of different sizes. Each granuloma is composed of epithelioid cells and multinucleated classic Langerhan giant cells. Areas of caseous necrosis are seen. The same granulomatous lesion is seen in lung specimen with wider necrotic changes.
Diagnosis:
Appearances are consistent with caseating tuberculosis in both hilar, mediastinal lymph nodes and lung specimen.
Scrotum 6 mth later presented with marked scrotal swelling
Both testes are enlarged with homogeneous heterogeneous texture, interstitial edema and mildly increased vascularity and no focal lesions noted.
The epididymis on both sides is enlarged with heterogeneous hypoechoic pattern and mildly increased vascularity.
Marked bilateral non-communicating hydrocele.
Multiple bilateral inguinal enlarged lymph nodes, with preserved oval shape and central fatty hilum. Heterogeneous texture of their parenchyma noted.
Aspiration cytology from hydrocele
Gross: Aspirated fluid from hydrocele (15 ml)
Microscopic: Examination reveals cellular sediment consisting of predominately small mature lymphocytes, mixed with histocytes, some reactive mesothelial cells, scattered in homogeneous pale eosinophilic background. No malignant cells could be detected. ZN smears negative form A.F.B
Conclusion: Inflammatory hydrocele.
Case Discussion
The patient first presented to the ultrasonography unit for assessment of parotid enlargement and the abdomen.
Neck ultrasound revealed bilateral symmetrical infiltration of both parotid glands with small hypoechoic pseudo-nodules, mostly representing lymphoid infiltration. The submandibular glands are much less affected. Abdominal ultrasound revealed mild hepatosplenomegaly and porta-hepatis lymphadenopathy.
Chest CT was requested that showed generalized mediastinal lymphadenopathies which were non-specific and minor pulmonary changes seen as scattered confluent pulmonary nodules, giving the "galaxy sign". It is most commonly described in sarcoidosis, but is also seen in tuberculosis, progressive massive fibrosis and even tumors. However, it favors a benign etiology.
These findings mostly represent a multisystem disease. We first thought of sarcoidosis as a possibility. The internest requested video-assisted thoracoscopic surgery (VATS) biopsy from hilar and mediastinal lymph nodes and lung biopsy which revealed tuberculosis. He started antituberculous treatment.
Six months later, the patient presented with marked scrotal swelling. Ultrasound shows bilateral symmetrical epididymo-orchitis with marked bilateral hydrocele, suggestive of tuberculous epididymo-orchitis. The patient's general condition improved with antituberculous treatment, however, hepatosplenomegaly is still present with mild progression and porta-hepatis lymphadenopathies.
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