Tuberculous appendicitis, terminal ileitis and necrotic mesenteric lymph nodes

Case contributed by Dr Kenny Sim

Presentation

Right iliac fossa pain, on a background of known HIV and recent haemoptysis and night sweats. Family member currently being treated for TB.

Patient Data

Age: 25
Gender: Female

The appendix lies within the right paracolic gutter with tip adjacent to the inferior border of the right lobe of the liver. The appendix is dilated and measures up to 12 mm. It demonstrates very prominent wall enhancement and there is surrounding fat stranding. No appendicolith. No periappendiceal collection. The remainder of the large bowel is unremarkable.

The terminal ileum appears diffusely abnormal. It is dilated and demonstrates prominent wall enhancement. There is no evidence of bowel obstruction.

Multiple ring-enhancing lesions are demonstrated in the central mesentery extending into the right iliac fossa which demonstrates central low attenuation. Together these measure up to 9.2 x 2.5 cm in maximum axial dimension. The appearances suggest multiple necrotic lymph nodes. There is associated mesenteric fat stranding and small pockets of fluid within the abdomen and pelvis, most prominent in the pouch of Douglas. Mildly enlarged inguinal lymph nodes bilaterally.

The spleen is enlarged, measuring approximate 12.7 cm in bipolar length, without focal abnormality.

The liver, pancreas, adrenal glands and kidneys have a normal appearance.

Within the posterior segment of the left lower lobe, there is a wedge-shaped area of tree in bud opacity. This is associated with a 13 mm ovoid opacity. No pleural effusion.

No suspicious bony lesion.

Interpretation: 

The combination of findings, including multiple necrotic mesenteric lymph nodes, abnormal terminal ileum, and left lower lobe pulmonary changes suggest a diagnosis of tuberculosis.

The appendix is abnormal and suspicious for appendicitis however the underlying aetiology may also be tuberculous.

The patient went on to have a laparotomy. 

Case Discussion

Histopathology (appendix):

Findings: Acute on chronic granulomatous appendicitis; with multiple granulomata, most non-necrotising, but with a few showing necrosis.

Comment: The differential diagnoses include tuberculosis, atypical mycobacterial infection, Yersinia infection and Crohn disease. In the clinical context, infection, particularly with tuberculosis, is considered far more likely than Crohn disease.

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Case Information

rID: 31379
Case created: 5th Oct 2014
Last edited: 11th Oct 2016
Inclusion in quiz mode: Included

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