Tuberculous lymphadenitis - abdomen

Case contributed by Dr Bruno Di Muzio

Presentation

Weight loss and abdominal pain. Worsening fevers post commencement of treatment.

Patient Data

Age: 30 years
Gender: Male
Ultrasound

Abdomen

Multiple enlarged lymph nodes are present in the abdomen.  This includes adjacent to the pancreatic head (36 mm), porta hepatis (24 mm), adjacent to the inferior liver (27 mm), right iliac fossa (40 mm).
2 mm gallbladder wall polyp.  The gallbladder is otherwise unremarkable.  No intra-hepatic or extrahepatic biliary dilatation.  The CBD measures up to 2 ml.
The liver is unremarkable, with normal echotexture and echogenicity and no focal lesions.  The portal and hepatic veins are patent.
The right and left kidneys measure 10 cm and 11 cm in long-axis and both appear normal.
The spleen measures 13 cm in the craniocaudal axis and is normal in appearance.

Conclusion: Multiple enlarged abdominal lymph nodes, suspicious for tuberculomas in the clinical context.Mild splenomegaly. 

CT

Abdomen and pelvis

The liver, pancreas, gallbladder, adrenals and kidneys, are normal. Enlarged spleen.
Incidental infrarenal duplication of the IVC.

Multiple rounded foci within the mesentery surrounding the mesenteric vessels and epigastrium demonstrate peripheral enhancement with a hypodense center measuring up to 16 mm in the short axis are favored to represent necrotic nodes and are more prominent than on the prior study (not shown). These don't appear to communicate with each other or the adjacent similar-appearing bowel-loops. Several lymph nodes also identified within the inguinal region.

Unremarkable loops of the small and large bowel, no signs of terminal ileitis.  
Small volume intra-abdominal or pelvic free fluid, similar to the prior CT.
Unremarkable urinary bladder.

No osseous lesions.
Patchy pulmonary nodules are partially imaged in the right lung base.

Case Discussion

This case illustrates extensive necrotic lymphadenopathy in the upper abdomen associated with mild splenomegaly and a small amount of ascites. Also, enlarged bilateral inguinal lymphadenopathy. 

With this clinical presentation, differentials would include tuberculous adenitis or, less likely, lymphoma. This patient has a known history of immunosuppression and is in treatment for widespread tuberculosis. Although non-specific, the findings in the lung bases are a clue for this diagnosis. 

See differentials for low attenuation lymphadenopathy

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Case information

rID: 75749
Published: 18th Apr 2020
Last edited: 16th Jun 2020
Inclusion in quiz mode: Included