A Rare Case of Granulomatous Lymphadenitis Presenting as a Duodenal Mass in a Patient with Celiac Disease

Abstract

Introduction: Celiac disease (CD) is an immune-mediated enteropathy that is precipitated by dietary gluten in predisposed individuals. Mesenteric lymphadenopathy is common in active CD and not always require workup. However sometimes it may be difficult to differentiate mesenteric lymphadenopthy from an intestinal neoplasm by imaging alone. Such clinical dilemma warrants further workup to exclude gastrointestinal malignancy. Here we present one such case of CD that presented with granulomatous lymphadenopathy mimicking a duodenal mass. Case presentation: A 66 year old male with history of CD presented with chronic abdominal pain and diarrhea. He was non adherent to gluten free diet (GFD). CT scan of abdomen revealed a 5 cm mass abutting the duodenal wall. It was unclear if it was arising from the duodenum or was para-duodenal lymphnode close to the wall. Given this uncertainly, endoscopic examination was performed that revealed no duodenal mass. Endoscopic ultrasound (EUS) revealed a hypoechoic mass just outside the duodenal wall. Fine-needle aspiration revealed granulomatous lymphadenitis. Causes of systemic granulomatosis were ruled out. After strict adherence to GFD, his symptoms resolved and follow up CT scan revealed interval decrease in the size of mass to 1.5 cm. Discussion: There is an increased risk of lymphoproliferative disease and gastrointestinal cancer in patients with CD. In our patient, CT scan of abdomen revealed a heterogeneous appearing duodenal mass that was concerning for lymphoma. However EGD showed that the mass was outside the gut wall and EUS confirmed this observation. Benign biopsy of the mass was reassuring and it was decided to serially monitor the mass with GFD. Mesenteric lymphadenopathy in active CD is usually benign and does not require workup. However the reason for granulomatous lymphadenitis remained unclear in our patient even after extensive workup and it was attributed to CD given its resolution with GFD. Conclusion: There is an increased risk of lymphoma in patients with CD and when suspected, an abdominal imaging modality such as CT scan should be employed. Lymphadenopathy does not itself, indicate a need workup to exclude lymphoma. However it may sometimes be difficult to distinguish intestinal mass from mesenteric lymphadenopathy. In such cases EGD with EUS is a helpful tool. Non neoplastic mass should be serially monitored for resolution with GFD.