EUS with Trucut Biopsy for Diagnosis of Intra-Abdominal Tuberculosis

Abstract

An 80-year Italian old male presented with left upper quadrant pain, excessive fatigue, weight loss and normocytic anemia. EGD revealed thickened and inflamed gastric mucosa and 2 submucosal gastric impressions. CT scan of the abdomen showed low attenuation lesions in the omentum adjacent to the stomach and low attenuation gastrohepatic ligament lymph nodes. The working diagnosis was lymphoma. Using linear EUS and fine needle aspiration, tissue was collected for cytology and microbiology. Cytology was initially non-diagnostic, so Trucut needle biopsy was performed. Perigastric lymph nodes cytology was positive for necrotic material with numerous lymphoid cells. AFB and fungal studies were negative. Trucut biopsy on pathology revealed necrotizing granuloma without acid-fast bacilli. 4 weeks later AFB culture grew M. Tuberculosis complex. Another patient who was a 44-year-old male with AIDS presented with fever, dysphagia, vomiting, weight loss and intermittent non-bloody diarrhea. On admission he was febrile and tachycardic. Physical exam revealed cachectic ill-appearing male. Abdominal examination was unremarkable. There was no palpable lymphadenopathy. Patient was anemic; CD4 cell count was 5. EGD revealed extrinsic compression of the stomach. CT scan of the abdomen showed a mass in the splenic hilum, indenting the posterior aspect of the stomach, and smaller masses in the paragastric region. EUS was performed with multiple fine needle aspirations of the lesions and but it did not provide definitive diagnosis, so EUS was repeated with Trucut biopsy. Histology revealed necrotic tissue mixed with lymphoid cells, histiocytes, caseating granuloma with presence of AFB, further identified as Mycobacteria tuberculosis. Patient was treated with four-drug regimen; his condition improved and he was discharged. Diagnosis of abdominal tuberculosis presents a challenge because it is uncommon, inaccessible, and yields few numbers of bacilli on FNA. It is important to realize, that TB seems to be resurging and abdominal TB needs to be considered in the differential in both immunocompromised and immunocompetent patients. In the above 2 cases we show that EUS with Trucut needle tissue acquisition can be an accurate and safe method of diagnosing lesions accessible through the gastrointestinal tract. EUS guided Trucut biopsy played crucial role in diagnosis of intra-abdominal tuberculosis in both the immunocompromized and immunocompetent patient.