Mesenteric Lymphadenopathy Research Articles

About one case of common mesentery: embryological study, morphological profile and interest of the doppler ultrasound

Common mesentery is an anatomical abnormality resulting from a defect in the embryonic development of the digestive tract, resulting in a fetal disposition of the intestine in patients. It is mostly revealed during the neonatal period and in children with severe accidents of occlusion. At the anatomo-embryological level, the common mesentery is the consequence of malrotation and attachment of the primary intestinal loop during its embryological development. Attachment abnormalities may or may not be associated with rotation abnormalities (the latter favor them), and they are of 2 types: excessive attachments or attachments defects.We report the case of an 8-years-old female patient received in the emergency room for severe abdominal pain, inability to pass stools and gas, and bilious and incoercible vomiting for 2 days. The surgical exploration showed a volvulus of the small bowel with a 270° clockwise rotation, and the presence of a complete common mesentery and numerous mesenteric lymphadenopathies. The stomach and colon were distended, with adhesions between the colon and the small bowel, but no ischemia or intestinal perforation was noted. The operative procedures consisted of untwisting the volvulated loops in an anti-clockwise direction(270°), a release of adhesions, an appendectomy. We also emptied the small intestine and repositioned it.Common mesentery is a rare pathological state and its incidence is poorly understood due to clinical latency. But a good knowledge of embryology, attentive listening to patients and an accurate reading of the various radiological examinations can lead us thinking about malrotation. The occurrence of occlusive accidents is the main frequent cause of discovery of this abnormality.

English

BACKGROUND Acute appendicitis is one of the commonest causes of pain abdomen. Appendicitis has a good prognosis but a delay in diagnosis may result in risk of perforation, peritonitis, abscess formation, sepsis, and even death. METHODS A retrospective study was conducted from December 2019 to April 2020 in MVJ Medical College and the pre-operative ultrasonographic images of all the patients who underwent surgery for suspected acute appendicitis were reviewed. A total of 50 such cases were found and included in the study. The direct signs were enlarged appendix, hyperaemia of wall of appendix, non-compressibility and appendicolith. The indirect signs were increased echogenicity and thickening of mesenteric fat in right iliac fossa (RIF), increased vascularity in RIF, thickening of caecal wall, RIF probe tenderness, free fluid in the RIF and mesenteric lymphadenopathy. RESULTS 32 (64 %) were in the adult age group and 18 (36 %) patients were in the paediatric age group (below 18 years); the mean age was 38 years. 68 % (34) of the study population were males and 32 % (16) were females. At least one direct sign was present in 86 % of the cases, 2 and 3 direct signs were seen in 80 % and 56 % of the cases respectively. At least 1 indirect sign was noted in 97 % of the cases, 2 and 3 indirect signs were seen in 90 % and 70 % of the cases respectively. 2 cases had no indirect signs and all indirect signs were present in none of the cases studied. In the absence of direct signs, RIF probe tenderness (98 %) and increased echogenicity & thickness of mesenteric fat in RIF (86 %) were the most noted indirect signs in acute appendicitis. CONCLUSIONS There was a high incidence of indirect ultrasonography (USG) signs, of which the sign with maximum incidence was probe tenderness in 98 % of the cases, and increased mesenteric fat echogenicity in the RIF in 86 %. Among direct signs of acute appendicitis enlarged appendix (95 %) had the highest incidence followed by non-compressibility of appendix (90 %). KEYWORDS Acute Appendicitis, Ultrasound

Sonographic criteria for the evaluation of dietary compliance of children with celiac disease

Aim: Although the only known way to avoid complications like iron deficiency anemia, short stature in celiac disease is a strict gluten-free diet, it is a known fact that not all patients follow the diet. Diet compliance is practically evaluated with serum antibodies, such as tissue transglutaminase antibody. The aim of this study was to evaluate the contribution of less invasive ultrasound and Doppler ultrasound in evaluating dietary compliance in celiac patients.Materials and Methods: Twenty-five male and 47 female cases aged five to 17 years were included in the study. Seventy-two patients diagnosed with celiac disease and followed up were divided into two groups according to dietary compliance based on the results of tissue transglutaminase IgA antibody. Pericardial fluid, hepatosteatosis, mesenteric lymphadenopathy, intraabdominal free fluid, small intestine diameter, small intestine wall thickness and gallbladder volume, superior mesenteric artery (SMA) diameter, portal vein diameter, SMA peak systolic velocity, and portal vein velocity were measured on ultrasound. The differences between the groups were statistically compared.Results: The frequency of mesenteric lymphadenopathy, superior mesenteric artery diameter, SMA peak systolic velocity, and portal vein velocity were increased in children who did not follow the recommended diet. There was no significant difference between the groups in terms of hyperperistalsis, gallbladder volume, and portal vein diameter. Pericardial fluid, fatty liver, small intestine dilatation, and increased intestinal wall thickness were not detected in either group.Conclusion: Ultrasound can play an important role in the follow up of children with celiac disease. It can provide clinicians with an insight into the dietary compliance of these cases.

Role of laparoscopy in the management of chronic abdominal pain: A clinical study in north Indian teaching hospital

Background: Chronic abdominal pain can be diagnostic challenge. These difficult patients are frequently seen by many different physicians and are subjected to myriad of tests without identifying the etiology of pain. Surgical consultation often occurs late after other modalities have failed to provide resolution of their symptoms.Subjects and Methods: This prospective study was conducted in the Department of Surgery, SGT Medical College Hospital & Research Institute, Budhera, Gurugram, Haryana, India. 48 Patients with chronic abdominal pain participate in this study. This study included patients presenting with history of nonspecific abdominal pain for 3 weeks or more who were admitted in surgical wards.Results: The most common site of pain was the periumbilical region (52.08%) followed by the right lower abdominal quadrant (31.25%). Twenty two patients were using either non-steroidal drugs or pain killers to relieve the pain, and five patients were using proton pump inhibitors. Fifteen patients (31.25%) had undergone at least one previous surgical abdominal procedure. All patient characteristics are summarised in table 3. The average length of the operative time was 54.09 minutes with the range from 32 to 116 minutes. There were no cases converted to open procedures. Out the 48 patients with chronic abdominal pain, a definitive diagnosis was established in 46 patients (95.16%), while no identifiable cause could be reached in two patients (4.4%). The most common laparoscopic findings were adhesions (79.16%). Other findings included appendiceal pathology (10.41%), hernia (2.08%), gall bladder pathology (2.08%), and mesenteric lymphadenopathy (2.08%). Table 2 summarises the laparoscopic diagnoses assigned to all patients. Laparoscopic management included adhesiolysis [38], appendectomy [5], hernia repair [1], cholecystectomy [1], and lymph node biopsy [1]. Two patients had no interventions performed. Postoperative hospital stay ranged from two to twelve days with a mean of 3.8 days.Conclusion: Although Chronic abdominal pain of unknown origin represents a significant problem in surgical patients. Due to improvement in instrumentation and greater experience in the laparoscopy, the procedure no longer limited to visualization. This study showed that laparoscopy is an effective approach in the management of patients with chronic abdominal pain in whom conventional methods of investigations have failed to elicit a certain cause.

Pericecal Hernia

Background: Internal hernias involve prolapse of any viscus through normal or abnormal mesenteric or peritoneal aperture and constitute <1% of all cases of hernia. Pericecal hernia is one form of internal hernia rarely reported in the pediatric population. Clinical Description: We describe the case of a 10-year-old boy with underlying tetralogy of Fallot, who presented with third episode of severe abdominal pain, requiring hospital admission with tenderness in the umbilical and right iliac quadrants, voluntary guarding but no organomegaly or abdominal distension, and preserved bowel sounds. Management: Baseline investigations (complete blood count, C-reactive protein, erythrocyte sedimentation rate, blood culture sensitivity, and stool and urine microscopy) and serum amylase and lipase were normal. Ultrasound showed mesenteric lymphadenopathy but no pancreatitis or appendicitis. Computed tomography (CT) demonstrated circumferential wall thickening in distal ileum with clustering of distal ileal loops, posterior and lateral to the cecum, extending into right paracolic gutter, suggestive of pericecal hernia. Child received conservative management and improved. Definitive surgical reduction was deferred due to negative parental consent. Conclusion: To conclude, internal abdominal hernia is rare in children with nonspecific clinical presentation. CT should be considered when underlying etiology of acute abdomen is not found on the basis of history, examination, and baseline investigative workup. Early intervention helps in reducing the morbidity and mortality to great extent.

Sonographic detection of abdominal pathologies in human immunodeficiency virus/acquired immunodeficiency syndrome patients and its correlation with CD4 counts – A prospective analysis

Objectives: Abdominal pathologies are the second most common after pulmonary diseases in human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) patients. Ultrasonography (USG) is a vital imaging technique for the evaluation of abdominal pathologies. This study was aimed at evaluating the abdominal pathologies using USG in HIV/AIDS and further analysis of its correlation with CD4 count. Material and Methods: The present study was carried out on 392 HIV-positive patients with abnormal abdominal sonographic findings. All data were analyzed by Chi-square test and one-way analysis of variance using SPSS 16.0 software. Results: Of these 392 patients, 66.3% were males, the mean age was 35.7 years, (range 7–64 years) and most of them were in 4th decade. On ultrasonographic evaluation, spleen was involved in 45.2% patients and liver as well as lymph nodes each was involved in 43.6% patients. Other cases displayed ascites and bowel thickening in 5.3% and 3.8% patients, respectively. Less involvement of kidney (2.3%), pancreas (1.5%), and biliary system (1.3%) was observed. In addition, pathologies such as hepatomegaly, splenomegaly, splenic microabscess, focal pancreatic lesion, mesenteric, and periportal lymphadenopathy showed significant correlation with CD4 counts. Lymphoma was found in 1% of patients, involving liver, pancreas, and retroperitoneal lymph nodes. Conclusion: Our study highlights the clinical utility of abdominal USG in HIV/AIDS patients. CD4 counts largely affect the differential diagnosis in HIV/AIDS patients. USG findings interpreted in the context of CD4 count may help in guiding the exact diagnosis.

Tropheryma whipplei: an unusual cause of the accumulation in positron emission tomography

A 51-year-old man presented with watery diarrhea and 7-kg weight loss for six months. As computed tomography scans showed multiple mesenteric and retroperitoneal lymphadenopathy, 18F-fluoro-deoxyglucose positron emission tomography was performed, showing marked accumulation in the jejunum. Enteroscopy disclosed diffuse yellow-white swollen villi in the jejunum and biopsies revealed clubbed villi with marked periodic acid-Schiff-positive foamy macrophages. The electron microscopic examination showed numerous extracellular bacilli and bacillary forms of degradation in the macrophages. 16S rRNA PCR revealed Tropheryma whipplei in the mucosal specimens, making the diagnosis of Whipple's disease. Therapy with ceftriaxone followed by long-term trimethoprim-sulfamethoxazole was effective. Whipple's disease is briefly discussed.

Image-guided fine-needle aspirates in thoracoabdominal lesions with particular reference to liver malignancies

The present research has been conducted to find the utility of image-guided fine-needle aspiration cytology in the diagnosis of thoracoabdominal lesions. It also has attempted to study the frequency of distribution of thoracoabdominal lesions. At the same time tried to classify various thoracoabdominal lesions with the help of image-guided fine-needle aspiration cytology. The study of image-guided FNAC of thoracoabdominal lesions was carried out for twenty-four months, i.e. from MAY 2014 to APRIL 2016, which included 80 cases. Most patients (80%) were in the 5th-7th decade of life. All cases of ovarian lesions were diagnosed as malignant tumours on cytology, 08 were diagnosed as adenocarcinoma and one case of granulosa cell tumour. 06 out of 08 cases which diagnosed as adenocarcinoma on cytology, were confirmed on histology and diagnosed as mucinous cystadenocarcinoma(03 cases) and papillary serous carcinoma (03 cases). A case of malignant granulosa cell tumour was diagnosed on cytology and confirmed on histopathology. A case of mesenteric lymphadenopathy was diagnosed as granulomatous inflammation, suggestive of tuberculosis and was confirmed on histopathology with 100% accuracy. This was the only paediatric case in our study. A case of para-spinal abscess of thoracic vertebrae was diagnosed as chronic inflammation on guided FNAC, and the etiological agent was identified with histopathology as actinomyces.

Abdominal Imaging Findings in Critically Ill Children With Multisystem Inflammatory Syndrome Associated With COVID-19.

We report findings on abdominal imaging in critically ill children admitted with MIS-C. On sonography, hepatomegaly, nephromegaly, gallbladder wall edema, ascites, intestinal inflammation and mesenteric lymphadenopathy were seen, while CT showed fluid-filled small bowel loops, mural thickening of the terminal ileum, diffuse lymphadenopathy, and moderate ascites.

Visual PET/CT scoring of mesenteric fdg uptake to differentiate between tuberculous peritonitis and peritoneal carcinomatosis.

We aimed to differentiate tuberculous peritonitis (TBP) from peritoneal carcinomatosis (PC) using a visual positron-emission tomography/computed tomography (PET/CT) scoring system based on mesenteric fluorodeoxyglucose (FDG) uptake. PET/CT scans from 31 patients with TBP and 92 patients with PC were retrospectively reviewed. A visual PET/CT scoring system for mesenteric FDG uptake was used according to the following characteristics: FDG uptake intensity (low = 0, moderate = 1, high = 2), FDG uptake deposits (uniform = 0, irregular = 1, ascitic = 2), FDG uptake focality (diffuse = 0, segmental = 1, focal = 2), nodularity on the corresponding CT (nonnodular = 0, micronodular = 1, macronodular = 2) and mesenteric lymphadenopathy (absent = 0, lymphadenopathy without FDG uptake = 1, lymphadenopathy with FDG uptake = 2). The FDG uptake intensity, deposits, focality, nodularity and mesenteric lymphadenopathy scores between TBP and PC were compared using chi-square tests. The diagnostic performance of this scoring system for differentiating TBP from PC was analyzed using a receiver operating characteristic (ROC) curve. P < 0.05 was considered statistically significant. Twenty-four patients with TBP (77.4%) and 56 patients with PC (60.9%) had mesenteric FDG uptake (P = 0.095) and were included for evaluation with the visual PET/CT scoring system. PC lesions scored higher than TBP lesions in FDG uptake deposits (P < 0.001), focality (P < 0.001) and nodularity (P < 0.001). No significant differences were observed between PC and TBP lesions in FDG uptake intensity (P = 0.396) and lymphadenopathy (P = 0.074). The total score that combined deposits, focality and nodularity had significant value for differentiating TBP from PC (area under the curve (AUC) = 0.869, P < 0.001), and a cutoff > 1 had a sensitivity (the accuracy for diagnosis of PC) of 80.4% and a specificity (the accuracy for diagnosis of TBP) of 75.0%. A visual PET/CT scoring system based on mesenteric FDG uptake performed well in differentiating between TBP and PC.

Medical management of a large intra‐abdominal mass caused by Rhodococcus equi in a foal

SummaryA 4‐month‐old Thoroughbred filly presented with pyrexia, inappetence and diarrhoea. Abdominal ultrasonography revealed a multilobulated abdominal mass that was determined to be associated with the caecum using computed tomography. Computed tomography also identified mesenteric lymphadenopathy and a pulmonary mass in the left caudal lung lobe. Percutaneous aspiration of the abdominal mass yielded pure growth of Rhodococcus equi. The filly responded in a positive fashion to the administration of clarithromycin, rifampin and gallium maltolate. Follow‐up computed tomography revealed complete resolution of the abdominal mass and lymphadenopathy. Extrapulmonary disorders associated with R. equi should be considered even when thoracic ultrasonography reveals no evidence of pulmonary pathology. Although intra‐abdominal abscesses have a grave prognosis, successful treatment is possible. Gallium maltolate can be safely administered to foals and may improve patient outcomes.

A Case of Jejunal Stricture and Mesenteric Lymphadenopathy in a Young Man

Question: A 29-year-old man with a past medical history significant only for an open appendectomy for appendicitis as a child presented with complaints of right-sided abdominal flank pain. Upon further interview, he endorsed colicky abdominal pain for approximately 1 year with intermittent nausea, vomiting, and a significant weight loss of 15–20 pounds. He admitted to passing flatus but had not had a bowel movement for 3 days. Physical examination showed a soft, nondistended abdomen with a well-healed surgical scar in the right lower quadrant.

Mesenteric lymphadenopathy in COVID-19 infection (Jammu and Kashmir sign) as a presenting sign in adult: case report

Introduction: Mesenteric lymphadenopathy in an adult with gastrointestinal COVID-19 infection is a very rare. Ultrasonography is helpful in the diagnosis of mesenteric lymphadenopathy in COVID-19 infection. Presentation of Case: A 33-year-old man presented with recurrent abdominal pain of 5 days duration. Ultrasonography and computed tomography of abdomen documented findings of the diffuse mesenteric lymphadenopathy, mostly on the left upper abdomen followed by right upper abdomen. Real time-polymerase chain reaction for SARS-CoV-2 was found reactive. Patient was managed by the local protocol and had regression of mesenteric lymphadenopathy. Discussion: This is a first kind of case report where an adult patient having gastrointestinal COVID-19 infection presented with mesenteric lymphadenopathy only and named as the “Jammu and Kashmir sign (JK sign) in COVID-19 infection.” Conclusion: Mesenteric lymphadenopathy in an adult with COVID-19 infection is very rare. This may be the only presenting sign in gastrointestinal COVID-19 infection.

S2864 A Rare Presentation of Immunoproliferative Small Intestinal Disease

INTRODUCTION: Immunoproliferative small intestinal disease (IPSID), is a form of extra-nodal marginal zone B-cell lymphoma, seen in young adults in the Mediterranean basin and Southeast Asia. It characterized by the production of monoclonal heavy chain without light chains that are deposited in the lamina propria, culminating in blunting of intestinal villi, malabsorption, and protein-losing enteropathy. It manifests as colicky abdominal pain, persistent diarrhea, malabsorption, weight loss and failure to thrive. IPSID is associated with chronic Campylobacter jejuni infection and has a range of presentation from lymphoid infiltration to malignant diffuse large-B-cell lymphoma, early stages of which are completely responsive to antibiotics. CASE DESCRIPTION/METHODS: A 50-year-old woman presented after syncope and a two-week history of persistent watery diarrhea and thirty-pound weight loss over six months (Table A). Four months prior, she was hospitalized in Nigeria for similar symptoms. She was ill-appearing and malnourished with a diffusely tender abdomen. Computed tomography revealed diffuse mesenteric lymphadenopathy. An extensive infectious (Table A) and non-infectious (Table B) was negative except for a positive Campylobacter stool antigen. Endoscopy revealed moderate gastritis and colitis, duodenal biopsy revealed blunted villi and lymphocytic infiltration (Figure A). Her diarrhea improved with antibiotics and she was discharged.One month after discharge, she presented with recurrence of symptoms. An extensive workup yielded the same results as before. Biopsy of mesenteric lymph nodes revealed reactive lymphadenitis. One year later, the patient presented to the hospital again, now with neck pain and dysphagia in addition to the prior GI symptoms. She was found to have cervical lymphadenopathy biopsy of which revealed lymphoma. She was diagnosed with IPSID Stage C initiated on chemotherapy. However, she succumbed to her disease. DISCUSSION: IPSID should be considered in all patients from endemic regions after other causes of infectious and non-infectious diarrhea and mesenteric lymphadenopathy are ruled out. Early diagnosis and treatment, at a stage responsive to antibiotics, may lead to resolution of the disease. In the case of our patient, Campylobacter stool antigen was persistently positive even after she had left an endemic region (West Africa) and received multiple courses of antibiotics, underscoring the puzzling nature of the source of her recurrent bacterial infection.Table 2.: Diarrhea and mesenteric lymphadenopathy can be caused by a multitude of pathology, which should be considered and ruled out because a diagnosis of IPSID is madeTable 1.: Initial presentation versus one month later versus one year laterFigure 1.: 4x magnification, Low power view of the small intestinal mucosa with marked villous blunting and expansion of lamina propria by small, mature lymphoid cells. Figure 2: 40x magnification, High power view of the small intestinal mucosa showing sheets of predominantly mature lymphoid cells with scattered plasma cells and eosinophils.

EP26 HIV infection masquerading as connective tissue disease

Case report - IntroductionConnective tissue diseases are multisystem disorders. Diagnosis and evaluation of suspected cases is not straight forward in most of the cases. This case describes the significance of considering a broader approach when evaluating a suspected case of connective tissue disease.Case report - Case descriptionWe describe a case of 58 years old non-smoker lady, presented with acute onset livedo reticularis rash on lower limbs and background of sicca symptoms, oral ulcers, fatigue, paraesthesias in feet and arthralgias without any systemic or inflammatory joint symptoms.General examination showed livedo reticularis rash on both elbows and lower legs. There was no evidence of peripheral joint synovitis, but she had nodal osteoarthritis in her hands. Systemic examination was unremarkable.Investigations revealed anaemia, pancytopenia, ESR of 77, low C4 and urine dipstick positive for leucocytes, nitrates, protein, and blood. Schirmer’s test, ANA and ENA screen was positive with positive RNP and SMdp antibody. She also had hypergammaglobulinemia in a polyclonal pattern. Nerve Conduction and EMG studies revealed mild axonal sensory neuropathy.Case report - DiscussionThis lady appeared to have mixed connective tissue disease with mixed features of Sjögren’s syndrome and systemic lupus erythematosus. She was started on Hydroxychloroquine but stopped it shortly after developing floaters in her eye. She had poor response to Depomedrone injection. She had ongoing symptoms of fatigue, weight-loss, loose stools, and abdominal pain, investigated further and CT scan showed hyperdense liver lesions and mesenteric lymphadenopathy. Esophagogastroduodenoscopy showed oesophageal candidiasis. She was admitted with progressive symptoms. Further investigations showed a positive HIV test and liver biopsy came back positive for anaplastic lymphoma, later she was diagnosed with advanced HIV disease, rapidly deteriorated with neutropenic sepsis and multi-organ failure, and unfortunately died.Case report - Key learning pointsThis lady initially presented with symptoms of connective tissue disease and investigations in keeping with this diagnosis. Unfortunately, by the time she was tested for HIV infection, it was already too late. There could be overlap of symptoms of connective tissue disease and viral infections e.g. HIV infection. Autoantibodies may be falsely positive in infections e.g. HIV and in malignancy. Risk factors of HIV infection should be considered during assessment of multisystem diseases like connective tissue diseases particularly prior to immunosuppression. Viral screening including HIV test should be considered in all high-risk patients and particularly if the symptoms are atypical and do not quite fit well with the diagnosis.

S2790 Mycobacterium avium Complex Enteritis Mimicking Whipple's Disease in a Patient With Advanced AIDS

INTRODUCTION: Acquired Immunodeficiency Syndrome (AIDS) patients are susceptible to numerous opportunistic infections, including Mycobacterium avium complex (MAC). MAC infection usually presents as a disseminated disease with fever, nights sweats, diarrhea as well as lymphadenopathy which can be the presenting symptoms of various other diseases, such as Whipple's disease (WD). We present a case of MAC infection initially diagnosed as Whipple’s Disease in a patient resulting in delay in MAC treatment. CASE DESCRIPTION/METHODS: A 37 year old homosexual male presented with a one year history of progressively worsening abdominal pain accompanied by intermittent non bloody, non bilious vomiting, chronic diarrhea, fatigue and 60 lbs unintentional weight loss over several months. He underwent an elective EGD where abnormal appearing duodenal mucosa was seen with duodenal biopsy showing villous atrophy and period acid Schiff (PAS) stain positive macrophages, while abdominal imaging showed retroperitoneal and mesenteric lymphadenopathy (Image 1). Despite initiation on treatment for WD, he continued to clinically decline. Given his high risk social history and significant constitutional symptoms, HIV infection was considered as an alternative diagnosis. He was found to have HIV/AIDS (viral load of >100,000 copies/mL and CD4 count 9/μL) and blood cultures positive for MAC. On further review, his duodenal biopsies were positive for acid fast bacillus (AFB) confirming MAC enteritis. A CT chest revealed a 4.6 cm right lung mass with biopsy positive for AFB stain(Image 2). Patient was then initiated on appropriate treatment for disseminated MAC infection (azithromycin, rifabutin, ethambutol) as well as antiretroviral therapy resulting in clinical improvement. DISCUSSION: The differential diagnoses for villous atrophy include malabsorptive diseases, infections, malignancy, pancreatic insufficiency but other less common infectious entities such as MAC should be considered in the right clinical settings. MAC infections have become increasingly uncommon since the advent of highly effective antiretroviral therapy, control of HIV infection and appropriate antimicrobial prophylaxis. Due to the relative rarity, diagnosis and treatment may be delayed, especially when presenting symptoms are non-specific, which can result in morbidity and mortality.Figure 1.: View of duodenum during endoscopy which shows white color plaques in the second and third part of the duodenum (A). H&E stain (20X) of duodenal biopsy shows mildly blunted villi due to expansion of lamina propria by foamy macrophages in a patchy fashion (B). No fat vacuoles or increased intraepithelial lymphocytes seen. AFB stain (20X) of duodenal biopsy shows many positive bacillary forms confirming the presence of Mycobacterium avium intracellular complex (C). Abdominal lymphadenopathy noted on computed tomography of abdomen (red circle) (D).Figure 2.: Computed Tomography of Lung mass (red circle) (A). H&E stain (40X) lung mass biopsy shows florid lympho-histiocytic reaction (B) while CD68 stain (40X) shows many macrophages (C), and AFB stain (40X) confirms presence of mycobacterial organisms (D).

S2854 Peripheral T-Cell Lymphoma, Not Otherwise Specified (PTCL, NOS) Presenting With Gastrointestinal Bleeding in an HIV Patient

INTRODUCTION: Peripheral T-Cell lymphomas (PTCL) are a rare type of Non-Hodgkin’s Lymphoma (NHL) with an incidence of < 1 case per 100,000 people in the USA. PTCL, not otherwise specified (NOS) is an EBV-associated malignancy, encompassing a spectrum of disorders that do not fulfill the criteria of other PTCL subtypes. Presentation of PTCL, NOS with gastrointestinal bleeding has only been described in rare case reports. CASE DESCRIPTION/METHODS: A 32-year-old female with congenital HIV, on highly active anti-retroviral therapy (HAART), presented with multiple episodes of hematochezia, diffuse abdominal pain and hypotension. After hemodynamic stabilization with multiple units of packed red blood cells and intravenous fluids, esophagogastroduodenoscopy and colonoscopy were performed revealing no obvious source of bleeding. Subsequently, CT scan and MRI of the abdomen delineated two segments of small bowel wall thickening, luminal narrowing and mesenteric lymphadenopathy. Capsule endoscopy showed scattered patches of erythematous mucosa in the small bowel without active bleeding or stigmata of bleeding. Afterwards, she underwent a small bowel push enteroscopy revealing a large, non-obstructing, infiltrative mass in the mid-jejunum which was successfully biopsied (Figure 1). Biopsy was consistent with PTCL, NOS with a high Ki-67 proliferation index (80-90%) and positive Epstein-Barr encoding regions-in situ hybridization (EBER-ISH) (Figure 2, 3). Further staging workup showed a normal bone marrow biopsy. PET-CT scan demonstrated intense FDG uptake in jejunum and small bowel segments in the left and right lower quadrants but no distant metastases. During the preparation for chemotherapy, she developed acute small bowel perforation. Given the rapid deterioration, definitive treatment was not feasible. After family discussions, she was transferred to inpatient hospice where she passed away. DISCUSSION: Push enteroscopy is an effective tool for the diagnosis of small bowel malignancies like PTCL. The presence of HIV increases the risk of PTCL by 15 times and adversely impacts the prognosis, with a median survival of around 1 year. Around 30% cases of PTCL, NOS are EBV positive and the presence of EBER-ISH portends worse outcomes. Induction with anthracycline-based chemotherapy regimens along with brentuximab vedotin (an antibody-drug conjugate against CD30) for CD30 + PTCL, and early consolidation with autologous stem cell transplant (ASCT) are the cornerstones of PTCL, NOS treatment.Figure 1.: Small bowel push enteroscopy: Panel (A) and (B) show a prominent mass lesion in the mid-jejunum. Panel (C) and (D) show the same area after biopsy and tattooing.Figure 2.: Small bowel mucosa with large pleomorphic cells infiltrating the lamina propria. Surface ulceration and extensive areas of punctate necrosis are also present. Figure (A) is X10 and Figure (B) is X25 magnification.Figure 3.: The large pleomorphic cells are positive for (A) CD3 (B) CD7 and (C) CD8 immunostains as well as (D) EBER-ISH (X25).

S3469 An Atypical Presentation of Crohn's Disease in a Young Woman: Case Report

INTRODUCTION: Crohn’s disease (CD) is an inflammatory bowel disease (IBD) that may involve any part of the gastrointestinal (GI) tract that may present with varied extra intestinal manifestations. CASE DESCRIPTION/METHODS: A 21-year-old woman presented to the ED with a two-week history of subjective fevers and progressively worsening asymmetric ankle pain and swelling that caused difficulty with ambulation. She also noted several tender, raised, red papules on her shins concerning for erythema nodosum. On review of systems, she endorsed intermittent semi-solid stools the week prior that she attributed to a recent antibiotic course initiated by her physician for presumed cellulitis. In the ED she was febrile and tachycardic with a normal chest radiograph and laboratory studies notable for a leukocytosis of 25.6 × 109 /L with left shift, C-reactive protein of 28 mg/L and mildly elevated serum transaminases. The initial differential diagnosis included infection, autoimmune disease, and malignancy. On admission she met sepsis criteria and was empirically started on broad-spectrum antibiotics; however, throughout her stay all cultures and tissue biopsies failed to reveal a causative infectious etiology. Fecal calprotectin collected upon admission was found to be significantly elevated. A computed tomography scan of the abdomen demonstrated intracolonic polypoid lesions and mesenteric lymphadenopathy concerning for potential malignancy, although subsequent positron emission tomography scan was inconsistent with this diagnosis. Colonoscopy demonstrated diffuse patchy colonic inflammation, relative ileal sparing, and scattered ulcerations involving the proximal sigmoid colon to cecum. Biopsy of the lesions revealed surface ulceration, crypt abscesses, and mild architectural distortion all consistent with moderate to severe CD. Antibiotics were withdrawn and the patient was started on Infliximab induction with a rapid improvement of both intestinal and extraintestinal symptoms. DISCUSSION: Crohn’s disease may prove to be an elusive diagnosis as varying extraintestinal manifestations make for a rare “classic” phenotype. Retrospective interview with this patient yielded details of intermittent oligoarthritis and years of recurrent loose stools that were likely symptoms of a smoldering diagnosis of CD that went overlooked. This case demonstrates the importance of vigilance when an otherwise healthy patient presents with atypical symptoms and a chief compliant that is not primarily related to GI manifestations.Figure 1.: Erythema Nodosum and asymmetric ankle pain, swelling and erythema on presentation to the emergency room.Figure 2.: Asymmetric ankle pain, swelling and erythema on presentation to the emergency room.Figure 3.: Colonoscopy demonstrating diffuse patchy colonic inflammation and scattered ulcerations.

S2800 B-cell Lymphoma of the Small Bowel: Common Presentations of an Uncommon Disease

INTRODUCTION: The gastrointestinal (GI) tract is the most common site of extra nodal involvement of lymphoma; the most prevalent histopathological type is diffuse large B-cell lymphoma [1,3]. Primary GI lymphomas are rare, making up 1%–4% of all GI malignancies [2]. Here we discuss three different clinical presentations and endoscopic appearances of B-Cell lymphoma of the duodenum. CASE DESCRIPTION/METHODS: Case 1: An 83-year-old female with a history of cholecystectomy presented for endoscopy (EGD) after admission for abdominal pain and weight loss. EGD showed mucosa in the distal duodenal bulb with narrowing and pathology was significant for moderate chronic active duodenitis with villous. Four months later, the patient had a repeat EGD for right upper quadrant pain which again showed benign appearing mild stenosis the duodenal bulb that was traversed and dilated to 15mm, as well as nodularity and scalloping in the second portion of the duodenum (Figure 1). Biopsy showed Small B-Cell Lymphoid Neoplasm with plasmacytic differentiation. Case 2: A 67-year-old male with no medical history was referred to the gastrointestinal clinic for evaluation of reflux disease after presenting to the ER with burning chest pain. Patient underwent EGD which showed diffuse mucosal with white scattered nodules in the second portion of the duodenum (Figure 2). Pathology showed follicular lymphoma. Case 3: A 58-year-old man with a history of obscure gastrointestinal bleeding presented with two episodes of black stools. CT Abdomen/Pelvis demonstrated mesenteric lymphadenopathy measuring up to 1.2 cm with adjacent inflammatory process; capsule endoscopy showed jejuno-iileitis. Push Enteroscopy showed a clean based 1.2 cm ulcer (Figure 3) and a raised white about 1.2 cm in size with central ulceration in the jejunum. Jejunal ulcer pathology showed low grade B cell lymphoma and the white plaque was significant for atypical lymphoid infiltrate consistent with duodenal type follicular lymphoma. DISCUSSION: The three cases all share a diagnosis of B-Cell lymphoma but each case presented with unique symptoms and distinctive endoscopic findings. Small bowel lymphomas can be categorized into three main types and the clinical presentation varies based on this. Two of the cases presented are follicular lymphomas which are categorized as western-type non-immunoproliferative small intestinal disease (IPSID). One case was highly suggestive of extra nodal marginal zone lymphoma of mucosa associated lymphoid tissue (MALT) which is categorized as IPSID.Figure 1.: Benign appearing mild stenosis of the duodenal bulb that was traversed and dilated to 15 mm, as well as nodularity and scalloping in the second portion of the duodenum.Figure 2.: Diffuse mucosal changes with white scattered nodules in the second portion of the duodenum.Figure 3.: Clean based 1.2 cm ulcer.

Imaging Findings in Multisystem Inflammatory Syndrome in Children (MIS-C) Associated With Coronavirus Disease (COVID-19).

BACKGROUND. A multisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease (COVID-19) has recently been described. OBJECTIVE. The purpose of our study was to evaluate the imaging findings of MIS-C associated with COVID-19. METHODS. Imaging studies and medical records of patients (age range, 0-20 years) admitted with MIS-C between April 22 and May 21, 2020, were retrospectively reviewed. Thoracic imaging studies were evaluated for parenchymal, mediastinal and hilar, and cardiovascular abnormalities. Abdominal imaging studies were evaluated for abnormalities of solid viscera, hollow viscera, and the peritoneum as well as the mesentery and retroperitoneum. Studies were reviewed independently by two radiologists, and disagreements were resolved by a third senior radiologist. RESULTS. Sixteen patients (10 male and six female patients; age range, 20 months-20 years) were included in this study. All 16 patients presented with fever. Other presenting signs and symptoms included the following: vomiting (12/16, 75%), abdominal pain (11/16, 69%), rash (10/16, 63%), conjunctivitis (8/16, 50%), diarrhea (7/16, 44%), headache (6/16, 38%), and sore throat (5/16, 31%). Shortness of breath and cough were each present in one patient. Chest radiography showed cardiomegaly (10/16, 63%), congestive heart failure or cardiogenic pulmonary edema (9/16, 56%), atelectasis (9/16, 56%), pleural effusions (7/16, 44%), acute respiratory distress syndrome (2/16, 13%), and pneumonia (1/16, 6%). Eight patients (50%) were evaluated for pulmonary embolism (PE) (six [75%] by CT angiography [CTA] and two [25%] by ventilation-perfusion scintigraphy). In two of the eight patients (25%), CTA showed a segmental PE. Abdominal imaging findings (ultrasound, CT, and radiography) included small-volume ascites (6/16, 38%), hepatomegaly (6/16, 38%), echogenic kidneys (5/16, 31%), bowel wall thickening (3/16, 19%), gallbladder wall thickening (3/16, 19%), mesenteric lymphadenopathy (2/16, 13%), splenomegaly (1/16, 6%), and bladder wall thickening (1/16, 6%). The frequencies of findings based on all the reviewed modalities were as follows: cardiomegaly (12/16, 75%), pleural effusion (10/16, 63%), and atelectasis (10/16, 63%). Absolute interobserver agreement was 0.69-1 for thoracic findings and 0.17-1 for abdominal findings. Fifteen patients (94%) were discharged from the hospital (length of hospital stay: range, 3-20 days), and one patient remained in the hospital at the end of the study period. There were no mortalities. CONCLUSION. MIS-C associated with COVID-19 is characterized predominantly by cardiovascular abnormalities, although solid visceral organ, gallbladder, and bowel abnormalities as well as ascites are also seen, reflecting a multisystemic inflammatory process. CLINICAL IMPACT. The constellation of imaging findings in the setting of COVID-19 may alert radiologists to the diagnosis of MIS-C before rapid deterioration of patients.