Question: A 56-year-old man with celiac disease presented to the emergency room with intermittent fever for the last month. There was no history of cough, urinary symptoms, or abdominal pain. He had a recent right colectomy for adenocarcinoma. His physical examination was unremarkable. Laboratory investigation showed anemia, and negative blood and urine cultures. Initial investigation with a postcontrast computed tomography scan of the abdomen showed multiple, coalescent, rim-enhancing, round cystic lesions with low-attenuation in the root of the small bowel mesentery (Figure A, arrows); some of them showed fat attenuation (Figure A, arrowheads). To better evaluate the findings, magnetic resonance imaging was performed. Axial T2-weighted magnetic resonance imaging demonstrated several cystic masses in root of mesentery with marked hyperintense signal (Figure B, arrows), some with fat–fluid levels (Figure B, arrowheads). Axial fat-suppressed T1-weighted image shows signal intensity consistent with fat inside the cystic lesions (Figure C, arrows), with fat–fluid levels (Figure C, arrowheads). What are the differential diagnoses? Look on page 16 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and images in GI. As the patient had a history of colonic adenocarcinoma and celiac patients are at risk for lymphoma, the differential diagnoses included metastatic lymph nodes and lymphoma with necrosis.1Lucey B.C. Stuhlfaut J.W. Soto J.A. Mesenteric lymph nodes seen at imaging: causes and significance.Radiographics. 2005; 25: 351-365Crossref PubMed Scopus (111) Google Scholar Tuberculosis and Whipple’s disease were also possibilities, because they may present with hypoattenuating nodal disease owing to necrosis.1Lucey B.C. Stuhlfaut J.W. Soto J.A. Mesenteric lymph nodes seen at imaging: causes and significance.Radiographics. 2005; 25: 351-365Crossref PubMed Scopus (111) Google Scholar However, some of these lesions contained fat and a fat–fluid level, which increased the suspicion for cavitating mesenteric lymph node syndrome and decreased the probability of lymphoma, metastatic lymph nodes, and infection.2Huppert B.J. Farrell M.A. Kawashima A. et al.Diagnosis of cavitating mesenteric lymph node syndrome in celiac disease using MRI.AJR Am J Roentgenol. 2004; 183: 1375-1377Crossref PubMed Scopus (22) Google Scholar Cavitating mesenteric lymph node syndrome is a rare complication of celiac disease with <40 cases reported in the literature.2Huppert B.J. Farrell M.A. Kawashima A. et al.Diagnosis of cavitating mesenteric lymph node syndrome in celiac disease using MRI.AJR Am J Roentgenol. 2004; 183: 1375-1377Crossref PubMed Scopus (22) Google Scholar, 3Scholz F.J. Afnan J. Behr S.C. CT findings in adult celiac disease.Radiographics. 2011; 31: 977-992Crossref PubMed Scopus (36) Google Scholar Many of these cases also underwent surgery owing to the rarity of this syndrome and possibility of neoplasia.1Lucey B.C. Stuhlfaut J.W. Soto J.A. Mesenteric lymph nodes seen at imaging: causes and significance.Radiographics. 2005; 25: 351-365Crossref PubMed Scopus (111) Google Scholar In our case, because lymphoma could also be a diagnosis, the patient underwent surgery. Intraoperative view shows fluid with characteristic cream-like appearance in the peritoneal cavity that originated from the mesenteric cysts (Figure D). Histopathology revealed residual lymph node tissue on the cystic wall. A fibrous capsule and residual lymph node tissue were noted (Figure E, arrows). Atrophic cavitated lymph node was also observed (Figure F, arrow). Fat necrosis was compatible with the diagnosis of cavitating mesenteric lymph node syndrome. The patient was discharged with immunosuppression, but evolved with pancytopenia, was readmitted for pulmonary sepsis, and died.
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Dec 31, 2022
Deepak Mishra + 3
Open Access
