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Electronic Clinical Challenges and Images in GI
Electronic Clinical Challenges and Images in GI
Image 4
Question: A 75-year-old woman with a history of normal pressure hydrocephalus post ventriculoperitoneal shunting presented to the emergency department with complaints of left abdominal pain and fever for 2 weeks. There was no cough on initial presentation. On physical examination, heart murmur and splenomegaly were noted. Laboratory investigations revealed an elevated D-dimer level (1,462 ng/ mL) and markedly depressed platelet count (32,000/L). Total leukocyte count (6,400/L) was within normal limits, with neutrophilic predominance (51%). Blood culture was negative growth. Chest film showed mild interstitial infiltration in the retrocardiac region of left lower lung with left pleural effusion (Figure A). Abdominal computed tomography (CT) was performed for persistent left abdominal pain and revealed an enlarged spleen with several wedge-shaped, poorly enhanced lesions. Several enlarged lymph nodes (Figure B, arrow) along the splenic artery were also noted. What is the most likely diagnosis? See the GASTROENTEROLOGY web site (www.gastrojournal. org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
CHING HSUEH Department of Medical Imaging Changhua Christian Hospital Taiwan CHEN-TE CHOU Department of Radiology Changhua Christian Hospital Erlin Branch and Department of Biomedical Imaging and Radiological Science National Yang-Ming Medical University Taiwan MEI-LING CHEN Department of Pathology Changhua Christian Hospital Taiwan
© 2009 by the AGA Institute
0016-5085/09/$36.00 doi:10.1053/j.gastro.2008.11.032
GASTROENTEROLOGY 2009;136:e7– e8
e8
GASTROENTEROLOGY Vol. 136, No. 1
Answer to the Clinical Challenges and Images in GI Question: Image 4: Splenic Tuberculosis Mimicking Splenic Infarction A CT scan of chest was performed 5 days after the initial presentation and revealed interlobular septal thickness with centrilobular pattern (Figure C, arrow) in the left upper and right lower lobes of the lung. Bilateral pleural effusion was also noted. Owing to aggravated thrombocytopenia and coagulopathy, splenectomy was performed. Grossly, the spleen was congested with areas of wedge-shaped necrosis (Figure D). Microscopically, the areas of geographic necrosis composed of granular cell debris admixed with neutrophils and aggregation of Langerhans giant cells in adjacent splenic parenchyma. Acid-fast stain revealed bacilli of mycobacteriae (Figure E, arrow) and mycobacterial culture showed a growth of Mycobacterium tuberculosis. Tuberculosis (TB) with extrapulmonary involvement accounts for almost 15% of all cases of TB, and the abdomen is the most common focus of extrapulmonary TB.1 Typical CT findings TB with abdominal involvement include lymphadenopathy, splenomegaly, hepatomegaly, hepatosplenic masses, ascites, and bowel involvement. The most common manifestations are lymphadenopathy, seen in 55%– 66% of patients. Solid organ involvement occurs less frequently, except in association with miliary dissemination.2 Splenic TB is rarely the main feature in patients with disseminated TB. Splenic abscesses owing to mycobacterial infection are even more uncommon. It usually occurs after the hematogenous spread of infection, occasionally owing to contiguous spread of infection or as a part of disseminated disease. Fever and left upper quadrant pain may be presenting features in these patients. Splenomegaly in patients with TB may result in a variety of a hematologic abnormalities, including pancytopenia, myelodysplasia, and polycythemia vera. Timely diagnosis of the disease is paramount, because delayed treatment is associated with severe morbidity. A correct clinical diagnosis of abdominal TB is possible only if there is a past history of TB or evidence of healed lesions in other parts of the body. Aspiration biopsy or splenectomy may be needed to confirm TB as the etiology. The treatment of splenic TB is antituberculosis therapy, with splenectomy as required.3 References 1. Lam KY, Lo CY. A critical examination of adrenal tuberculosis and a 28-year autopsy experience of active tuberculosis. Clin Endocrinol 2001;54:633– 639. 2. Sinan T, Sheikh M, Ramadan S, et al. CT features in abdominal tuberculosis: 20 years’ experience. BMC Med Imaging 2002;2:3. 3. Sharma N, Sharma S. Tuberculous abscess of the abdominal wall and multiple splenic abscesses in an immunocompetent patient. Indian J Chest Dis Allied 2004;46:221–223. For submission instructions, please see the GASTROENTEROLOGY website (www.gastrojournal.org).
Image 4
Question: A 75-year-old woman with a history of normal pressure hydrocephalus post ventriculoperitoneal shunting presented to the emergency department with complaints of left abdominal pain and fever for 2 weeks. There was no cough on initial presentation. On physical examination, heart murmur and splenomegaly were noted. Laboratory investigations revealed an elevated D-dimer level (1,462 ng/ mL) and markedly depressed platelet count (32,000/L). Total leukocyte count (6,400/L) was within normal limits, with neutrophilic predominance (51%). Blood culture was negative growth. Chest film showed mild interstitial infiltration in the retrocardiac region of left lower lung with left pleural effusion (Figure A). Abdominal computed tomography (CT) was performed for persistent left abdominal pain and revealed an enlarged spleen with several wedge-shaped, poorly enhanced lesions. Several enlarged lymph nodes (Figure B, arrow) along the splenic artery were also noted. What is the most likely diagnosis? See the GASTROENTEROLOGY web site (www.gastrojournal. org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
CHING HSUEH Department of Medical Imaging Changhua Christian Hospital Taiwan CHEN-TE CHOU Department of Radiology Changhua Christian Hospital Erlin Branch and Department of Biomedical Imaging and Radiological Science National Yang-Ming Medical University Taiwan MEI-LING CHEN Department of Pathology Changhua Christian Hospital Taiwan
© 2009 by the AGA Institute
0016-5085/09/$36.00 doi:10.1053/j.gastro.2008.11.032
GASTROENTEROLOGY 2009;136:e7– e8
e8
GASTROENTEROLOGY Vol. 136, No. 1
Answer to the Clinical Challenges and Images in GI Question: Image 4: Splenic Tuberculosis Mimicking Splenic Infarction A CT scan of chest was performed 5 days after the initial presentation and revealed interlobular septal thickness with centrilobular pattern (Figure C, arrow) in the left upper and right lower lobes of the lung. Bilateral pleural effusion was also noted. Owing to aggravated thrombocytopenia and coagulopathy, splenectomy was performed. Grossly, the spleen was congested with areas of wedge-shaped necrosis (Figure D). Microscopically, the areas of geographic necrosis composed of granular cell debris admixed with neutrophils and aggregation of Langerhans giant cells in adjacent splenic parenchyma. Acid-fast stain revealed bacilli of mycobacteriae (Figure E, arrow) and mycobacterial culture showed a growth of Mycobacterium tuberculosis. Tuberculosis (TB) with extrapulmonary involvement accounts for almost 15% of all cases of TB, and the abdomen is the most common focus of extrapulmonary TB.1 Typical CT findings TB with abdominal involvement include lymphadenopathy, splenomegaly, hepatomegaly, hepatosplenic masses, ascites, and bowel involvement. The most common manifestations are lymphadenopathy, seen in 55%– 66% of patients. Solid organ involvement occurs less frequently, except in association with miliary dissemination.2 Splenic TB is rarely the main feature in patients with disseminated TB. Splenic abscesses owing to mycobacterial infection are even more uncommon. It usually occurs after the hematogenous spread of infection, occasionally owing to contiguous spread of infection or as a part of disseminated disease. Fever and left upper quadrant pain may be presenting features in these patients. Splenomegaly in patients with TB may result in a variety of a hematologic abnormalities, including pancytopenia, myelodysplasia, and polycythemia vera. Timely diagnosis of the disease is paramount, because delayed treatment is associated with severe morbidity. A correct clinical diagnosis of abdominal TB is possible only if there is a past history of TB or evidence of healed lesions in other parts of the body. Aspiration biopsy or splenectomy may be needed to confirm TB as the etiology. The treatment of splenic TB is antituberculosis therapy, with splenectomy as required.3 References 1. Lam KY, Lo CY. A critical examination of adrenal tuberculosis and a 28-year autopsy experience of active tuberculosis. Clin Endocrinol 2001;54:633– 639. 2. Sinan T, Sheikh M, Ramadan S, et al. CT features in abdominal tuberculosis: 20 years’ experience. BMC Med Imaging 2002;2:3. 3. Sharma N, Sharma S. Tuberculous abscess of the abdominal wall and multiple splenic abscesses in an immunocompetent patient. Indian J Chest Dis Allied 2004;46:221–223. For submission instructions, please see the GASTROENTEROLOGY website (www.gastrojournal.org).