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Open Access Case report

2D ultrasonography and contrast enhanced ultrasound for the evaluation of cavitating mesenteric lymph node syndrome in a patient with refractory celiac disease and enteropathy T cell lymphoma

Cristina Pojoga1, Lidia Ciobanu12, Alexandru Florin Badea2, Emil Boţan1, Cosmin Caraiani1, Claudia Hagiu12, Grigore Băciuţ12 and Radu Badea12*

Author affiliations

1 “Octavian Fodor” Regional Institute of Gastroenterology and Hepatology, 19-21, Croitorilor Street, 400 162, Cluj-Napoca, Romania

2 “Iuliu Hatieganu” University of Medicine and Pharmacy, 8, Victor Babes Street, 400 012, Cluj-Napoca, Romania

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Citation and License

BMC Gastroenterology 2013, 13:26  doi:10.1186/1471-230X-13-26

Published: 11 February 2013

Abstract

Background

The cavitating mesenteric lymph node syndrome (CMLNS) is a rare manifestation of celiac disease, with an estimated mortality rate of 50%. Specific infections and malignant lymphoma may complicate its clinical course and contribute to its poor prognosis. Diagnosing the underlying cause of CMLNS can be challenging. This is the first report on contrast enhanced ultrasound (CEUS) findings in enteropathy associated T-cell lymphoma (EATL) complicating CMLNS in a gluten-free compliant patient with persistent symptoms and poor outcome.

Case presentation

We present the case of a 51-year old Caucasian male patient, diagnosed with celiac disease and CMLNS. Despite his compliance to the gluten-free diet the symptoms persisted and we eventually considered the possible development of malignancy. No mucosal changes suggestive of lymphoma were identified with capsule endoscopy. Low attenuation mesenteric lymphadenopathy, without enlarged small bowel segments were seen on computed tomography. CEUS revealed arterial rim enhancement around the necrotic mesenteric lymph nodes, without venous wash-out. No malignant cells were identified on laparoscopic mesenteric lymph nodes biopsies. The patient died due to fulminant liver failure 14 months later; the histopathological examination revealed CD3/CD30-positive atypical T-cell lymphocytes in the liver, mesenteric tissue, spleen, gastric wall, kidney, lung and bone marrow samples; no malignant cells were present in the small bowel samples.

Conclusions

CEUS findings in EATL complicating CMLNS include arterial rim enhancement of the mesenteric tissue around the cavitating lymph nodes, without venous wash-out. This vascular pattern is not suggestive for neoangiogenesis, as arteriovenous shunts from malignant tissues are responsible for rapid venous wash-out of the contrast agent. CEUS failed to provide a diagnosis in this case.

Keywords:
CEUS; Celiac disease; Peripheral T-cell lymphoma; Cavitating mesenteric lymph node syndrome