British Journal of Radiology 75 (2002),378-380 © 2002 The British Institute of Radiology
Mesenteric panniculitis associated with abdominal tuberculous lymphadenitis: a case report and review of the literature
G Ege, MD1,
H Akman, MD1 and
G Cakiroglu, MD2
1 Radiology Department and 2 Pathology Department, Istanbul International Hospital, Istanbul cad. No: 82 34800 Yesilkoy, Istanbul, Turkey
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Abstract
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Mesenteric panniculitis is a rare disease characterized by chronic non-specific inflammation of the mesenteric adipose tissue. The specific aetiology of the disease is previously unknown. A case diagnosed as mesenteric panniculitis is presented. The cause was biopsy-proved abdominal tuberculous lymphadenitis. To our knowledge, mesenteric panniculitis associated with tuberculosis infection has not been reported previously in the literature. Thus, we would like to present the first case and describe CT features of the disease.
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Introduction
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Mesenteric panniculitis is a rare disease characterized by chronic non-specific inflammation involving the adipose tissue of bowel mesentery [1]. The specific aetiology of the disease is unknown, although various causes such as infection, trauma or ischaemia of the mesentery have been proposed. The disease has been related to a variety of conditions such as vasculitis, granulomatous disease, malignancies and pancreatitis [2]. In this case, abdominal tuberculous lymphadenitis was the cause. Following 9 months of antituberculous therapy, the patient recovered clinically and the imaging findings almost completely resolved. To our knowledge, mesenteric panniculitis associated with tuberculosis infection has not been reported previously in the literature. Therefore, we would like to present the first case, and describe CT features of the disease.
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Case report
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A 49-year-old man was admitted to hospital with complaints of intermittent abdominal pain, lack of appetite and weight loss. Physical examination revealed a slightly tender possible mass in the mid abdomen. Laboratory findings were normal except for a mild microcytic anaemia owing to iron deficiency. Upper gastrointestinal endoscopy and biopsy were performed, which showed congestion and erosion of the gastric antrum. Histology showed villous abnormality, marked plasma cell infiltration and slight leucocyte infiltration in the duodenum, which were ascribed to non-specific enteropathy-duodenitis [3]. Gluten enteropathy was considered in the differential diagnosis, but the characteristic flat mucosa and prominent intraepithelial lymphocytes were not seen. Jejunal biopsy could not be obtained because the patient objected. The iron deficiency anaemia was explained as a consequence of mucosal damage caused by non-specific duodenitis. CT (Somatom Plus 4 helical CT; Siemens, Erlangen, Germany) showed that a mass was arising from the mesentery, surrounding the superior mesenteric artery (SMA) accompanied by variably sized lymph nodes (Figure 1
). The mesenteric fat was markedly dense owing to inflammation, and surrounded by a sheath-like stripe. The patient subsequently underwent surgery. Laparotomy showed the mass in the small bowel mesentery with encasement of the SMA. Only a few superficial mesenteric lymph nodes were resected. Histology showed lipid-laden macrophages, which are usually seen in mesenteric panniculitis; fibrosis was not observed in the resected tissue. Langhans giant cells, caseous necrosis and bacilli were also not present in the mesenteric tissue. The lymph nodes were reactive, benign, hyperplastic in nature and contained caseous necrosis, establishing a diagnosis of tuberculous lymphadenitis. After 9 months of anti-tuberculous treatment, repeat CT was performed. The abdominal lymph nodes had disappeared. Although there was marked improvement in the mesenteric findings, a mild increase in density in the mesentery with a slightly hyperdense stripe could be seen (Figure 2).
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Figure 1. Enhanced abdominal CT scan of a 49-year-old man with a well defined mass arising from mesentery fatty tissue, surrounded by a sheathlike stripe (arrows) and accompanied by multiple lymph nodes.
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Figure 2. Following 9 months of specific therapy, repeat CT showed that the disease had resolved. Despite improvement in the mesenteric findings, a slightly hyperdense stripe could still be seen.
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Discussion
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Approximately 200 cases of mesenteric panniculitis-fibrosis have been reported in the literature under several names, including retractile mesenteritis, mesenteric panniculitis, liposclerotic mesenteritis, isolated lipodystrophy of the mesentery, mesenteric lipomatosis, lipogranuloma of the mesentery, mesenteric manifestations of Weber–Christian disease and sclerosing mesenteritis [1, 4]. The exact diagnosis is made by using one of three major pathologic features: fibrosis, chronic inflammation, or fatty infiltration of the mesentery. To some extent, all three components are present in most cases. Mata et al [5] described that CT findings depended on the stage of disease and whether the inflammatory, fibrous or fatty component was dominant. When the dominant pathologic component is inflammatory or fatty, the disease is known as mesenteric panniculitis [6]. For cases in which fibrosis is the dominant feature, diagnosis has generally been retractile mesenteritis [4].
Mesenteric panniculitis was also described as a benign tumour-like mesenteric lesion formed as a result of chronic inflammation of adipose tissue [7].
The specific aetiology of the disease is unknown. Autoimmune responses to unknown insults and ischaemia of the mesentery have been proposed as pathogenetic mechanisms [8, 9]. An association of mesenteric panniculitis and malignancy, mainly lymphoma, has previously been indicated in the literature [2, 10, 11]. The pathogenic mechanism linking mesenteric panniculitis with malignancy is also unknown. Kipfer et al [2] suggested that mesenteric panniculitis was a non-specific response to an underlying abdominal malignancy. However, another study [1] did not support that suggestion because in 19 (55.8%) of their patients with mesenteric panniculitis and malignancy, the disease was extra-abdominal. Moreover, a cause common to all patients was not identified in their series.
In this case, the cause was biopsy-proved abdominal tuberculous lymphadenitis. The disease is usually asymptomatic. When symptomatic, patients may present with abdominal tenderness or a palpable abdominal mass and systemic manifestations including abdominal pain, pyrexia, weight loss and bowel disturbance of variable duration [6, 12]. Symptoms may be progressive, intermittent or absent. Laboratory findings, including elevation in erythrocyte sedimentation rate and anaemia, are absent or non-specific. Complete resection of the mass is usually impossible and is generally considered to be of no benefit [12].
Recently, mesenteric panniculitis has been diagnosed using CT features of the disease. Daskalogiannaki et al [1] diagnosed the disease predominantly on the basis of CT features in their large series. Only 4 of 49 patients had a biopsy-proved diagnosis. Chopra et al [13] showed that mesenteric, omental and retroperitoneal oedema occurred commonly in patients with cirrhosis, but their CT findings of mesenteric oedema were similar to those of mesenteric panniculitis. Their description was almost the same as that of Daskalogiannaki et al [1].
Sabate et al [14] mentioned the presence of "pseudotumoral stripe" around a mesenteritic lesion on CT and suggested that the finding was important for diagnosis of the disease. In this case, this finding was definitely present therefore supporting Sabate et al's hypothesis.
The CT features of this case included a well delineated mass-like lesion composed of markedly dense mesenteric fatty tissue owing to inflammation and surrounded by a sheathlike stripe, and engulfment of superior mesenteric vessels accompanied by lymph nodes. However, no evidence of invasion of adjacent small bowel loops.
On follow-up CT, progression from panniculitis to fibrosis has rarely been documented in the literature [15]. This case was followed for 9 months during which the findings almost completely regressed.
In conclusion, mesenteric panniculitis is a rare disease that occurs independently or in association with other disorders. In this case, the aetiology of the disease was tuberculous lymphadenitis. As far as we know, this is the first case report of a patient with mesenteric panniculitis associated with tuberculous infection. CT features of the disease, which are quite diagnostic, have recently been clearly described. Open biopsy is not always necessary for diagnosis.
Received for publication September 6, 2001.
Revision received November 27, 2001.
Accepted for publication November 29, 2001.
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References
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Abstract
Introduction
