17 yr old boy presented to out patient clinic with intermittent fever for 2 months,anorexia and anemia

 

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Doctor's Information

Name : RAM KUMAR .S
Family : NADIU
Affiliation :INDIAN MEDICAL COUNCIL
Academic Degree : M.D RADIOLOGY ASST PROFESSOR
Email : This email address is being protected from spambots. You need JavaScript enabled to view it.
Resident : M.S. HEMHNATH

 

Case Section

Abdominal Imaging

 

Patient's Information

Gender : Male
Age : 17

 

Clinical Summary

17 yr old boy presented to out-patient clinic with intermittent fever for 2 months, anorexia, weight loss and anaemia. The patient also had vague abdominal pain in left hypochondrium and lumbar region. Initial investigations showed reduced Hb% , normal total and differential blood counts and elevated ESR.

 

Imaging Findings

Fig.1: CECT showing intraluminal mass with mesenteric lymphadenopathy Fig.2: CECT image showing the mass in the  lumen

 

Differential Diagnosis

Another mass seen in relation to the bowel is gastrointestinal stromal tumour (GIST). These tumours are large masses seen in relation to the bowel wall. These tumours usually are seen in the middle and old ages. Incidence of GISTs in younger age group is very rare. These tumours when large usually have necrotic centres. Lymph node metastases are not reported in GISTs. At surgery Lobulated soft tissue mass was seen in the wall of the jejunum. There was no evidence of extension outside the bowel wall. Multiple lymph nodes were seen in the adjacent mesentery. The involved segment was resected and end to end anastomosis was done. Complete removal of the enlarged lymph nodes was done. The specimen was sent for histopathological examination.

 

Final Diagnosis

At histopathology the final diagnosis was primary NHL of the jejunum with secondaries in the mesenteric lymph nodes.

 

Discussion (Related Text)

Abstract The case study reported here involves a 17 old boy who presented with intermittent fever for 2 months, anorexia, weight loss and anaemia. Initial ultrasound evaluation of the abdomen revealed a soft tissue mass in left lumbar region associated with small bowel. Multiple bulky lymph nodes were seen in the adjacent mesentery. Computed tomography (CT) scan showed eccentric mass lesion in the jejunum with bulky lymph nodes in the adjacent mesentery. Surgical excision with histopathological examination confirmed the mass to be primary non-Hodgkin’s lymphoma (NHL) of the jejunum. Introduction Primary gastrointestinal tract (GIT) lymphoma is the most common manifestation of extra-nodal non-Hodgkin lymphoma, accounting for up to 20% of all cases(1). Most common site for primary GIT lymphoma is stomach. Incidence of primary jejunal lymphoma is very rare. Primary or secondary lymphomas may occur in any portion of the gut. Secondary GIT involvement is common because of the frequent occurrence of lymphomas in the mesenteric or retroperitoneal nodes and the abundance of lymphoid tissue in the gut. Multiple sites are typically involved. But primary lymphomas of the GIT usually involve only one site. Dawson et al (2) mentioned five criteria for the diagnosis of a primary GI lymphoma: 1. No palpable superficial lymph nodes. 2. Normal chest radiograph. 3. Normal total and differential white blood cell count. 4. At surgery, the gut is predominantly involved and lymph node involvement (if any) is confined to the drainage area of the involved gut. 5. Normal liver and spleen. Discussion Lymphoma is the most common malignancy of the small bowel and recently its incidence in HIV- positive patients has increased. Primary NHL (both B-cell and T-cell type), Burkitt lymphoma, MALT lymphoma and rarely Hodgkin lymphoma have been described in the small intestine, with small bowel lymphoma accounting for 20%–30% of all primary gastrointestinal lymphomas(3). The distal ileum is classically the most common site of small bowel B-cell lymphoma because of the greater amount of lymphoid tissue in this segment of the bowel. Aneurysmal dilatation of the lumen in the involved segment may be seen due to replacement of the muscularis propria and destruction of the autonomic nerve plexus by lymphomatous infiltration. Bowel obstruction is uncommon in the small bowel lymphoma, as the tumor does not elicit a desmoplastic response. Complications like spread of lymphomatous cells to the regional lymph nodes, formation of entero-enteric fistulas, infiltration in to the adjacent organs and intussusceptions are all can be seen in advanced lymphomas. As compared with peritoneal carcinomatosis, peritoneal lymphomatosis from primary GIT lymphoma is rare, and patterns of lymphomatous involvement of the mesentery, omentum and peritoneum are indistinguishable from peritoneal carcinomatosis or tuberculous peritonitis. At ultrasonography, these tumors are hypoechoic and most comm

 

References

1. Crump M, Gospodarowicz M, Shepherd FA. Lymphoma of the gastrointestinal tract. SeminOncol 1999;26:324–337. 2. Dawson IM, Cornes JS, Morson BC. Primary malignant tumors of the intestinal tract. Br J Surg 1961;49:80–89. 3. Balthazar EJ, Noordhoorn M, Megibow AJ, Gordon RB. CT of small-bowel lymphoma in immunocompetent patients and patients with AIDS: comparison of findings. AJR Am J Roentgenol 1997;168:675–680. 4. Koh PK, Horsman JM, Radstone CR, Hancock H, Goepel JR, Hancock BW. Localised extranodal non-Hodgkin’s lymphoma of the gastrointestinal tract: Sheffield Lymphoma Group experience (1989–1998). Int J Oncol 2001;18:743–748. 5. Byun JH, Ha HK, Kim AY, et al. CT findings in peripheral T-cell lymphoma involving the gastrointestinal tract. Radiology 2003;227:59–67.

 

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