Intra-abdominal tuberculous lymphadenitis can mimic a variety of other abdominal disorders such as pancreatic cancer, metastatic lymph nodes, or lymphoma, which can make a proper diagnosis difficult. A correct diagnosis of intra-abdominal tuberculous lymphadenitis can lead to appropriate management. Endoscopic ultrasonography (EUS)-guided needle biopsy may be the procedure of choice for tissue acquisition when onsite cytopathology examination is unavailable because it is essential to obtain sufficient material suitable for the examination using an ancillary method, such as flow cytometry, molecular diagnosis, cytogenetics, or microbiological culture. We report a case of intra-abdominal tuberculous lymphadenitis diagnosed using an EUS-guided, 22-gauge histology new needle biopsy without an onsite cytopathology examination.
Intra-abdominal tuberculous lymphadenitis can present as a cystic or solid mass that mimics malignancies, such as pancreatic cancer, metastatic lymph nodes, or lymphoma, which makes it difficult to differentiate these conditions.
An immunocompetent, 61-year-old woman was referred to our hospital for the evaluation of a gastric subepithelial lesion found incidentally during an upper endoscopy screening. Her medical history was unremarkable. She denied abdominal pain, weight loss, anorexia, fever, jaundice, night sweats, and fatigue. The general physical examination was unremarkable. The chest radiograph showed multiple variably sized calcified nodules in both upper lobes, suggesting the sequelae of pulmonary TB (
After the lesion was endosonographically visualized and the region was scanned for vessels by power Doppler, FNB using a 22-gauge ProCore needle was performed from the stomach. The needle was advanced into the lesion under endosonographic guidance. Once the lesion was inserted, the stylet was removed, and suction was applied for 20 seconds using a 10 mL syringe while moving the needle to and fro within the lesion. Suction was released before the needle was removed. Adequate tissue materials were obtained on one needle pass with one to and fro needle movement (
For lymph node enlargement in a patient with no history of malignant disease, the differential diagnosis is very broad, including TB, lymphoma, and lymph node metastases from an unknown primary.
Recently, the EUS-guided ProCore biopsy was introduced.
Therefore, we performed EUS-guided 22-gauge ProCore needle biopsy, ultimately diagnosing intra-abdominal tuberculous lymphadenitis in our case. EUS-guided 19-gauge Trucut biopsy (EUS-TCB) might also have been useful for the diagnosis of intra-abdominal tuberculous lymphadenitis in our case without onsite cytopathology. Lee et al.
In conclusion, we safely performed EUS-FNB using a 22-gauge ProCore needle in a case of intra-abdominal tuberculous lymphadenitis, and were able to provide an accurate diagnosis. We believe that EUS-ProCore biopsy is a good alternative to EUS-TCB in suspected intra-abdominal tuberculous lymphadenitis, especially with no available onsite cytopathology. EUS-FNB using a 22-gauge ProCore needle might also have some technical advantages over EUS-TCB if tight angulation of the echoendoscope is necessary.
Based on our observations, we believe that a prospective trial to further evaluate the role of EUS-ProCore biopsy and its complications in suspected intra-abdominal tuberculous lymphadenitis is warranted.
The authors have no financial conflicts of interest.
Clinical findings. (A) Chest X-ray showing multiple variably sized calcified nodules in both upper lobes. (B) Upper endoscopy showing a 3×3 cm intraluminal protruding mass with normal overlying mucosa in the cardiac region of the lesser curvature of the stomach. (C) Abdominal computed tomography showing enlarged lymph nodes with rim enhancement and central low attenuation at the gastrohepatic ligament. (D) Endoscopic ultrasonography showing an enlarged heterogeneous hypoechoic lymph node.
Pathological findings. (A) Tissue materials obtained using the endoscopic ultrasonography-guided ProCore biopsy. (B) Caseous necrotic material with no epithelioid granuloma (H&E stain, ×100). (C) Acid-fast bacillus (arrow) (Ziehl-Neelsen stain, ×1,000).
Detailed image of the 22-gauge ProCore needle.