Summary: A 50-year-old woman presents with abdominal complaints and weight loss.
Low attenuation retroperitoneal adenopathy. Miliary nodules in the upper and lower
lobes of the lungs.
The differential diagnosis of retroperitoneal adenopathy is wide and varied.
Categories to consider include neoplastic etiologies such as metastatic
adenopathy and lymphoma, infectious etiologies, such as fungal disease, HIV,
and TB, and inflammatory etiologies, such as sarcoidosis and Castleman’s
The attenuation of adenopathy may narrow the differential diagnosis. Hyperenhancing
nodes are seen with Castleman’s disease, whereas low attenuation nodes may be
seen with necrotic adenopathy and TB. Treated lymphoma also may be low in
As per the World Health Organization, there were 8.8
million new cases of TB diagnosed in 2010, and 1.45 million deaths, most of
these occurring in developing countries. While the majority of active
disease involves the pulmonary system, 15% to 25% of cases may be
extrapulmonary, manifesting as meningitis, genitourinary disease or
osteomyelitis. Abdominal TB, which may involve the gastrointestinal tract, peritoneum, lymph nodes or
solid viscera, constitutes up to 12% of extrapulmonary TB. Most commonly,
abdominal TB involves the gastrointestinal (GI) tract, typically affecting the
terminal ileum, where TB granulomas form in the mucosa or the Peyer’s
patches. On computed tomography (CT), there may be diffuse bowel wall
thickening with or without stricture formation. In later stages of disease,
adherent loops, mesenteric thickening and regional lymph nodes may produce a
mass-like appearance centered at the terminal ileum. Complications of
perforation, abscess, and obstruction can also be seen.
Only a minority of abdominal TB will have
concurrent pulmonary findings, making TB an important consideration when
evaluating imaging studies in patients with risk factors for the disease.
Including this entity in the differential may avoid unnecessary treatment
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- Uzunkoy A, Harma M, Harma M. Diagnosis of abdominal tuberculosis:
Experience from 11 cases and review of the literature. World J Gastroenterol. 2004;10:3647-3649.