Solution to Unknown Case #21 – Mesenteric Lymphadenopathy Differential Diagnosis

History: 30 year old female with HIV and abdominal pain. This case demonstrates small bowel mesenteric lymphadenopathy, which is just enlarged lymph nodes in the mesentery. The differential diagnosis along with distinguishing factors is as follows: 1. Lymphoma – the most common malignant cause of mesenteric lymphadenopathy (most commonly Non-Hodgkins Lymphoma). Will commonly show node…

radiologypics

March 14, 2013

1 minute

abdomen, abdominal pain, aids opportunistic infections, female, GI, lymphoma, mesenteric adenitis, non hodgkins lymphoma, solutions

History: 30 year old female with HIV and abdominal pain.

Mesenteric Lymphadenopathy: Axial CT of the abdomen shows a large confluent mass of lymph nodes in the mesentery (between yellow arrows). The hyperdense contrast in the middle of the mass is a "sandwich sign," which is the vessel sandwiched between the mass. As a side note, there is also a large amount of ascites and small bowel wall thickening. — **Mesenteric Lymphadenopathy with Sandwich Sign**: Axial CT of the abdomen shows a large confluent mass of lymph nodes in the mesentery (between yellow arrows). The hyperdense contrast in the middle of the mass is a “sandwich sign,” which is a mesenteric vessel sandwiched between the mass. As a side note, there is also a large amount of ascites and small bowel wall thickening.

Mesenteric Lymphadenopathy: Coronal CT of the abdomen with contrast shows the large amount of soft tissue mass within the mesentery (between the yellow arrows), compatible with mesenteric lymphadenopathy. — **Mesenteric Lymphadenopathy**: Coronal CT of the abdomen with contrast shows the large soft tissue mass within the mesentery (between the yellow arrows), compatible with mesenteric lymphadenopathy.

This case demonstrates small bowel mesenteric lymphadenopathy, which is just enlarged lymph nodes in the mesentery. The differential diagnosis along with distinguishing factors is as follows:

1. Lymphoma – the most common malignant cause of mesenteric lymphadenopathy (most commonly Non-Hodgkins Lymphoma). Will commonly show node enlargement in other parts of the body. Treated lymphoma will show calcifications.

2. Cancer/Cancer Metastases – Carcinoid tumors will have a desmoplastic reaction, small bowel tumors, colon cancer, pancreatic cancer

3. Mesenteric Adenitis – usually right lower quadrant, usually children and young adults, classically seen with Yersinia infection

4. Sclerosing mesenteritis – ill-defined fat stranding in the mesentery with lymph node clusters

5. AIDS – Opportunistic infections such as TB or MAC, Kaposi sarcoma, actual HIV direct infection. Kaposi sarcoma will enhance, TB will commonly show necrosis and calcification

6. Other – diverticulitis, ulcerative colitis, Crohn disease, appendicitis, etc.

This case shows a nice example of the “sandwich sign,” which is mesenteric vessels sandwiched between conglomerations of lymph nodes. It is highly suggestive of lymphoma, most commonly Non-Hodgkins Lymphoma.

Thank you to Paul Murphy, M.D. Ph.D. for these images.