Horie Masafumi, Tarui Megumi, Kashizaki Fumihiro, Kawashima Masahiro, Suzuki Junko, Shimada Masahiro, Araki Kousuke, Komiya Kousaku, Matsui Yoshinori, Ohshima Nobuharu, Masuda Kimihiko, Tamura Atsuhisa, Nagayama Naohiro, Toyoda Emiko, Nagai Hideaki, Akagawa Shinobu, Nakajima Yutsuki
Department of Respiratory Diseases, National Hospital Organization Tokyo National Hospital, Japan.
Kekkaku. 2009 Oct;84(10):675-9.
Abdominal tuberculous lymphadenitis is very rare. We report a case of pulmonary tuberculosis showing marked abdominal lymphadenopathy and splenomegaly. A 95-year-old man was admitted to our hospital because of abnormal chest X-ray and body weight loss in last 6 months. He had low grade fever with no abdominal pain. He did not have past history of tuberculosis. Laboratory examination showed mild renal dysfunction and mild glucose intolerance. Soluble interleukin 2 recepter was highly elevated (3800 U/ml). Tumor markers, such as carcinoembryonic antigen (CEA), cytokeratin 19 fragment (CYFRA), and progastrin-releasing peptide (Pro GRP) were all within normal limit. Chest X-ray showed multiple nodules in bilateral lung fields. Chest computed tomography showed multiple nodules in bilateral lungs, especially in upper part of lungs, right hilar lymphadenopathy and upper mediastinal lymphadenopathy. Abdominal and pelvic enhanced computed tomography showed marked abdominal lymphadenopathy and splenomegaly (67 x 49 mm). Abdominal lymph nodes were hepatoduodenal (50 x 50 mm), splenic hilar (40 x 25 mm), upper paraaortic (30 x 60 mm), and small superior mesenteric (10 x 10 mm) lymph nodes. FDG-PET showed accumulation in the nodules of right lung field, right hilar lymph nodes, upper mediastinal lymph nodes, and abdominal lymph nodes. Bronchial lavage fluid (BAL) smear for acid-fast bacilli was positive, polymerase chain reaction for Mycobacterium tuberculosis was positive and acid-fast bacilli was cultured. Transbronchial lung biopsy specimen demonstrated non-specific intraalveolar organization and alveolitis. The patient was diagnosed as pulmonary tuberculosis, but about abdominal lymphadenopathy and splenomegaly we had to differentiate malignant lymphoma, and for definite diagnosis, laparotomy was necessary. But considering his age and general condition, we followed up carefully with anti-tuberculosis therapy. Pulmonary tuberculosis, abdominal lymphadenopathy and splenomegaly all showed marked improvement 4 months after starting anti-tuberculosis therapy with isoniazid, rifampicin, and ethambutol, so we clinically diagnosed abdominal tuberculous lymphadenitis and splenic tuberculosis.
腹部结核性淋巴结炎非常罕见。我们报告一例肺结核患者，其表现为明显的腹部淋巴结肿大和脾肿大。一名95岁男性因胸部X线异常及过去6个月体重减轻入住我院。他有低热，无腹痛。既往无结核病史。实验室检查显示轻度肾功能不全和轻度糖耐量异常。可溶性白细胞介素2受体高度升高（3800 U/ml）。癌胚抗原（CEA）、细胞角蛋白19片段（CYFRA）和胃泌素释放肽前体（Pro GRP）等肿瘤标志物均在正常范围内。胸部X线显示双侧肺野多发结节。胸部计算机断层扫描显示双侧肺部多发结节，尤其是肺上部，右肺门淋巴结肿大和上纵隔淋巴结肿大。腹部和盆腔增强计算机断层扫描显示明显的腹部淋巴结肿大和脾肿大（67×49 mm）。腹部淋巴结为肝十二指肠淋巴结（50×50 mm）、脾门淋巴结（40×25 mm）、主动脉旁上部淋巴结（30×60 mm）和肠系膜上小淋巴结（10×10 mm）。氟代脱氧葡萄糖正电子发射断层扫描显示右肺野结节、右肺门淋巴结、上纵隔淋巴结和腹部淋巴结有放射性浓聚。支气管灌洗（BAL）液涂片抗酸杆菌阳性，结核分枝杆菌聚合酶链反应阳性且培养出抗酸杆菌。经支气管肺活检标本显示肺泡内非特异性机化和肺泡炎。患者被诊断为肺结核，但对于腹部淋巴结肿大和脾肿大，我们必须鉴别恶性淋巴瘤，为明确诊断，有必要进行剖腹手术。但考虑到他的年龄和一般状况，我们在抗结核治疗的同时进行了仔细随访。在开始使用异烟肼、利福平及乙胺丁醇进行抗结核治疗4个月后，肺结核、腹部淋巴结肿大和脾肿大均有明显改善，因此我们临床诊断为腹部结核性淋巴结炎和脾结核。
