primary peritoneal tuberculosis presenting as a huge cystic mass · yul lee. et al.. primary...
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大韓放射線햄學會誌 第 24 卷 第 4 號 pp. 645 - 647, 1988 Journal of Korean Radiological Society, 24(4) 645 - 647, 1988
Primary Peritoneal Tuberculosis Presenting as a Huge Cystic Mass
- A Case Report-
Yul Lee, M.D. , Jong SUp Yoon, M.D.
Department of Radiology, Co l1ege of Medicine, Hal1ym University
〈국문초록〉
거대 낭성종괴 소견을 보인 원발성 복막강 결핵
-증례보고-
한립 대학 의학부 방사선과학교실
01 열·윤 := i
= A세 I=f
위 장판계 의 침뱀 이 없는 원말성 복악강 결핵의 진단에는 아직 많은 어려움이 있마. 이 질환의 CT 및 초음파촬영소견 둥이 보고되고 있지만 내부분 수술 및 영러 조직 검사로 확신되 고 있다. 저자들은 거의
복강 전체를 차지하는 커다란 낭성 종괴의 소견을 보인 원발성 복막강 결핵을 경험하였기에 보고하는
바이 마.
Introduction
Primary peritoneal tuberculosis without involve
ment of gastrointestinal tract is still a diagnostíc
problem. Though peritoneal tuberculosis has be
come an uncommon disease in developed coun
tries , it is occasionally encountered in endemic
areas. Various CT and sonographic findings of
peritoneal tuberculosis have been reported but
they are not characteristic and many cases could
be confirmed by laparotomy and pathologic ex
amination . We report a case of peritoneal tubercu
losis presenting as a huge cystic mass with a
fluid-fluid level and multiple internal solid mate-
이 논운은 1 988년 6월 30일에 접 수하여 1988년 7월 27일 에 채 택되었음. Received June 30, Accepted July 27 , 1988
rials.
Case Report
A 23 year old male patient presented with prog
ressive abdominal distension for 7 years. On
physical examination a large protruding mass was
palpated in the abdomen which was firm , not ten
der, not movable . Routine laboratory examina
tions including chest X-ray were all normal. Ultra
sonography showed a large cystic mass in the
abdomen. Multiple variable sized solid
hyperechoic materials were noted in the depen
dent portion of the mass . A sharply delineated
fluid-fluid level was noted in the mass , upper part
was anechoic and lower part was hypoechoic(Fig.
lA). CT also demonstrated a cystic mass measur
ing about 12x18x20cm in the abdomen. Ascending
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- 大韓放射線뽑學會誌 : 第 24 卷 第 4 號 1988 -
colon and small bowel were posterolaterally dis
placed suggesting intraperitoneal location of the
mass. Multiple soft tissue density materials were
also noted in the mass some of which contained
caIcifications . But the fluid-fluid level which was
noted on sonography was not demonstrable on
CT(Fig. 1B). U.G. I., small bowel series and co
lon study demonstrated only displaced bowels wi
thout mucosal abnormality(Fig. l C). Preoperative
radiological diagnosis was an intraperitoneal cystic
tumor such as cystic Iymphangioma. At lapar
otomy an intraperitoneal cystic mass was removed.
The capsule adhered densely to the peritoneum
and the mesentery. About 3000cc dark brownish
colored fluid was evacuated from the cyst and
muItiple yellowish soft tissue materials were also
found in the mass , some of which contained caIci-
Fig. lA. Abdominal sonography. A large cystic mass containing multiple internal hyperechoic solid materials. N ote a sharply delineated fluid-fluid level in the cystic portion of the mass; The upper part is anechoic and the lower part is hypoechic
Fig. lB . Abdominal CT , A well encapsulated cystic mass containing multiple partly calcified soft tissue density materials in the dependent portion. Posterolateral displacement of bowel loops suggest intraperi tonc:al location 。 f the mass. The fluid-fluid level which was noted on sonography is not shown
Fig. lC. Delayed film of small bowel series. Small bowel and colon are displaced by the mass but mucosal abnormality is not noted
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Yul Lee. et al.. Primary Peritoneal Tuberculosis Presenting as a Huge Cys tic Mass-
fications. Adjacent mesentery was diffusely thick- Usually the caseation necrosis of tuberculosis is
ened and several enlarged mesenteric lymph nodes cheese-like material , but sometimes it can solidify
were also found. Both the cystic mass and mesen- with or without calcifications and sometimes li-
teric lymph nodes were confirmed to be tuberculo- quify acquring a more fluid- like consistencyB). Our
sis on pathologic examination. case showed the possible different states of casea
tion necrosis in peritoneal tuberculosis especially
Discussion
Peritoneal tuberculosis may occur without gas
trointestinal tract involvement. Bhansali et al. re
ported that among the 300 cases of abdominal
tuberculosis up to one thirds of patients had Iym
phadenopathy or peritoneal disease without
alimentary canal involvement1) . Peritoneal tuber
culosis on CT may produce some abnormalities
such as enlarged mesenteric lymph nodes , high
density ascites , diffuse peritoneal enhancement
and omental or mesenteric masses2-4
). Sonogra
phy can also demonstrate ascites and abdominal
masses of variable echogenecity3 ,5). Among these
manifestations of peritoneal tuberculosis the in
traabdominal mass or abscess type of presentation
may be a more difficult diagnostic problem be
cause enlarged mesenteric lymph nodes , omental
or mesentric thickening , matted loops of bowels
all can be demonstrated as a mass on CT or
sonography with variable shape , CT No. or
echogenecity3,6)
The centrallow low density of tuberculous lym
phadenopathy has been well known but it is not
charaeteristic for tuberculosis because it may be
found occasionally in metastatic malignancy , lym
phoma , pyogenic infection and Whipple’s
disease2 ,7). Our case was such a huge mass that
preoperative diagnosis was a cystic tumor and
tuberculosis was not included in differential di
agnosis. The fluid-fluid level which was noted on
sonography in our case has not been previously
described on the literature to o ur knowledge . It
was probably due to the different components of
the cystic fluid that could be delineated on
sonography , not on CT
on sonography: supernatent anechoic fluid , depen
dent hypoechoic fluid and hyperechoic solid mate-
rials.
Our case is very unusual for peritoneal tubercu
losis but in view of the protean clinical and
radiological manifestations , the possibility of peri
toneal tuberculosis could be considered even with
cystic tumor-like appearance in endemic areas.
For there is an effective chemotherapy so good
prognosis can be expected if promptly diagnosed , but misdiagnosis of peritoneal tuberculosis is
traglc
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