Intra-Abdominal Tuberculous Lymphadenitis Diagnosed Using an Endoscopic Ultrasonography-Guided ProCore Needle Biopsy
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 (). She was negative on a human immunodeficiency virus screening test. Laboratory tests showed a hemoglobin of 12.5 g/dL and a white blood cell count of 5,800/mm3 with normal differential count. The liver and renal profiles were normal. On upper endoscopy, a 3×3 cm intraluminal protruding mass with normal overlying mucosa was noted in the cardiac region of the lesser curvature of the stomach (). Abdominal computed tomography (CT) detected enlarged lymph nodes with rim enhancement and central low attenuation at the gastrohepatic ligament (). EUS was performed to better characterize this lesion, and showed a heterogeneous hypoechoic lesion (3×2 cm) (). We performed an EUS-guided fine needle biopsy (EUS-FNB) because no onsite cytopathology examination was available. The EUS-FNB was done using a convex array echoendoscope (Pentax EG-3870 UTK; PENTAX Co., Ltd., Tokyo, Japan) and the newly designed 22-gauge Echotip Ultra FNB needle, featuring ProCore reverse bevel technology (Cook Endoscopy, Limerick, Ireland).\nAfter 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 (). Pathology revealed caseous necrotic material (). Although no epithelioid granuloma was found, a few acid-fast bacilli were identified on Ziehl-Neelsen staining (). She was also positive in a TB polymerase chain reaction assay. Intra-abdominal tuberculous lymphadenitis was diagnosed based on these results. The patient underwent anti-TB treatment. On the follow-up CT scan obtained 2 months later, the size of the previous intra-abdominal tuberculous lymph nodes was dramatically reduced.