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Mesenteric Lymph Node Cavitation in Celiac Disease

Loyola University Medical Center Maywood, IL 60153

Mesenteric lymph node cavitation is a rare feature of celiac disease [1,2,3,4]. On CT, these lymph nodes can be fluid or fat attenuation or contain fat—fluid levels. This finding helped lead to the diagnosis in an 83-year-old woman with a 3-month history of diarrhea and weight loss. CT revealed enlarged low-attenuation mesenteric lymph nodes containing fat—fluid levels and an atrophic spleen (Figs. 4A and 4B). Laboratory results included findings of serum protein, 4.9 g/dL; serum carotene, 0 g/dL; and slightly elevated fecal fat, 8.6g/24 hr. Villous atrophy was found at duodenal biopsy. After 3 months on a gluten-free diet, the patient's diarrhea had markedly improved, and she had gained weight.

View larger version (130K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A. —Signs of celiac disease in 83-year-old woman. CT scan shows cavitary mesenteric lymph nodes (arrow) containing fat—fluid levels.

View larger version (152K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B. —Signs of celiac disease in 83-year-old woman. CT scan reveals nodes with low central attenuation. One node contains fat—fluid level.

Cavitary lymph nodes in celiac disease were first reported in 1969. From 1969 to 1998, 30 more cases were reported [3]. These patients also had splenic atrophy, but splenic atrophy is common in celiac disease (Fig. 4C). The prognostic importance of lymph node cavitation is uncertain, but some researchers have reported a poor prognosis because of infection, cachexia, and electrolyte problems [1, 2].

View larger version (131K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4C. —Signs of celiac disease in 83-year-old woman. CT scan shows that patient's spleen is atrophic (volume, 50 mL).

Several patients have undergone laparotomy and excision of nodes because lymphoma was suspected. These lymph nodes have a rim of atrophic lymphocytes with central cavitation containing milky fluid and lipid droplets [2]. The cause of cavitation has been attributed to mesenteric lymphoid depletion and the effect of antigenic material crossing abnormal intestinal mucosa [1, 2].

Low-attenuation lymphadenopathy has a limited differential diagnosis including celiac disease, Whipple's disease, tuberculosis, lymphoma, necrotic metastases, and germ cell tumors. Cavitary lymph nodes have been reported in Whipple's disease, but lymph nodes containing fat—fluid levels have been reported only in celiac disease.

Clinical, biochemical, and histologic response to a gluten-free diet; small-bowel biopsy; detection of antibodies to (or an increased serum level of) gliadin, a substance found in wheat; or antibodies to endomysium, an extracellular protein in the bowel wall, can help to confirm the diagnosis of celiac disease. In some patients, however, the presentation of celiac disease is mild, atypical, or eclipsed by complications of malabsorption. In these patients, discovery of cavitary lymph nodes by a radiologist who is aware of their relationship to celiac disease can lead to the correct diagnosis and obviate invasive procedures to obtain lymph node tissue.

References

1. Matuchansky C, Colin R, Hemet J, et al. Cavitation of mesenteric lymph nodes, splenic atrophy, and a flat small intestinal mucosa: report of six cases. Gastroenterology 1984;87:606 -614[Medline]
2. Howat AJ, McPhie JL, Smith DA, et al. Cavitation of mesenteric lymph nodes: a rare complication of coeliac disease associated with a poor outcome. Histopatholology 1995;27:349 -354
3. Bardella MT, Trovato C, Quatrini M, Conte D. Mesenteric lymph node cavitation: a rare hall-mark of celiac disease. Scand J Gastroenterol 1999;34:1257 -1259[Medline]
4. Burrell HC, Trescoli C, Chow K, Ward MJ. Mesenteric lymph node cavitation: an unusual complication of celiac disease. Br J Radiol 1994;67:1139 -1140[Abstract]

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This Article Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Reddy, D. Articles by Cosar, E. Search for Related Content PubMed PubMed Citation Articles by Reddy, D. Articles by Cosar, E. Social Bookmarking                      What's this?