
==== Front
J Int Med Res
J Int Med Res
IMR
spimr
The Journal of International Medical Research
0300-0605
1473-2300
SAGE Publications Sage UK: London, England

39216074
10.1177/03000605241272702
10.1177_03000605241272702
Case Report and Case Series
Retroperitoneal lymph node tuberculosis complicated by intestinal obstruction: a case report
Zhang Fulong
https://orcid.org/0000-0001-6047-1224
Xu Jing
https://orcid.org/0000-0002-6384-6412
Zhu Yuandong
Department of Gastroenterology, HangZhou Xixi Hospital, HangZhou, Zhejiang, China.
Yuandong Zhu, Department of Gastroenterology, HangZhou Xixi Hospital, 2 Hengbu Street, Xihu District, HangZhou, Zhejiang 310023, China. Email: 20111033@zjtcm.edu.cn
8 2024
31 8 2024
52 8 0300060524127270227 5 2024
8 7 2024
© The Author(s) 2024
2024
SAGE Publications
https://creativecommons.org/licenses/by-nc/4.0/ Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).
The widespread occurrence and severity of tuberculosis make it a major global health concern. Abdominal issues often affect the intestine, peritoneum, and lymph nodes, with retroperitoneal involvement being rare. We herein present a case involving a 51-year-old man who experienced abdominal pain and fever. He had a history of pulmonary tuberculosis 1 year prior, which had been cured 6 months before presentation to our hospital. Abdominal unenhanced computed tomography revealed incomplete bowel obstruction. Abdominal enhanced computed tomography showed significant enlargement of the retroperitoneal lymph nodes, which were compressing the intestinal lumen. Colonoscopy indicated that the terminal ileum and colon were normal. Ultrasound-guided percutaneous lymph node aspiration was performed, and Mycobacterium tuberculosis fluorescence staining was positive. After anti-tuberculosis treatment, the patient’s abdominal pain and fever improved. Retroperitoneal lymph node tuberculosis presents atypically, and obtaining histopathology early is therefore crucial for diagnosis and treatment.

Retroperitoneal lymph node
tuberculosis
intestinal obstruction
diagnosis
treatment
case report
typesetterts2
==== Body
pmcIntroduction

The prevalence and severity of tuberculosis make it a significant global public health issue. 1 If left untreated, tuberculosis can spread widely through blood-borne transmission from an initial infection or the reactivation of dormant illnesses. The intestine, peritoneum, and lymph nodes are frequently affected by abdominal tuberculosis. 2 Incidences of retroperitoneal involvement are rare. 3 The present case study details an intestinal blockage accompanied by a retroperitoneal mass, ultimately diagnosed as tuberculosis. This case emphasizes the importance of timely and accurate diagnosis. This report adheres to the CARE guidelines. 4

Case presentation

A 51-year-old man presented for evaluation of abdominal pain and fever. He had a history of pulmonary tuberculosis 1 year previously, which had been cured 6 months before presentation to our hospital. Abdominal examination revealed tenderness around the umbilicus. Most laboratory test results were within normal limits, including the T-SPOT.TB test, tuberculosis smear fluorescence, erythrocyte sedimentation rate, white blood cell count, serum amylase, prothrombin time, alanine aminotransferase, total bilirubin, creatinine, carbohydrate antigen 199, carcinoembryonic antigen, hepatitis B surface antigen, human immunodeficiency virus antibody, syphilis antibody, anti-nuclear antibody, and hepatitis C antibody. However, significant elevations were found in the serum C-reactive protein level (88.9 mg/L), carbohydrate antigen 125 level (201 kU/L), and D-dimer level (8.25 mg/L) (Table 1).

Table 1. Patient’s laboratory results.

	Laboratory result	Reference range	
WBC count (×109/L)	4.9	(3.4–9.5)	
HB (g/L)	120	(115–150)	
Platelet count (×109/L)	158	(125–350)	
CRP (mg/L)	88.9	(0–10)	
ESR (mm/hour)	14	(0–15)	
PT (s)	12.1	(9.7–13.5)	
Dimer (mg/L)	8.25	(0.00–0.55)	
ALT (U/L)	12	(9–50)	
TB (µmol/L)	5.8	(3–20)	
Cr (µmol/L)	52	(40–80)	
CA199 (kU/L)	7.3	(0–35)	
CA125 (kU/L)	201	(0–35)	
CEA (µg/L)	2.1	(0–5)	
Amylase (U/L)	101	(35–135)	
Lipase (U/L)	75	(0–190)	
Glucose (mmol/L)	4.8	3.0–6.1	
T-SPOT.TB test	Negative	Negative	
TSF	Negative	Negative	
HbsAg	Negative	Negative	
HIV Ab	Negative	Negative	
Sp Ab	Negative	Negative	
ANA	Negative	Negative	
HC Ab	Negative	Negative	
WBC: white blood cell; N: neutrophil; HB: hemoglobin; CRP: C-reactive protein; ESR: erythrocyte sedimentation rate; PT: prothrombin time; ALT: alanine aminotransferase; TB: total bilirubin; Cr: creatinine; CA199: carbohydrate antigen 199; CA125: carbohydrate antigen 125; CEA: carcinoembryonic antigen; TSF: tuberculosis smear fluorescence; HbsAg: hepatitis B surface antigen; HIV-Ab: human immunodeficiency virus antibody; Sp Ab: syphilis antibody; ANA: anti-nuclear antibody; HC Ab: hepatitis C antibody.

An abdominal X-ray and unenhanced computed tomography revealed incomplete bowel obstruction (Figures 1 and 2). Enhanced abdominal computed tomography showed significant enlargement of the retroperitoneal lymph nodes, compressing the intestinal lumen (Figure 3). A subsequent colonoscopy indicated that the terminal ileum and colon were normal (Figures 4 and 5).

Figure 1. Bowel obstruction suggested through abdominal X-ray.

Figure 2. Diagnosis of incomplete bowel obstruction confirmed by abdominal unenhanced computed tomography.

Figure 3. Abdominal enhanced computed tomography showing significant enlargement of retroperitoneal lymph nodes compressing the intestinal lumen.

Figure 4. Normal appearance of the colon under colonoscopy.

Figure 5. Normal appearance of the terminal ileum under colonoscopy.

Ultrasound-guided percutaneous lymph node aspiration was performed to clarify the diagnosis (Figures 6–8), and Mycobacterium tuberculosis fluorescence staining was positive (Figure 9). Following anti-tuberculosis treatment, the patient’s abdominal pain and fever improved.

Figure 9. Positive Mycobacterium tuberculosis fluorescence staining.

Figure 6. Retroperitoneal lymph node visualized under ultrasound.

Figure 7. Performance of ultrasound-guided percutaneous lymph node aspiration.

Figure 8. Pus aspirated from the retroperitoneal lymph node.

Discussion

The global burden of tuberculosis is significant, with an estimated 1.7 billion individuals infected by M. tuberculosis. Without treatment, widespread tuberculosis can develop secondary to hematogenous dissemination from the initial infection or the reactivation of dormant disease. 5 The abdominal area is commonly affected, accounting for 5% to 10% of all cases. 6 Reports of retroperitoneal lymph node tuberculosis are rare, and there are no known reports of intestinal obstruction caused by retroperitoneal lymph node tuberculosis. Early detection and appropriate management often result in successful clinical and radiological outcomes of anti-tuberculous therapy. 7

In this case, extrapulmonary tuberculosis was initially not considered because the patient had been cured of pulmonary tuberculosis 6 months earlier. However, his symptoms of abdominal pain and fever persisted despite treatment for intestinal obstruction. Subsequent ultrasound-guided percutaneous lymph node aspiration confirmed retroperitoneal lymph node tuberculosis.

Conclusion

The symptoms of retroperitoneal lymph node tuberculosis are atypical, and histopathological analysis should be performed as soon as possible for early diagnosis and treatment.

Acknowledgement

The authors thank Professor Delin Liu for his assistance in the diagnosis of this case.

Data availability statement

The data analyzed in this study are available from the corresponding author upon reasonable request.

Ethics approval and consent to participate

The study protocol conformed to the ethical guidelines of the Declaration of Helsinki and was approved by the ethics review committee of HangZhou XiXi Hospital (202401141400000250708). The committee waived the requirement for informed consent.

Author contributions: Yuandong Zhu designed the study. Fulong Zhang wrote the manuscript. Jing Xu collected the clinical information. Yuandong Zhu revised the manuscript. All authors read and approved the final manuscript.

The authors declare that there are no conflicts of interest.

Funding: No funding was received for this study.

ORCID iDs: Jing Xu https://orcid.org/0000-0001-6047-1224

Yuandong Zhu https://orcid.org/0000-0002-6384-6412
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