Case Communications
Sclerosing Mesenteritis: a Diagnostic Challenge
1
2
Ibrahim Azzam MD , Simona Croitoru MD
1
Departments of
Internal Medicine A and
2
1
and Jochanan E. Naschitz MD
Diagnostic Imaging, Bnai Zion Medical Center, Haifa, Israel
Affiliated to Tecnion Faculty of Medicine, Haifa, Israel
Key words: sclerosing mesenteritis, sclerosing mesenteritis, mesenteric cyst
IMAJ 2004;6:567±568
Sclerosing mesenteritis is a rare disorder
units [Figure B]. Tissue cultures for Myco-
C]. Several round masses, up to 4.5 cm in
characterized
bacterium
The
diameter, with a density corresponding to
inflammation involving the adipose tissue
diagnosis of lobular sclerosing panniculitis
fluid content (HU 8) were found in the
of the small bowel mesentery. The cause of
was established.
mesentery [Figure D]. A differential diag-
by
a
chronic
non-specific
tuberculosis
were
negative.
still
nosis of infections such as Mycobacterium
infectious, traumatic, and ischemic factors
complained of abdominal discomfort. The
tuberculosis or M. avium intracellulare, Whip-
have been reported in the etiopathogen-
body temperature was normal. There was
ple's disease and malignancy was consid-
esis
no change in bowel habits, nor was there
ered.
cutaneous eruption, arthralgia or systemic
neoplastic etiology, laparoscopy was per-
spectrum of findings on abdominal com-
symptoms.
formed and biopsies were taken. Histologic
puterized
the
defined abdominal mass measuring 10 x
examination
diagnosis
18 cm. Results of laboratory examinations,
areas of fat tissue necrosis. Dilated lym-
the disease is unclear, and autoimmune,
[1].
The
laboratory
findings
presentation
are
tomography
diagnosis
requires
clinical
[1,2]
but
non-specific.
may
hint
definite
Palpation
the
patient
revealed
an
ill-
In
considering
showed
such
infectious
inflammation
or
and
including complete blood count, C-reactive
phatic
protein, liver and renal function tests, were
inflammatory process. There were no gran-
teritis in whom mesenteric lymphadeno-
within the normal range. CT examination
ulomas, vasculitis or malignancy. Excised
pathy and large cystic lesions on abdomi-
demonstrated infiltration and haziness of
mesenteric
nal
the mesenteric adipose tissue, containing
a
challenging
[3].
visits
We
posed
confirmation
at
A
follow-up
describe a patient with sclerosing mesen-
CT
histologic
and
On
diagnostic
problem.
numerous low attenuation masses [Figure
channels
were
nodes
spread
showed
amid
the
non-specific
HU = Hounsfield units
Patient Description
A 63 year old woman with cholelithiasis
was admitted for elective cholecystectomy.
On laparatomy, the mesentery was found
to be diffusely thickened, with numerous
whitish nodes ranging from 0.4 to 2.5 cm in
size. The cut section of such nodes was
either an elastic-firm yellow tissue or a
cyst-like structure containing a milky fluid.
Pathologic samples revealed infiltration of
the
adipose
tissue
by
a
predominantly
A
B
C
D
lymphocytic and histiocytic infiltrate surrounding
areas
Fibrotic
bands
adipose
cells.
of
liquefactive
circumscribed
Lymph
nodes
necrosis.
lobules
within
of
the
mesenteric fat tissue exhibited features of
reactive lymphadenopathy. The patient had
no evidence of fat necrosis or cellulitis at
other sites, pancreatitis or inflammatory
bowel
disease.
demonstrated
A
soft
subsequent
tissue
CT
scan
infiltration
of
the small bowel mesentery with numerous
1±2 cm diameter low attenuation masses
which were thought to be lymph nodes
[Figure A]. A few low attenuation masses
measured between 8 and 16 Hounsfield
IMAJ . Vol 6 . September 2004
Findings on CT examination performed in [A and B] December 2001 and [C and D] December 2002.
Area of increased attenuation within the mesentery comprising numerous hypodense masses. [B]
Round, fluid-filled cysts, 2.5 cm in diameter (arrows). [C] Non-homogeneous fat tissue mass surrounding
the mesenteric vessels. The low attenuation lesions are larger than in previous CTs. [D] Large, clearly
defined, smooth, thin-walled lesions with fluid content (arrow heads).
[A]
Sclerosing Mesenteritis
567
Case Communications
inflammatory changes. Other nodes were
tion is a soft tissue mass in the small bowel
tions may suggest the diagnosis of perito-
found
a
mesentery. Mass lesions may be homoge-
neal tuberculosis. Histologic examination
milky fluid inside. Dilated lymph channels
neous or heterogeneous. Two CT findings,
of a sizeable tissue specimen obtained on
filled with fluid suggested an element of
"fat ring sign" and "tumor pseudocapsule,"
excisional
lymphatic obstruction. Tissue Gram stain
are considered to be somewhat specific for
definitive diagnosis [2]. CT is the preferred
and Gomori stain were negative. At the
sclerosing mesenteritis [2]. The fat ring sign
method for periodic assessment on follow-
time of writing, 3 years after the initial
describes the common finding (in 75±90%
up.
diagnosis of sclerosing mesenteritis, the
of patients) of preservation of the densito-
This case demonstrates the diagnostic
patient is on symptomatic treatment and is
metric values of fat nearest the mesenteric
challenge in finding multiple cystic and
essentially unchanged.
vessels. A tumoral pseudocapsule (seen in
nodular mesenteric lesions in a patient
up to 60% of patients) refers to the finding
with sclerosing mesenteritis. The contribu-
of
sur-
tion and limitations of imaging are illu-
Sclerosing mesenteritis is part of a spec-
rounding the mass. These features are not
strated, with a definite diagnosis estab-
trum of idiopathic primary inflammatory
seen in other mesenteric diseases such as
lished only after repeated laparotomy and
and
lipoma,
histologic assessment.
to
have a
pseudocapsule with
Comment
fibrotic
processes
that
affect
the
a
hyper-attenuated
lymphoma
or
stripe
partly
liposarcoma.
The
mesentery. The epidemiology of sclerosing
term "misty mesentery" has been used to
mesenteritis is unknown. An autopsy series
describe the finding of increased attenua-
reported a prevalence of 1%, suggesting
tion of mesenteric fat with small lymph
that many cases are undiagnosed during
nodes but without evidence of a discrete
life.
a
mass. Vascular displacement, encasement
prevalence of 0.6% in over 7,000 abdominal
or thrombosis may be seen in over one-half
CT examinations [1]. Pathophysiologically,
of
these processes may affect the integrity of
lymphadenopathy is present in 20±40% of
the gastrointestinal lumen and mesenteric
patients. Cystic components have occasion-
A
more
recent
report
described
cases.
been
Mesenteric
described
or
retroperitoneal
vessels by a mass effect. These disorders
ally
may result in a variety of gastrointestinal
consequence of lymphatic or venous ob-
and
may
be
and
1.
los
P,
et
Horton
the
3.
locular mesenteric mass and cystic spaces
patients. Masses tend to be deep-seated
corresponding to dilated lymphatic chan-
and
nels [5]. The above features on CT may
reported normal laboratory parameters.
suggest the diagnosis of sclerosing mesen-
Lawler
LP,
TS,
Monihan
and
mesenteric
entity?
Am
J
Multiple
NJ,
et
al.
lipodystrophy:
Pathol
a
1997;21:
mesenteric
lymphatic
cysts:
an
unusual feature of sclerosing mesenteritis.
J Comput Assist Tomogr 1997;21:103±5.
5.
Kawashima A, Fishman EK, Hruban RH, et
multilocular
inflammatory conditions may give rise to
include lymphoma, carcinoid tumor, carci-
Imaging 1993;17:112±16.
similar findings. Ultrasonography may de-
nomatosis, peritoneal tuberculosis, perito-
monstrate
neal
mesenteric
CT
Johnson LA, Longacre TA, Wharton KA, et al.
may present a similar appearance. These
primary
EK.
392±98.
4.
teritis; however, several other conditions
sarcoidosis,
Carr
Surg
The radiologic features are non-specific.
heterogeneous
sclerosing
associated
Fishman
JM,
Ischemic, neoplastic, infectious and other
well-defined,
of
and
Sclerosing mesenteritis, sclerosing mesen-
osing mesenteritis presented with a multi-
have
MK,
Emory
inal mass can be palpated in up to 50% of
studies
prevalence
culitis): spectrum of disease. Radiographics
diarrhea, weight loss and fever. An abdom-
Most
CT evaluation
2003;23;1561±7.
single
defined.
a
findings in sclerosing mesenteritis (panni-
teritis,
poorly
for
diseases. Am J Roentgenol 2000;174:42±31.
2.
case, similar to the present patient, scler-
and
al.
mesenteritis:
struction or necrotic liquefaction [4]. In one
nausea
necessary
Daskalogiannaki M, Voloudaki A, Prassopou-
including
manifestations,
pain,
is
References
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al. Sclerosing mesenteritis presenting as a
cystic
Correspondence:
mesenteric
mass.
Clin
Dr. J.E. Naschitz, Dept. of
masses that are predominantly hyperechoic
mesothelioma and mesenteric edema. Peri-
owing to the presence of fat and fibrosis.
toneal thickening, omental caking, and the
Center, P.O. Box 4940, Haifa 31048, Israel.
The most common finding on CT examina-
presence of ascites with fine mobile septa-
email: Naschitz@tx.technion.ac.il
Internal
Medicine
A,
Bnai
Zion
Medical
Capsule
Critical period for learning smells
The
incredible
receptors to a given glomerulus are sorted out to produce a
diversity of odors. In the olfactory bulb, each type of odor
mammalian
sense
of
smell
discriminates
an
mature glomerulus that responds to only one type of odorant
receptor links up to unique glomeruli that relay the signals up for
signal. Thus, the experience of smell during a critical period is
higher processing in the brain. Zou et al. have now analyzed the
required for maturation of the odorant interpretation system.
process of refinement using mice in which expression of two
specific odorant receptors had been marked. Elimination of
odoriferous input during specific times of development stalled an
Science 2004;304:1976
intrinsic process by which the inputs from multiple odorant
E. Israeli
568
I. Azzam et al.
IMAJ . Vol 6 . September 2004