Xanthogranulomatous inflammation in terminal ileum presenting as an appendiceal mass: case report and review of the literature

Imaging and Clinical Findings of Xanthogranulomatous Inflammatory Disease of Various Abdominal and Pelvic Organs: A Pictorial Essay

Xanthogranulomatous (XG) inflammatory disease is a rare benign disease involving various organs, including the gallbladder, bile duct, pancreas, spleen, stomach, small bowel, colon, appendix, kidney, adrenal gland, urachus, urinary bladder, retroperitoneum, and female genital organs. The imaging features of XG inflammatory disease are nonspecific, usually presenting as a heterogeneous solid or cystic mass. The disease may also extend to adjacent structures. Due to its aggressive nature, it is occasionally misdiagnosed as a malignant neoplasm. Herein, we review the radiological features and clinical manifestations of XG inflammatory diseases in various organs of the abdomen and pelvis.

Xanthogranulomatous inflammation requiring small bowel anastomosis revision: A case report

BACKGROUND

Xanthogranulomatous inflammation (XGI) is an uncommon process involving an accumulation of inflammatory cells, commonly lipid-laden macrophages. XGI has been described to occur throughout the body but only rarely in the lower gastrointestinal tract. We describe a case of XGI contributing to chronic obstructive symptoms in the terminal ileum, in which the patient had an initial diagnostic laparoscopy, continued to have symptoms, then proceeded to have the definitive treatment. To our knowledge, this is the first report of XGI associated with a prior small bowel anastomosis.

CASE SUMMARY

We report the case of a 42-year-old female who presented with intermittent epigastric pain and subjective fevers. She had undergone a laparoscopic small bowel resection for Meckel’s diverticulum five years prior. Her workup was notable for computed tomography scan demonstrating mild inflammation and surrounding stranding at the level of the prior anastomosis. She underwent a laparotomy, resection of the prior anastomosis and re-anastomosis, with final histopathological examination findings consistent with mural XGI.

CONCLUSION

XGI can occur at the site of a prior bowel anastomosis and cause chronic obstructive symptoms.

Xanthogranulomatous inflammation and spindle cell proliferation in response to silicone breast implant leakage

This case study highlights the rare complications of silicone breast implants, as well as the diagnostic limitations of imaging. The patient initially presented with leakage of bilateral breast implants as discovered by a positron emission tomography (PET)-computerized tomography (CT) scan performed as part of a workup for small bowel Langerhans cell sarcoma metastases. The imaging results of the PET-CT scan revealed increased activity bilaterally with an enhancing, irregular, heterogeneously enhancing mass in the right breast. Given the clinical suspicion for breast implant-associated anaplastic large cell lymphoma, further investigation including surgical excision was undertaken. What initially was a concern for a serious complication of long-standing breast implants, fortuitously turned out to be a benign but exuberant xanthogranulomatous inflammatory reactive process. We hope that our report will add to the literature of this rare phenomenon and highlight it as a differential diagnosis of a mass in association with breast implants.

Xanthogranulomatous appendicitis diagnosed on routine PET scan: a case report

Xanthogranulomatous appendicitis (XGA) is a rare process affecting the appendix vermiformis. Due to the atypical presentation of XGA, it is most commonly diagnosed post operatively on surgical pathology and is associated with interval appendectomies. Here, we describe a rare case of XGA diagnosed on pathology after acute appendicitis was found on routine Positron emission tomography scan for a minimally symptomatic patient with stage IV adenocarcinoma of the lung. Further prospective studies are required to evaluate the atypical presentation of XGA and the use of interval appendectomies following acute appendicitis diagnosis.

Xanthogranulomatous Oophoritis in the Setting of Post-IVF Twin Pregnancy with History of Endometriosis: A Rare Case Report with Review of Literature

Xanthogranulomatous inflammation is an uncommon, nonneoplastic, chronic process in which the affected organ is destroyed by massive cellular infiltration of foamy histiocytes admixed with multinucleated giant cells, plasma cells, fibroblasts, neutrophils, and foci of necrosis. The organs most commonly affected by this entity are kidney and gallbladder. Only a few cases involving the ovary have been reported. The etiology of this entity is unknown, but the associated risk factors are infection, inappropriate antibiotic therapy, use of intrauterine contraceptive device, abnormalities in lipid metabolism, endometriosis, leiomyoma, and recurrent pelvic inflammatory disease. The current case was a 31-year-old female with post-in vitro fertilization (post-IVF) twin pregnancy, who presented with pain in the abdomen, provisionally diagnosed as ovarian mass with suspicion of malignancy. Patient was treated with antibiotics and an elective lower segment cesarean section was planned, due to lower abdominal pain and the presentation of both fetuses being breech. Patient underwent exploratory laparotomy with right oophorectomy and left double-J stenting, in view of left hydronephrosis. Diagnosis of xanthogranulomatous oophoritis was established on histopathological examination. There is only a single case; previously documented from India, in the setting of primary infertility. The present case report stresses that the condition may affect women of any age group and may be encountered in pregnancy, as has been observed in this case. Hence, thinking about this differential diagnosis in the cases presenting with similar complaints, would be of great value to avoid misdiagnosing them.

Abdominal manifestations of histiocytic disorders in adults: imaging perspective

Histiocytic disorders (HDs) are a diverse group of diseases characterized by pathologic infiltration of normal tissues by cells of the mononuclear phagocyte system. The spectrum of these diseases ranges from treatable infectious diseases to rapidly progressive, life-threatening conditions. Although they are rare and difficult diagnoses, HDs can be diagnosed with the help of clinical and laboratory analyses, imaging features and tissue biopsy. The clinicopathology and imaging spectrum of select entities belonging to this disorder are presented in this review.

[A Case of Xanthogranulomatous Inflammation of Terminal Ileum Presenting as a Mass in a Woman with Severe Obesity]

Xanthogranulomatous inflammation is an acute or chronic inflammatory condition most frequently reported in pyelonephritis and cholecystitis. However, the involvement of the terminal ileum is extremely rare. Its clinical significance is that it can m imic a malignant lesion clinically and intraoperatively, as well as radiographically. A 34-year-old European ethnic female presented with gradually aggravated abdominal pain in right lower quadrant for 15 days. There was no significant medical, surgical or traumatic history, except class III obesity (BMI, 41.0 kg/m ² ). An abdominal CT showed about a 4.7×3.7 cm sized, mass-like lesion in the terminal ileum. Despite symp tomatic treatment, her clinical symptoms did not improve. After six days, she underwent a laparoscopic ileocecectomy. Pathologic findings showed extensive inflammation with occasional multinucleated giant cells and aggregates of foamy histiocytes, consistent with xanthogran ulomatous inflammation. Here, we present a case of xanthogranu-lomatous inflammation in the terminal ileum presenting as subacute abdominal pain and a mass on imaging study. Xanthogranulomatous inflammation should be added to the differential diagnosis of patients with a suspected mass-like lesion in the terminal ileum.

Small Bowel Obstruction due to Intestinal Xanthomatosis

Vast majority of bowel obstruction is due to postoperative adhesions, malignancy, intestinal inflammatory disease, and hernias; however, knowledge of other uncommon causes is critical to establish a prompt treatment and decrease mortality. Xanthomatosis is produced by accumulation of cholesterol-rich foamy macrophages. Intestinal xanthomatosis is an uncommon nonneoplastic lesion that may cause small bowel obstruction and several cases have been reported in the English literature as obstruction in the jejunum. We report a case of small intestinal xanthomatosis occurring in a 51-year-old female who presented with one day of copious vomiting and intermittent abdominal pain. Radiologic images revealed jejunal loop thickening and inflammatory changes suggestive of foreign body obstruction, diagnostic laparoscopy found two strictures at the jejunum, and a pathologic examination confirmed a segmental small bowel xanthomatosis. This case illustrates that obstruction even without predisposing factors such as hyperlipidemia or lymphoproliferative disorders.