A 65-year-old male diagnosed with celiac disease of 10 years duration.
From the time of diagnosis, the patient presented with high titulation of anti-transglutaminase tissue antibodies (ATGT) and repeated episodes of watery diarrhea, diagnosed with "therapeutic failure".
In the last 6 months, these conditions became increasingly frequent, even after following a diet without gluten and accompanied by a loss of 20 kg of weight, without constitutional syndrome or accompanying fever.
He was admitted to our department for study.
Analytical data included a complete blood count with mild thrombocytosis (602,000 platelets), the rest of the formula being normal, and in the biochemical analysis an albumin of 2.1 pg/dl and a prealbumin of 8.82 pg/dl were normal.
The ATGT value was 76 IU (+++).
Proteinogram: IgG 2480 mg/dl, IgA 189 mg/dl, IgM 26.8 mg/dl. Abdominal CT showed a portal vein of 2 cm, with normal liver size and morphology.
Bazo, intestinal loops and mesentery were unaltered.
A gastroscopy showed multiple gastric ulcers and in the biopsies that were diagnosed a marked duodenal villi with increased intraepithelial lymphocytes, compatible with celiac disease.
Pathologic examination was normal.
despite ruling out these findings and due to the lack of clinical improvement of the patient it was decided to perform endoscopic video capsule (ECV), where it was observed, at 3 hours of examination, multiple ulcer and areas of suggestive stenosis in the jejunum.
Exploratory laparoscopy was performed to take biopsies of the cervix and determine possible lymphadenopathies, one of 1.5 cm in diameter in the mesentery, which was removed.
In the anatomopathological study, the adenopathy showed very peculiar macroscopic alterations, mainly due to the presence of an empty central cavity with content and anfractuous walls, which was immersed in the material.
Microscopically, this material corresponded to a fibrinous necrotic material that included degenerated cellular debris, small lipid vacuolae, macrophages x sclerotic tissue and polynuclear.
In some isolated focus of this material, suggestive (not conclusive) images of bacteria of short bacilli morphology could be observed.
In its external area, the ganglion had a narrow ribet of usual lymphoid tissue, although of little reactive aspect (atrophic), as well as a moderate conservative infiltrate.
Ziehl and PAS techniques were negative.
Malignancy (lymphoma) was ruled out.
Biopsy of the intestine showed erosion of the mucosa that had been sustained by a nonspecific inflammatory tissue.
A separate fragment showed a better preserved mucosa, although with lymphocytic inflammatory infiltrate and moderate partial hair loss, compatible with celiac disease.
All these findings were consistent with celiac disease and cavitated mesenteric lymph node syndrome.
Corticosteroid treatment was started at a dose of 1 mg/kg of weight and, after 5 days of intravenous therapy, the patient was discharged with clear clinical improvement.
The patient underwent maintenance oral corticosteroid treatment and, in the follow-up visit, the patient was asymptomatic and had decreased levels of ATGT antibodies.
