case_images: PMC11324283_01
case_images: Esophagogastroduodenoscopy showing an ulcerated, bulging 20 mm mass abutting the gastroesophageal junction on retroflexion (a) and submucosal mass at the proximal duodenal bulb (b).
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case_images: PMC11324283_01_crg-2024-0018-0001-540292_F01.jpg
case_images: F1
case_images: Esophagogastroduodenoscopy (EGD) revealed a 2 cm ulcerated mass, abutting the gastroesophageal junction (GEJ) inferiorly on retroflexion (Fig. 1) and a subepithelial lesion in the duodenal bulb with normal overlying mucosa.
case_images: Biopsy from index esophagogastroduodenoscopy showing active inflammation and reactive epithelial changes on gastroesophageal junction mass (a; H&E stain, x200) and inflammation with histiocytes and neutrophils on duodenal submucosal mass (b; H&E stain, x100).
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case_images: PMC11324283_01_crg-2024-0018-0001-540292_F02.jpg
case_images: F2
case_images: Mucosal biopsies were taken from both lesions and histopathology revealed ulcerated mucosa with acute and chronic inflammatory infiltrates composed of histiocytes, granulocytes, and lymphocytes (Fig. 2).
case_images: Axial view of CT abdomen with oral contrast and IV contrast in portal venous phase showing the gastroesophageal junction mass (a) and the submucosal mass at the pyloric channel opening (b).
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case_images: F3
case_images: This demonstrated infiltrative soft tissue masses at the GEJ and duodenal bulb, each measuring up to 4.5 cm in size (Fig. 3).
case_images: Axial (a) and coronal (b) view of CT chest with IV contrast showing a nodular band-like opacity 6 mm in thickness at the left lung apex (a), with adjacent discrete nodules, the largest at 12 mm in size (b). Associated linear scarring, focal mild bronchiolectasis, and volume loss were suggestive of post-infectious scarring. No calcified pulmonary nodule was identified.
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case_images: F4
case_images: There was linear scarring and several discrete nodules at the left lung apex, the largest 12 mm (Fig. 4).
case_images: Endoscopic ultrasound image of the submucosal lesion at the duodenal bulb, just distal to pyloric channel.
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case_images: F5
case_images: A second lesion, involving the proximal duodenum, was round with well-defined margins and measured 20 mm x 14 mm (Fig. 5).
case_images: Endoscopic ultrasound guided fine-needle aspiration showing necrotizing granuloma at gastroesophageal junction mass (a; H&E stain, x200) and duodenal bulb (b; H&E stain, x200) with Ziehl-Neelsen stain negative for mycobacteria (c; x400).
case_images: crg-2024-0018-0001-540292_F06.jpg
case_images: PMC11324283_01_crg-2024-0018-0001-540292_F06.jpg
case_images: F6
case_images: EUS-guided fine-needle biopsy of both lesions was performed, which revealed fragments of necrotizing granulomatous inflammation (Fig. 6). No mycobacteria were seen on Ziehl-Neelsen stain (Fig. 6).