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Case Report

Mesenteric lymphadenopathy in COVID-19 infection (Jammu and Kashmir sign) as a presenting sign in adult: case report

Wani, Imtiaz MSa,; Tantray, Hanief M. MDb; Agha, Nadeem MBBS, MSa; Rashid, Masood MBBS, DAc; Lone, Wasim MBBS, MSa; Younus, Umar MBBS, MSa; Khan, Nawab MBBS, MSd; Ashraf, Samina MBBSe; Pandith, Samiullah BUMSf; Jan, Tariq MBBSf

Author Information
doi: 10.1097/SR9.0000000000000010
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Abstract

Mesenteric lymphadenopathy is occasionally detected as an incidental finding on the routine ultrasonography of abdomen1. The common causes of mesenteric lymphadenopathy are infectious, inflammatory or of the neoplastic origin. A variety of infective conditions may lead to the mesenteric lymphadenopathy. Site, shape, size, number, type, and extent of mesenteric lymphadenopathy found on abdominal imaging helps in reaching the specific diagnosis2. On ultrasonography or the computed tomography, the criteria of diagnosis of mesenteric lymphadenopathy is well documented3. Mesenteric lymphadenopathy may be the only indicator of an underlying infective focus causing abdominal pain4. There are scanty reports of mesenteric lymphadenopathy presenting as an initial manifestation of COVID-19 infection in adult, though mesenteric adenitis occurring in the children diagnosed with COVID-19 infection have been reported5. Treatment targeting COVID-19 infection causes regression of mesenteric lymphadenopathy. The work has been reported as per “SCARE Guidelines” 2018 by Agha et al6.

Case report

A 33-year-old man presented with episodic mild abdominal pain of 5 days duration. There was no history of any respiratory illness, loose motion, fever, arthritis, rash, any drug intake of any autoimmune disease or malignancy. On examination, patient was afebrile. There was no palpable lymphadenopathy at any sites on the body. Systemic examination was normal. Per abdominal examination revealed tenderness on both left and right side of upper abdomen. Laboratory values were normal except for slight neutrophilia. Liver function parameters, serum amylase and C-reactive protein levels were normal. Sputum for acid fast bacilli was negative and the Mantoux test was nonreactive. Nasopharyngeal swab for real time-polymerase chain reaction (RT-PCR) for SARS-CoV-2 was reactive. Both x-ray chest and upright x-ray abdomen were unremarkable. Ultrasound of abdomen showed findings of diffuse mesenteric lymphadenopathy, primarily on the left upper abdomen followed by right upper abdomen. These lymph nodes exhibited oval shape, perinodal stranding with the preserved fatty hilum appearing as an echogenic area at center of node and the largest lymph node was measuring 16×7.5 mm (Fig. 1). Chest computed tomography showed insignificant lymphadenopathy with normal lung fields. The findings on computed tomography abdomen, as well as in follow-up, were in line with the ultrasonography of abdomen. Computed tomography revealed findings of diffuse mesenteric lymphadenopathy, mainly on the left upper and right upper abdomen with small and large bowel being unremarkable (Fig. 2). Patient was managed conservatively at designated COVID quarantine center as per the local treatment protocol. On nasopharyngeal swab, repeat RT-PCR for SARS-CoV-2 tested negative on 10th day after the first test. On follow-up scans, progressive regression of lymphadenopathy with insignificant nodes recorded after 4 weeks.

Figure 1
Figure 1:
Abdominal ultrasound showing large hypoechoic mesenteric lymph nodes with gastrointestinal COVID-19 infection.
Figure 2
Figure 2:
Computed tomography with follow-up scan showing regressing lymphadenopathy on longitudinal section.

Discussion

Mesenteric lymphadenopathy typically occurs in children, adolescents and young adults3. Males have slight preponderance over females in the occurrence of mesenteric lymphadenopathy7. Primary mesenteric lymphadenopathy is a right-sided lymphadenopathy without any identifiable underlying etiology. In this type, there are no apparent pathologic findings on an imaging. Secondary mesenteric lymphadenopathy occurs after abdominal pathology as in the appendicitis, variety of viral or bacterial gut infections, inflammatory bowel diseases, chronic granulomatous disease, systemic chronic inflammatory diseases and neoplasia8. Mesenteric lymphadenopathy may be the only sign of an underlying infectious focus causing abdominal pain, this is considered as an indirect finding in acute abdomen due to the gastrointestinal COVID-19 infection9,10. This finding is consistent with present COVID-19 infected case where mesenteric lymphadenopathy lead to abdominal pain and was the only sign present, diagnosed on imaging.

The ultrasonographic criteria for mesenteric lymphadenopathy have been variably defined as the detection of nodes larger than 4 mm in adult or 8 mm in children in the short axis11,12. This sonographic definition is in agreement with that of a study based on computed tomography studies in an adult population, where mesenteric lymphadenopathy is defined as 3 or more lymph nodes, each 5 mm or >5 mm in short axis13,14. In the present case, there was documentation of mesenteric lymphadenopathy as per imaging criteria for diagnosis on abdominal ultrasonography and computed tomography. There is a risk of generalized lymphadenopathy of whole body depending on the specific etiology. In this case, there was documentation of only mesenteric lymphadenopathy on abdominal ultrasonography and computed tomography. The size, number and distribution of mesenteric lymph nodes may indicate the exact nature of the underlying etiology8. The mesenteric lymphadenopathy may be found at the mesenteric root, along the mesenteric border, or may be diffuse. Inflammatory changes in the small or large bowel are usually present in areas drained by mesenteric nodes but are not always present. The clinical scenario, RT-PCR confirmed SARS-CoV-2, imaging criteria documented lymphadenopathy of oval shaped lymph nodes primarily in upper abdomen with absent inflammatory changes of intestinal wall confirms mesenteric lymphadenopathy due to gastrointestinal COVID-19 infection.

Conclusion

Mesenteric lymphadenopathy in gastrointestinal COVID-19 infection is rare. This Jammu and Kashmir sign may be sole presenting sign in COVID-19 infection.

Consent statement

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

The publication of my article is exempt from ethical approval in my institution.

Source of funding

None.

Author contribution

I.W., H.M.T., N.A., and M.R.: substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data for the work. I.W., W.L., and U.Y.: drafting the work or revising it critically for important intellectual content. I.W., N.A., and N.K.: final approval of the version to be published. I.W., N.K., S.P., and T.J.: agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Conflicts of interest disclosure

The authors declare that they have no financial conflict of interest with regard to the content of this report.

Research registration unique identifying number (UIN)

There was no registration unique identifying number for this case report. The writing of this manuscript did not involve human subjects and does not constitute a clinical trial. Registration in a publicly available database was not required for this review.

Guarantor

Imtiaz Wani is guarantor and accepts full responsibility for the work and the conduct of the study, had access to the data, and controlled the decision to publish.

References

1. Ezhapilli SR, Moreno CC, Small WC, et al. Mesenteric masses: approach to differential diagnosis at MRI with histopathologic correlation. J Magn Reson Imaging 2014;40:753–69.
2. Maconi G, Di Sabatino A, Ardizzone S, et al. Prevalence and clinical signifi cance of sonographic detection of enlarged regional lymph nodes in Crohn’s disease. Scand J Gastroenterol 2005;40:1328–33.
3. Helbling R, Conficconi E, Wyttenbach M, et al. Acute nonspecific mesenteric lymphadenitis: more than “no need for surgery”. Biomed Res Int 2017;2017:9784565.
4. Ekbatani MS, Hassani SA, Tahernia L, et al. Atypical and novel presentations of Coronavirus Disease 2019: a case series of three children. Br J Biomed Sci 2020;15:1–6.
5. Tullie L, Ford K, Bisharat M, et al. Gastrointestinal features in children with COVID-19: an observation of varied presentation in eight children. Lancet Child Adolesc Health 2020;4:e19–e20.
6. Agha RA, Borrelli MR, Farwana R, et al. For the SCARE Group. The SCARE 2018 Statement: Updating Consensus Surgical CAse REport (SCARE) Guidelines. Int J Surg 2018;60:132–6.
7. Maconi GMaconi G, Bianchi Porro G. Mesenteric lymphadenopathy. Ultrasound of the Gastrointestinal Tract. Berlin, Heidelberg: Springer Berlin Heidelberg; 2012:29–36.
8. Lucey BC, Stuhlfaut JW, Soto JA. Mesenteric lymph nodes seen at imaging: causes and significance. Radiographics 2005;25:351–65.
9. Calinescu AM, Vidal I, Graziofas S, et al. Comment on “Beware of Too Aggressive Approach in Children With Acute Abdomen During COVID-19 Outbreak!”. Ann Surg 2020;277:e244–5.
10. Gao Y, Xi H, Chen L. Emergency surgery in suspected COVID-19 patients with acute abdomen: case series and perspectives. Ann Surg 2020;272:e38–9.
11. Sivit CJ, Newman KD, Chandra RS. Visualization of enlarged mesenteric lymph nodes at US examination. Pediatr Radiol 1993;23:471–5.
12. Watanabe M, Ishii E, Hirowatari Y, et al. Evaluation of abdominal lymphadenopathy in children by ultrasonography. Pediatr Radiol 1997;27:860–4.
13. Macari M, Hines J, Balthazar E, et al. Mesenteric adenitis: CT diagnosis of primary versus secondary causes, incidence, and clinical signifi cance in pediatric and adult patients. AJR Am J Roentgenol 2002;178:853–8.
14. Rao PM, Rhea JT, Novelline RA. CT diagnosis of mesenteric adenitis. Radiology 1997;202:145–9.
Keywords:

COVID-19; Mesenteric; Lymphadenopathy; RT-PCR; SARS-CoV-2; Gastrointestinal

Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of IJS Publishing Group Ltd.