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

Hyung Ku Chon; Sang Wook Kim

doi:10.4166/kjg.2016.67.5.277

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Chon and Kim: A Case of Xanthogranulomatous Inflammation of Terminal Ileum Presenting as a Mass in a Woman with Severe Obesity

Case Report

Korean J Gastroenterol 2016;67(5):277-281.

Published online: 4 October 2016

DOI: https://doi.org/10.4166/kjg.2016.67.5.277

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

Hyung Ku Chon, Sang Wook Kim

Division of Gastroenterology, Department of Internal Medicine, Chonbuk National University Medical School, Jeonju, Korea

Correspondence to: Sang Wook Kim, Department of Internal Medicine, Chonbuk National University Hospital, 20 Geonji-ro, Deokjin-gu, Jeonju 54907, Korea. Tel: +82-63-250-2302, Fax: +82-63-254-1609, E-mail: clickm@jbnu.ac.kr

Received 23 December 2015 Revised 21 January 2016 Accepted 15 February 2016

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

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 mimic 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/m²). An abdominal CT showed about a 4.7×3.7 cm sized, mass-like lesion in the terminal ileum. Despite symptomatic 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 xanthogranulomatous inflammation. Here, we present a case of xanthogranulomatous 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.

Keywords: Xanthogranulomatous, Morbid obesity, Ileum

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Fig. 1.

CT scan of abdomen. Seen is an approximately 4.7×3.7 cm sized, mass-like lesion (white arrow) in the terminal ileum.

Fig. 2.

Intraoperative laparoscopic findings. (A) Inflammation and phlegmon with adhesions between the terminal ileum and abdominal wall.(B) Abscess pocket with pus discharges of the terminal ileum.

Fig. 3.

Gross finding of resected ileocecal segment. It revealed mass-like thickening of the mesenteric fat with hemorrhage and adhesion at the terminal ileum. White arrow, terminal ileum; white arrowhead, mass-like lesion; black arrow, ileocecal valve; black arrowhead, cecum.

Fig. 4.

Microscopic findings (H&E) of the resected specimen (A) showed extensive inflammation with occasional multinucleated giant cells and fibrosis (×100). (B) Higher magnification revealed aggregates of foamy histiocytes (×400).

Table 1.

Review of Reported Cases of Small Bowel Involvement in Xanthogranulomatous Inflammation (XGI)

Reference	Age (yr)/sex	Underlying disease	Location of small bowel XGI	Other involved organ	Clinical presentation	Radiologic findings	Treatment
Yoon et al.⁵	52/M	None	Terminal ileum	None	Abdominal pain	CT: Appendiceal mass; bowel wall thickening of terminal ileum	Laparoscopic right hemicolectomy
Wong et al.⁶	51/M	HTN DM Gout	Terminal ileum	Appendix	Abdominal pain	US: 1.5 cm mass like lesion at ileocecal area CT: None	Laparoscopic ileocecectomy
Bailey and Beck⁷	19/M	None	Ileum	Sigmoid colon	Abdominal pain Weight loss Flu-like symptoms	CT: Abscess between small bowel and sigmoid colon	Small bowel segmental resection and sigmoid colectomy
Present case	38/F	Obesity	Terminal ileum	None	Abdominal pain	CT: About 4.7×3.7 cm sized, mass like lesion in terminal ileum	Laparoscopic ileocecectomy

M, male; F, female; HTN, hypertension; DM, diabetes mellitus; US, ultrasonography.

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