PMC5266196_01
Intestinal brucellosis. (A) Initial US results revealed a thickened hypoechoic bowel wall in the terminal ileum, where mainly the mucosal and submucosal layers were thickened. The 5-layered structure of the bowel wall remained identifiable. (B) CT results showed thickened bowel walls in the ileocaecal area and the terminal ileum, with abnormally enhanced mucosa. (C) An endoscopic examination showed irregular ulcers in the distal ileum and mucosal edema. (D-F) After 1 month of treatment, sonogram (D), CT (E), and PET/CT (F) results revealed remarkable improvements in the bowel. (G, H) Both the ileocaecal area and the terminal ileum appeared normal after 3 mo of treatment. CT = computed tomography, PET = positron emission tomography, US = ultrasound.
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F1
The 5-layer structure of the bowel wall remained identifiable (Fig. 1). A computed tomography (CT) scan of the intestine confirmed the above findings; the scan showed a thickened bowel wall in the ileocaecal area and terminal ileum, with an abnormal enhancement of the mucosal surface (Fig. 1) and remarkably enlarged lymph nodes near the iliac vessels in the right lower quadrant of the abdomen. The results showed mildly increased metabolic activity in the terminal ileum and adherent lymph nodes (Fig. 1), which was indicative of an inflammatory disease instead of a malignancy.
Brucellosis complicated with SMA and CA involvement. (A, B) Color Doppler images showing elevated peak systolic velocity in the SMA (PSV: 64 cm/s) and CA (PSV: 439 cm/s). (C, D) CTA results confirming moderate stenosis in the CA and SMA (black arrow). (E, F) In the follow-up examination (1 mo later), the US (E) and CTA (F) results showed that the SMA stenosis had not improved. The Riolan artery, collateral circulation between the SMA and IMA, had opened (white arrows). CA = celiac artery, CT = computed tomography, CTA = computed tomographic angiography, IMA = inferior mesenteric artery, PSV = peak systolic velocity, SMA = superior mesenteric artery.
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F2
The results showed a dramatically increased flow velocity (peak systolic velocity: 643 cm/s) in the origin of the superior mesenteric artery (SMA) and celiac artery (CA) (Fig. 2), which suggested significant stenosis. An aortic computed tomographic angiography showed moderate narrowing in the beginning of the SMA and slight narrowing in the beginning of the CA (Fig. 2). However, the Riolan artery, a collateral circulation between the SMA and inferior mesenteric artery (IMA), had opened (Fig. 2). Due to the suspected secondary vasculitis, he was treated with minocycline and rifampicin for another 8 weeks, but there was little improvement in the noted arterial stenosis (Fig. 2).
Areas of infarction in the spleen and left kidney in the case of brucellosis. (A) Abdominal computed tomography showing areas of low attenuation in the lower pole of the left kidney and an enlarged spleen with multiple wedged lesions under the capsule (white arrows). (B) After 1 mo of treatment, the renal lesions were barely perceptible and the splenic lesions had become smaller (black arrows). (C) Both the kidneys and the spleen appeared normal after 3 mo of treatment.
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F3
Incidentally, the CT scan revealed an enlarged spleen with multiple wedged areas of low attenuation under the membrane (Fig. 3), and a similar lesion was also found in the inferior pole of the left kidney; these were suspected to be areas of infarction. The areas of splenic infarction were smaller than they were previously, and renal perfusion appeared normal (Fig. 3).