PMC6113983_01
Axial contrast-enhanced CT images show multiple omental nodules [white arrows in (a) and in (b)], some of which are measured in mm [yellow callipers in (a) and in (b)] and peri-hepatic and peri-splenic ascites [arrowheads in (b)].
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figure1
Ultrasound-guided biopsy of an omental nodule, whose diagnosis was suspicious for carcinoma with the unknown primary site.
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figure2
CT scan of the chest, including part of the superior abdomen, performed to complete staging after 2 weeks from the first CT scan, shows a dimensional and numerical reduction of peritoneal lesions [measures shown by yellow callipers in (a) and in (b)], as well as the resolution of perihepatic and peri-splenic ascites.
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figure3
Peritoneal lymphoid aggregate with a central core of epithelioid cells (see box at higher magnification) without atypia or mitosis (a) and with only focal and weak positivity for cytokeratins AE1/AE3 (b). A lot of immunohistochemical markers were performed (WT1, S100, Ber-EP4, oestrogen receptor, p63, ALK, BRAF, CD45, CD68 and CD79) and resulted negative.
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figure4
The pathological evaluation of the biopsies performed on the omentum and peritoneum revealed the presence of lymphoid aggregates with a central core of epithelioid cells with large eosinophilic cytoplasm, without atypia or mitosis (Figure 4) and with no immunohistochemical marker of oncologic malignancy.
Ziehl-Neelsen stain revealed the presence of acid-fast bacilli.
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figure5
Due to the presence of necrotic nodules with histiocytes and giant cells, a Ziehl-Neelsen stain was performed to identify bacilli (Figure 5), whose presence was then confirmed with molecular assays.