A 62-year-old patient was referred to a rheumatologist with complaints such as increasing body temperature up to 37.1-37.3 C, gnawing pains in the epigastric region, worsening at night, weight loss of 15 kg for the last 4 months, lack of appetite, fatigue and general weakness.
From the anamnesis it is known that during the last 4 months the patient suffered from pain in the epigastric region, and lack of appetite occurred without any apparent cause. Due to these complaints esophagogastroduodenoscopy (EGDS) was performed and revealed signs of chronic gastritis and also epithelial cell damage and regeneration with minimal inflammatory changes described as gastropathy. In the histopathological results minimal polymorphonuclear leukocyte infiltration with mononuclear cell infiltration was found. Helicobacter pylori was excluded. There were no pathological findings in abdominal ultrasound examination.
The patient had been treated by a gastroenterologist with domperidone 10 mg twice daily and bismuth subcitrate 240 mg twice daily, but this treatment was inefficient and the symptoms did not improve. The patient started to take nimesulide on his own, which positively influenced the abdominal pain. Abdomen and pelvis computed tomography (CT) was performed and revealed signs of MP, so the patient was referred to a rheumatologist.
In the patient's medical history only common colds and childhood infectious diseases were reported. From 2006, arterial hypertension occurred and was treated with ramipril and nebivolol. In 2018, increased glycemic levels were observed and diabetes type 2 was diagnosed. However, in the treatment a diet without any hypoglycemic drugs was sufficient.
According to the patient's information, no previous history of tuberculosis, infections such as virus hepatitis (A, B and C) or any allergic reactions was noted.
The physical examination revealed only pain in the epigastric area during abdominal palpation, temperature 37.0 C. There were no other evident abnormalities in the physical examination of the cardiovascular and musculoskeletal system, lungs or skin assessment.
The cardiac assessment using echocardiography did not reveal any significant disturbances; only due to arterial hypertension left ventricular hypertrophy was found, and the left ventricular ejection rate (LVEF) was 56%. Stool and diuresis were normal. No peripheral edema was observed. A blood test was performed and all results are presented in Table I.
In computed tomography (CT) imaging performed in spiral mode with 1 mm steps, an area of fatty tissue induration was found, enveloping the arterial trunk like a cuff and partially surrounding the upper mesenteric artery without any signs of narrowing of lumens, with approximate dimensions of 36 mm x 16 mm.
At this level, a single celiac lymph node with a maximum size of 17 mm x 9 mm is observed. The stomach was rather stretched by the fluid, but there were no signs of pathological thickening of the walls. The fat tissue surrounding the loops of the small intestine - visualized in a collapsed state - was not changed. The colon was inflated with gas, the walls of the loops were not thickened, paracolitic fatty tissue was not changed, and nor were the liver and intrahepatic ducts.
The gallbladder is not enlarged in size, with homogeneous contents. X-ray positive calculi were not found, the gallbladder walls were not changed. The common bile duct was not dilated. The portal vein was not dilated. The lymph nodes of the porta hepatis were not swollen. The pancreas was not enlarged, the head 26 mm, body 10 mm, tail 8 mm. The gland structure was homogeneous, and the parenchyma at the level of the body and tail was atrophic. The pancreatic duct is not dilated. Parapancreatic fiber is not changed. The area of the major duodenal papilla is without changes. The spleen is not enlarged, uniform structure, normal density. The adrenal glands are typically located, of uniform structure. The kidneys are typically located, of normal size and shape. The parenchyma of the kidneys is not thinned. Cortico-medullary differentiation of the parenchyma is retained, its contrasting without peculiar properties. The hollow system of the kidneys is not dilated. The abdominal aorta and iliac arteries are atherosclerotically altered. Retroperitoneal lymph nodes are not enlarged. The prostate gland is 36 mm x 44 mm in size, with homogeneous structure, of normal density. Surrounding fiber is not changed. Seminal vesicles are without peculiar properties. The bladder is of normal size and shape. X-ray positive calculi in the lumen are not defined. The walls of the bladder are not thickened; surrounding fiber is not changed. Pelvic lymph nodes and inguinal lymph nodes are not enlarged. Conclusion: CT signs of mesenteric panniculitis.
Taking into account the data listed, the clinical diagnosis of mesenteric panniculitis was established based on the imaging picture and clinical signs. The disease activity was determined taking into account clinical and laboratory parameters. In the clinical case presented, the prevalence of moderately severe clinical symptoms in the clinical picture with the absence of any significant changes in laboratory tests made it possible to determine the activity of the 1st degree.
Due to MP diagnosis therapy with methylprednisolone 8 mg per day and pantoprazole 40 mg/day was administered, and the patient also continued antihypertensive drugs. Rheumatologist, endocrinologist and cardiologist supervision was recommended at the place of the patient's residence.
On the background of conducted therapy after 2 months of treatment the temperature returned to the normal range, appetite improved, and weakness decreased. The main symptom, epigastric pain, disappeared.