A 22-year-old woman presented with epigastric discomfort and intermittent dark-colored stools of two months duration. She had no previous illness and denied constitutional symptoms such as fever, weight loss, or night sweating. A physical examination detected no abdominal mass or tenderness, and no rebound tenderness. Laboratory studies showed a hemoglobin of 13.9 g/dL, leukocytes of 7,580/mm3, and an ESR of 17 mm/hr. Other biochemical tests results were within normal ranges, and anti-HIV Ab was negative. Stool occult blood was also negative. An esophagogastroduodenoscopic (EGD) examination revealed a round mass of about 3-cm at the duodenal bulb, with normal surrounding mucosa and central ulceration (Figure 1). Several red or black spots on the base of the ulceration evidenced recent bleeding. An endoscopic biopsy taken at the ulceration margin identified chronic duodenitis.
Chest X-ray films showed inactive pulmonary tuberculosis at the left upper lobe, and abdominal computed tomography (CT) revealed a well-defined round mass that enhanced as gastric mucosa, at the posterior wall of the duodenal bulb suggestive of duodenal GIST (Figure 2). Endoscopic ultrasonography (EUS) showed an ulcerative hypoechogenic mass at the submucosal layer of the duodenal bulb (Figure 3).
Exploratory laparotomy was performed to exclude the possibility of malignant GIST of the duodenum. During laparotomy, a solitary mass was detected around the hepatic artery, which penetrated the duodenal bulb. The mass was excised and a histopathological analysis revealed lymphadenopathy with caseous granuloma (Figure 4). Polymerase chain reaction of DNA extracted from the node was positive for tuberculosis and acid-fast bacilli were found by Ziehl-Neelsen tissue staining. The patient was diagnosed with solitary tuberculous lymphadenopathy and discharged on anti-tuberculosis medication. No evidence of recurrence has been observed during nine months of treatment.