A 46-year-old woman presented with a 2-year history of recurrent fevers up to 38.9 C, fatigue, and frequent urination. Her symptoms were intermittent with episodes of muscle weakness, joint stiffness, and extreme headache lasting approximately 30 hours. She had no chest pain, no abdominal pain, no change in bowel habits, and no recent weight changes. Her past medical history was significant for thalassemia, dermatographism, and three early miscarriages. Her past surgical history was notable for gastric sleeve and hysterectomy complicated by pelvic abscess that required an interventional radiology drain 4 months prior to the presentation. Family history was significant for autoimmune diseases such as gout, rheumatoid arthritis, and systemic lupus erythematosus.
Her temperature was 36.6 C without any abdominal tenderness. Laboratory findings revealed a microcytic anemia with occasional schistocytes. Comprehensive metabolic panel, C-Reactive Protein (CRP), the erythrocyte sedimentation rate (ESR), HIV assay, Quantiferon tuberculosis, blood cultures, lactate dehydrogenase, anti-nuclear antibody, and serum protein electrophoresis were all within normal limits. Additional studies such as lupus anticoagulant, hepatitis virus profile, complement levels, Epstein-Barr virus acute infection, cardiolipin, rapid plasma reagin, DNA double strand, smooth muscle, Sjogren's extractable nuclear profile, beta-2-glycoprotein 1 antibodies, Smith, and ribonucleoprotein extractable nuclear were also normal.
Spiral CT of the abdomen and pelvis, using a reconstructed slice thickness of 5 mm after oral and IV contrast administration, showed a misty appearance of the mesentery in the left hemiabdomen with multiple enlarged mesenteric lymph nodes measuring up to 1 cm in the short axis (Figure 1). The radiological findings likely represent chronic mesenteric panniculitis with early suggestion of it seen in previous CT abdomen 2 years a priori. The rest of the exam was significant for nonobstructing 2 mm calcification noted within the inferior pole of the left kidney.
Mesenteric biopsy revealed fibroadipose tissue with focal fat necrosis with lymphohistiocytic inflammation and fibrosis. There was no evidence of malignancy. Flow cytometry did not reveal abnormal B or T cell populations, excluding a lymphoproliferative process.
The patient was offered treatment with prednisone, but the patient was hesitant to start steroids, so methotrexate 15 mg by mouth once a week was started but had minimal response. Further treatment options are being explored.