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A Rare Case of Early Visualization of Foregut Duplication Cyst in Meckel Scan
Address for correspondence: Prof. Rakesh Kumar, Department of Nuclear Medicine, Division of Diagnostic Nuclear Medicine, All India Institute of Medical Sciences, New Delhi - 110 029, India. E-mail: rkphulia@yahoo.com
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This article was originally published by Wolters Kluwer - Medknow and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Enteric duplications are rare congenital anomalies, which can have varying presentations depending on the size, location, and type of mucosa present. Meckel scan, using technetium-99m pertechnetate (Tc-99m pertechnetate), is a useful modality for the detection of ectopic functioning gastric mucosa. Thoracic duplication cysts present as the initial photopenic area which is getting filled by Tc-99m pertechnetate in the delayed static images of Meckel scan. We report a rare case of foregut duplication cyst, where foregut duplication cyst is visualized earlier in Meckel scan.
Keywords
Early visualization
foregut duplication cyst
Meckel scan
scintigraphic patterns
Tc-99m pertechnetate
Introduction
Duplications of the alimentary tract are rare congenital anomalies, which can be cystic or tubular in shape and can occur anywhere along the gastrointestinal tract.[1] It can vary greatly in presentation depending on the size, location, and type of mucosa present. 20%–30% of these duplications are reported to have ectopic gastric mucosa. Meckel scan, using technetium-99m pertechnetate, is a useful modality for the detection of ectopic functioning gastric mucosa. In Meckel scan, thoracic duplication cysts present as an initial photopenic area which is getting filled by a radiotracer in the delayed static images. Herein, we report a rare case of foregut duplication cyst of a 10-year-old boy, where foregut duplication cyst appears earlier in Meckel scan.
Case Report
A 7-year-old boy who was apparently well till February 2023 presented with moderate-grade fever, intermittent in nature, and relieved on medication. The fever was followed by an episode of hemoptysis, fresh bleed, about a bowl in quantity. The child was managed symptomatically in a local hospital. This was followed by a symptomatic-free period of 5 months till the child had another episode of hemoptysis in July 2023, without any preceding fever. The child was taken to a tertiary care center and was under follow-up. There was no history of foreign body aspiration, weight loss, decrease in appetite, cough, tuberculosis (TB) contact in the family, or bleeding from any other site. TB workup done was negative. Blood coagulation profile was within normal limits. ENT evaluation was normal. Chest X-ray was suggestive of consolidation of the right lung lower lobe. Contrast-enhanced computed tomography (CT) is suggestive of mediastinal lymphadenopathy with consolidation and cavity in the right lung lower lobe, closely related to the esophagus. The patient was referred to our hospital for bronchoscopy. CT angiography was done, which was suggestive of preexisting cyst with superimposed infection with prominent and dilated right bronchial artery. Right bronchial artery embolization was done. Bronchoscopy done for definite diagnostic workup was suggestive of dirty-looking secretion from the right lower lobe. Bronchoalveolar lavage samples were taken for GeneXpert, gram stain and culture, fungal culture, and KOH and the reports came out to be negative. Hydatid serology was also negative. The patient was referred to pediatric surgery for surgical intervention. CT angiography was repeated and was suggestive of esophageal duplication with rupture into adjacent lung. The patient was referred to our department for Meckel scan to rule out ectopic functioning gastric mucosa. Meckel scan using 99mTc-pertechnetate was performed, and dynamic, serial delayed static images and single-photon emission CT/CT were acquired. In the dynamic images, an area of increased radiotracer activity was seen in the lower thoracic region to the right of the midline, which appeared with stomach activity (obscured by cardiac activity in the initial frames) [Figure 1] and increased progressively with time till 60 min delayed static image [Figure 2]. The area of increased radiotracer activity corresponds to hypodense/cystic lesion measuring ~10.4 mm × 10.5 mm in the posterior wall of the lower thoracic esophagus [Figure 3]. Another area of consolidation, measuring ~2.9 cm × 5.6 cm in the posterobasal segment of the right lung lower lobe, adjacent to the abovementioned region, with air bronchogram, with no significant tracer accumulation was also noted.
Discussion
Foregut duplication cysts are rare congenital anomalies that can present with respiratory symptoms in younger patients, whereas heartburns and malena in older patients.[2] Peptic ulceration of these cysts with erosion into the adjacent lung, bronchus, and esophagus can cause hemorrhage and can even present as hemoptysis, as seen in our case.[3] Most of these duplication cysts occur in the posterior mediastinum, in retrocardiac location.[2] It is important to note that the diagnosis of foregut duplication cysts can be challenging since they often present with nonspecific symptoms. Imaging studies are important for diagnosing these cysts.[4] 99mTc pertechnetate is taken up by the functioning ectopic gastric mucosa that may occur in these cysts. Hence, Meckel scan using 99mTc pertechnetate can be a useful modality in the preoperative diagnosis of this rare anomaly.[5] Variety of scintigraphic patterns can be seen in patients with ectopic gastric mucosa depending upon the location and size of the ectopic tissue. The functioning ectopic gastric mucosa in the intrathoracic foregut duplication cysts is usually evident only in the delayed images, much later than the visualization of stomach activity.[6] The present case showed atypical scintigraphic pattern of early visualization of foregut duplication cyst, which has not been reported so far. The possible hypothesis of this rare presentation of foregut duplication cyst in Meckel scan could be the increased amount of functioning ectopic gastric mucosa present within the duplication cyst. This can also possibly explain the symptom of hemoptysis and the presence of consolidation in the adjacent lung, which could be due to the rupture of this duplication cyst to the adjacent lung.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.
Conflicts of interest
There are no conflicts of interest.
Nil.
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