Recent updates in diagnosis of abdominal tuberculosis with emphasis on nucleic acid amplification tests.

INTRODUCTION: Abdominal tuberculosis (TB) is a common epitome of extrapulmonary TB (EPTB), wherein peritoneal and intestinal TB are the most prevalent forms. Diagnosis of abdominal TB is a daunting challenge owing to variable anatomical locations, paucibacillary nature of specimens and atypical clinical presentations that mimic other abdominal diseases, such as Crohn's disease and malignancies. In this review, we made a comprehensive study on the diagnosis of abdominal TB. AREA COVERED: Various modalities employed for abdominal TB diagnosis include clinical features, imaging, bacteriological tests (smear/culture), histopathological/cytological observations, interferon-gamma release assays and nucleic acid amplification tests (NAATs). Among NAATs, loop-mediated isothermal amplification assay, PCR, multiplex-PCR, nested PCR, real-time PCR and GeneXpert® MTB/RIF were discussed. Identification of circulating Mycobacterium tuberculosis cell-free DNA by real-time PCR within ascitic fluids is another useful approach. EXPERT OPINION: Several novel molecular/immunological methods, such as GeneXpert Ultra, aptamer-linked immobilized sorbent assay, immuno-PCR (I-PCR) and nanoparticle-based I-PCR have recently been developed for detecting pulmonary TB and several EPTB types, which may also be explored for abdominal TB diagnosis. Precise and prompt diagnosis of abdominal TB may initiate an early therapy so as to reduce the complications, i.e. abdominal pain, ascites, abdominal distension, intestinal obstruction/perforation, etc., and avoid surgical involvement.Plain Language SummaryAbdominal tuberculosis (TB) is a manifestation of extrapulmonary TB (EPTB), where peritoneal and intestinal TB are two major forms. Diagnosis of abdominal TB is difficult owing to low bacterial load present in clinical samples and non-specific clinical presentations as it mimics other diseases such as inflammatory bowel diseases, abdominal malignancies, etc. Bacteriological tests (smear/culture) almost fail owing to poor sensitivities and it is not always possible to get representative tissue samples for histopathological and cytological observations. In recent years, molecular tests i.e. nucleic acid amplification tests (NAATs), such as PCR/multiplex-PCR (M-PCR), nested PCR and GeneXpert are widely employed. Markedly, PCR/M-PCR and nested PCR exhibited reasonable good sensitivities/specificities, while GeneXpert revealed low sensitivity in most of the studies but high specificity, thus it could assist in differential diagnosis of intestinal TB and Crohn's disease. Further, novel molecular/immunological tests employed for pulmonary TB and other EPTB types were described and those tests can also be utilized to diagnose abdominal TB. Reliable and rapid diagnosis of abdominal TB would initiate an early start of anti-tubercular therapy and reduce the severe complications.

Ectopic ovary presenting as mesenteric abscess.

Ectopic ovary is a rare gynaecological condition that results in problems with menstruation and pregnancy and may develop into a malignant tumour. However, as the condition is often asymptomatic, diagnosis is difficult and frequently delayed. We report a case of a 42-year-old female who presented with a 10-day history of abdominal pain. The patient underwent surgery that confirmed the diagnosis of an ectopic ovary with an internal abscess. The findings of our study indicate that ectopic ovaries can present with an abscess. Ectopic ovaries should be included in the differential diagnosis of masses with internal abscesses.

[Clinical Characteristics and Risk Factors of ESKAPE Pathogens Bloodstream Infection in Cancer Patients].

OBJECTIVE: To identify the risk factors of ESKAPE pathogens infection and related death in cancer patients, and to supply evidence for clinical precaution and diagnosis. METHODS: A retrospective study of clinical and experimental data of cancer patients with bloodstream infection were carried out in Sichuan Cancer Hospital from 2013 to 2018. The clinical feature, predisposing factors and risk factors of death in ESKAPE group and non-ESKAPE group were analyzed by univariate analysis and multivariate logistic regression. RESULTS: A total of 753 patients were enrolled in the study. Totally 795 pathogenic bacteria strains were isolated from blood culture and there were 278 ESKAPE strains, which took up 34.97% of isolated strains. Univariate analysis and multivariate logistic regression analysis showed that gender of male, multiple pathogens, history of exposure to enzyme inhibitors and agranulocytosis were independent risk factors of ESKAPE pathogens bloodstream infection. Peritoneal infection and combined fungal infection were independent risk factors of ESKAPE bloodstream infection related death. CONCLUSION: The bloodstream infection of ESKAPE pathogens is a problem worthy of clinical attention for cancer patients with neutrophil deficiency, previous antibiotic exposure, and fungal infection and peritoneal infection.

Hypothetical roadmap towards endometriosis: prenatal endocrine-disrupting chemical pollutant exposure, anogenital distance, gut-genital microbiota and subclinical infections.

BACKGROUND: Endometriosis is a gynaecological hormone-dependent disorder that is defined by histological lesions generated by the growth of endometrial-like tissue out of the uterus cavity, most commonly engrafted within the peritoneal cavity, although these lesions can also be located in distant organs. Endometriosis affects ~10% of women of reproductive age, frequently producing severe and, sometimes, incapacitating symptoms, including chronic pelvic pain, dysmenorrhea and dyspareunia, among others. Furthermore, endometriosis causes infertility in ~30% of affected women. Despite intense research on the mechanisms involved in the initial development and later progression of endometriosis, many questions remain unanswered and its aetiology remains unknown. Recent studies have demonstrated the critical role played by the relationship between the microbiome and mucosal immunology in preventing sexually transmitted diseases (HIV), infertility and several gynaecologic diseases. OBJECTIVE AND RATIONALE: In this review, we sought to respond to the main research question related to the aetiology of endometriosis. We provide a model pointing out several risk factors that could explain the development of endometriosis. The hypothesis arises from bringing together current findings from large distinct areas, linking high prenatal exposure to environmental endocrine-disrupting chemicals with a short anogenital distance, female genital tract contamination with the faecal microbiota and the active role of genital subclinical microbial infections in the development and clinical progression of endometriosis. SEARCH METHODS: We performed a search of the scientific literature published until 2019 in the PubMed database. The search strategy included the following keywords in various combinations: endometriosis, anogenital distance, chemical pollutants, endocrine-disrupting chemicals, prenatal exposure to endocrine-disrupting chemicals, the microbiome of the female reproductive tract, microbiota and genital tract, bacterial vaginosis, endometritis, oestrogens and microbiota and microbiota-immune system interactions. OUTCOMES: On searching the corresponding bibliography, we found frequent associations between environmental endocrine-disrupting chemicals and endometriosis risk. Likewise, recent evidence and hypotheses have suggested the active role of genital subclinical microbial infections in the development and clinical progression of endometriosis. Hence, we can envisage a direct relationship between higher prenatal exposure to oestrogens or estrogenic endocrine-disrupting compounds (phthalates, bisphenols, organochlorine pesticides and others) and a shorter anogenital distance, which could favour frequent postnatal episodes of faecal microbiota contamination of the vulva and vagina, producing cervicovaginal microbiota dysbiosis. This relationship would disrupt local antimicrobial defences, subverting the homeostasis state and inducing a subclinical inflammatory response that could evolve into a sustained immune dysregulation, closing the vicious cycle responsible for the development of endometriosis. WIDER IMPLICATIONS: Determining the aetiology of endometriosis is a challenging issue. Posing a new hypothesis on this subject provides the initial tool necessary to design future experimental, clinical and epidemiological research that could allow for a better understanding of the origin of this disease. Furthermore, advances in the understanding of its aetiology would allow the identification of new therapeutics and preventive actions.

Antibiotic therapy with metronidazole reduces endometriosis disease progression in mice: a potential role for gut microbiota.

STUDY QUESTION: Does altering gut microbiota with antibiotic treatment have any impact on endometriosis progression? SUMMARY ANSWER: Antibiotic therapy reduces endometriosis progression in mice, possibly by reducing specific gut bacteria. WHAT IS KNOWN ALREADY: Endometriosis, a chronic condition causing abdominal pain and infertility, afflicts up to 10% of women between the ages of 25 and 40, ~5 million women in the USA. Current treatment strategies, including hormone therapy and surgery, have significant side effects and do not prevent recurrences. We have little understanding of why some women develop endometriosis and others do not. STUDY DESIGN, SIZE, DURATION: Mice were treated with broad-spectrum antibiotics or metronidazole, subjected to surgically-induced endometriosis and assayed after 21 days. PARTICIPANTS/MATERIALS, SETTING, METHODS: The volumes and weights of endometriotic lesions and histological signatures were analysed. Proliferation and inflammation in lesions were assessed by counting cells that were positive for the proliferation marker Ki-67 and the macrophage marker Iba1, respectively. Differences in faecal bacterial composition were assessed in mice with and without endometriosis, and faecal microbiota transfer studies were performed. MAIN RESULTS AND THE ROLE OF CHANCE: In mice treated with broad-spectrum antibiotics (vancomycin, neomycin, metronidazole and ampicillin), endometriotic lesions were significantly smaller (~ 5-fold; P < 0.01) with fewer proliferating cells (P < 0.001) than those in mice treated with vehicle. Additionally, inflammatory responses, as measured by the macrophage marker Iba1 in lesions and IL-1ß, TNF-α, IL-6 and TGF-ß1 in peritoneal fluid, were significantly reduced in mice treated with broad-spectrum antibiotics (P < 0.05). In mice treated with metronidazole only, but not in those treated with neomycin, ectopic lesions were significantly (P < 0.001) smaller in volume than those from vehicle-treated mice. Finally, oral gavage of faeces from mice with endometriosis restored the endometriotic lesion growth and inflammation (P < 0.05 and P < 0.01, respectively) in metronidazole-treated mice. LARGE-SCALE DATA: N/A. LIMITATIONS, REASONS FOR CAUTION: These findings are from a mouse model of surgically-induced endometriosis. Further studies are needed to determine the mechanism by which gut bacteria promote inflammation, identify bacterial genera or species that promote disease progression and assess the translatability of these findings to humans. WIDER IMPLICATIONS OF THE FINDINGS: Our findings suggest that gut bacteria promote endometriosis progression in mice. This finding if translated to humans, could aid in the development of improved diagnostic tools and personalised treatment strategies. STUDY FUNDING AND COMPETING INTEREST(S): This work was funded, in part, by: a National Institutes of Health (NIH)/ National Institute of Child Health and Human Development (NICHD) grant (R00HD080742) to RK; Washington University School of Medicine start-up funds to RK; an Endometriosis Foundation of America Research Award to R.K.; and an NIH/NICHD grant (R01HD091218) to IUM. The authors report no conflict of interest.

Actinomycosis of the omentum with invasion of the abdominal wall, small bowel and transverse colon mimicking malignancy.

We report the case of a 59-year-old Russian man who presented with a painless, slow-growing, epigastric mass. CT revealed a large heterogeneous mass within the omentum infiltrating into adjacent tissues. During diagnostic laparoscopy, the omental mass was noted to be firm, raising the suspicion of malignancy. Surgical en-bloc resection of the mass, including the posterior rectus sheath, transverse colon and small bowel, was performed with primary anastomoses at laparotomy. Histological examination was inconsistent with malignancy and revealed the mass to be actinomycosis, confirmed by microscopy and gram staining. Surgical resection was followed by an 8-week course of penicillin and doxycycline antibiotic therapy. This treatment resulted in full clinical and radiological recovery with no complications. Although the clinical and radiological findings, in this case, were highly suspicious of malignancy, abdominal actinomycosis should be considered a differential diagnosis in patients with infiltrative abdominal masses and mild constitutional symptoms.

Disseminated tuberculosis - diagnostic challenges of atrial tuberculoma masquerading as atrial myxoma.

A 47-year-old female, with multiple comorbidities, presented with a cough of two months, loss of weight and appetite. She was treated for pneumonia. A chest X-ray showed bilateral reticulonodular opacities. She was noted to have a vague central abdominal mass and a systolic murmur over the mitral region. Ultrasonography and computed tomography of the abdomen showed an omental mass and loculated ascites. Oesophagoduedenoscopy showed antral gastritis and during colonoscopy the surgical team was unable to advance the scope beyond 40 cm due to external compression. An echocardiogram showed a right atrial mass and a pericardial effusion over the posterior wall. A possible diagnosis of atrial myxoma was made. Sputum acid-fast bacillus was negative. The patient was treated empirically for disseminated tuberculosis and scheduled for bronchoscopy by the pulmonology team. The patient showed remarkable improvement after day 7 of anti-tuberculosis medication. GeneXpert study came back as positive. CT abdomen and echocardiogram repeated after 2 weeks of treatment showed reduction in the mass.

[Primary omental actinomycosis]. / Primær aktinomykose i omentum majus.

We report a case of omental actinomycosis in a female patient with an intrauterine device. A computed tomography had shown an inflammatory tumour in the abdomen. The patient was treated with laparoscopic resection of the tumour and prolonged antibiotic therapy. Abdominal actinomycosis should be considered as a differential diagnosis in patients with abdominal symptoms and unspecific clinical, radiological and laboratory findings. Definitive diagnosis of actinomycosis requires histological examination of affected tissue. Laparoscopic resection seems feasible as an alternative to open surgery.

Peritoneal blastomycosis: a hidden mystery unfolds itself.

Blastomycosis is a disease caused by the fungus Blastomyces dermatitidis. Pulmonary blastomycosis is the most common form of blastomycosis. Disseminated blastomycosis is the fulminant form of the disease, with rare reports of peritoneal cavity involvement. We report a case of extensive form of the disease presenting initially as abdominal pain and mimicking peritoneal carcinomatosis.

A research agenda on the management of intra-abdominal candidiasis: results from a consensus of multinational experts.

INTRODUCTION: intra-abdominal candidiasis (IAC) may include Candida involvement of peritoneum or intra-abdominal abscess and is burdened by high morbidity and mortality rates in surgical patients. Unfortunately, international guidelines do not specifically address this particular clinical setting due to heterogeneity of definitions and scant direct evidence. In order to cover this unmet clinical need, the Italian Society of Intensive Care and the International Society of Chemotherapy endorsed a project aimed at producing practice recommendations for the management of immune-competent adult patients with IAC. METHODS: A multidisciplinary expert panel of 22 members (surgeons, infectious disease and intensive care physicians) was convened and assisted by a methodologist between April 2012 and May 2013. Evidence supporting each statement was graded according to the European Society of Clinical Microbiology and Infection Diseases (ESCMID) grading system. RESULTS: Only a few of the numerous recommendations can be summarized in the Abstract. Direct microscopy examination for yeast detection from purulent and necrotic intra-abdominal specimens during surgery or by percutaneous aspiration is recommended in all patients with nonappendicular abdominal infections including secondary and tertiary peritonitis. Samples obtained from drainage tubes are not valuable except for evaluation of colonization. Prophylactic usage of fluconazole should be adopted in patients with recent abdominal surgery and recurrent gastrointestinal perforation or anastomotic leakage. Empirical antifungal treatment with echinocandins or lipid formulations of amphotericin B should be strongly considered in critically ill patients or those with previous exposure to azoles and suspected intra-abdominal infection with at least one specific risk factor for Candida infection. In patients with nonspecific risk factors, a positive mannan/antimannan or (1→3)-ß-D-glucan (BDG) or polymerase chain reaction (PCR) test result should be present to start empirical therapy. Fluconazole can be adopted for the empirical and targeted therapy of non-critically ill patients without previous exposure to azoles unless they are known to be colonized with a Candida strain with reduced susceptibility to azoles. Treatment can be simplified by stepping down to an azole (fluconazole or voriconazole) after at least 5-7 days of treatment with echinocandins or lipid formulations of amphotericin B, if the species is susceptible and the patient has clinically improved. CONCLUSIONS: Specific recommendations were elaborated on IAC management based on the best direct and indirect evidence and on the expertise of a multinational panel.

Transvaginal access for NOTES: a cohort study of microbiological colonization and contamination.

BACKGROUND AND STUDY AIMS: Animal data and limited clinical evidence suggest a low incidence of infection following transvaginal natural orifice transluminal endoscopic surgery (NOTES). However, a systematic microbiological evaluation has not yet been carried out. The aim of this prospective cohort study was to evaluate the extent of microbiological contamination of the peritoneal cavity caused by the transvaginal access for NOTES and the impact of preoperative vaginal disinfection on vaginal colonization. PATIENTS AND METHODS: Consecutive female patients with symptomatic cholecystolithiasis were offered either transvaginal rigid-hybrid cholecystectomy (tvCCE) or conventional laparoscopic cholecystectomy. Patients who opted for tvCCE were prospectively evaluated between February and June 2010. Disinfection in patients undergoing tvCCE included hexetidine tablets and octenidine applied vaginally. All patients received a single dose of perioperative cefuroxime. Swabs were obtained from the posterior fornix and the peritoneal cavity at different intervals. RESULTS: Of 32 patients, 27 (84 %) opted to undergo tvCCE. One patient (4 %; 95 % confidence interval [CI] 0.7 % - 18.3 %) had a positive bacterial culture in the Douglas pouch prior to transvaginal access compared with two patients (7 %; 95 %CI 2.1 % - 23.4 %) following colpotomy closure (P = 1.000). Vaginal disinfection significantly decreased vaginal bacterial load (P = 0.001) and bacterial growth in routine cultures (P < 0.001); in 16 patients (59 %; 95 %CI 40.7 % - 75.5 %) vaginal swabs were sterile after disinfection. No postoperative surgical site infections occurred (95 %CI 0 % - 12.5 %). CONCLUSIONS: In selected patients and following vaginal antisepsis, transvaginal access for NOTES is associated with microbiological contamination of the peritoneal cavity in a minority of patients, indicating a low risk of peritoneal contamination caused by the transvaginal access.

Laparoscopic resection of omental actinomycosis forming fistula with transverse colon and jejunum: a case report and review of literature.

Omental actinomycosis without any predisposing factors is rare, and there are few reports on it invading the contiguous bowels to form fistulae. We describe the case of a 55-year-old male patient with omental actinomycosis that presented as an inflammatory tumor that formed fistulae with the transverse colon and upper jejunum. On admission, he had complaints of a palpable, tender mass on the left mid-abdomen without gastrointestinal symptoms. After 7 days of conservative treatments (NPO and intravenous antibiotics), the size of the mass was decreased and tenderness was more improved. Laparoscopic resected omental mass revealed fistulae to the colon and jejunum. There was no evidence of Crohn disease. After 1-week use of antibiotics owing to the concern about actinomycosis, the mass was decreased and it was more amenable to dissect laparoscopically.

Two-component polyethylene glycol surgical sealant influence on intraperitoneal infection in a refined rodent model.

OBJECTIVE: This study determined the influence of a 2-component polyethylene glycol surgical sealant (Coseal) as an adhesion prevention device on sepsis-related mortality and/or systemic bacterial translocation to the spleen. STUDY DESIGN: A bacterial inoculum and telemetry probe were implanted in 50 treated and 49 untreated rats. Telemetry probes monitored core-body temperature to determine time of death. Spleens were collected on day 3 for quantitative bacteriology of Escherichia coli and Bacteroides fragilis. RESULTS: Median survival time and mortality of treated rats (37.0 hours, 54.0%) were noninferior to untreated rats (47.5 hours, 55.1%). Median E coli titers in treated rats (2.24 log colony forming units/spleen) were significantly less than untreated rats (4.32 log colony forming units/spleen). B fragilis titers were not different. CONCLUSION: This study demonstrates intraperitoneal administration of a 2-component polyethylene glycol surgical sealant as an adhesion prevention device does not alter time to death or sepsis-related mortality and/or systemic bacterial translocation to the spleen.

Correlation of high-risk human papilloma viruses but not of herpes viruses or Chlamydia trachomatis with endometriosis lesions.

OBJECTIVE: To investigate whether sexually transmitted viruses or prokaryotes, like human papilloma viruses (HPV), herpes viruses, and Chlamydia trachomatis, are associated with endometriosis lesions. DESIGN: Sixty-six endometriosis lesions from 56 patients, including 49 peritoneum, 16 ovarian, and one endometrium, were analyzed using polymerase chain reaction-based ELISA and Invader technology. Thirty control tissues including endometrium and peritoneum from patient-matched (n = 13) and patients without endometriosis (n = 13) and one cervical carcinoma were tested for HPV DNA. SETTING: University hospital. PATIENT(S): Seventy individual patients with and without endometriosis. INTERVENTION(S): Laparoscopy or laparotomy was performed, and endometriotic lesions were isolated. RESULT(S): Herpes viruses and Chlamydia trachomatis were not detected in endometriosis lesions. High-risk and medium-risk HPV were detected in 11.3% of lesions, corresponding to 13.2% of patients. In addition, 27.5% of control tissues were positive for HPV high and medium risk. One HPV18-positive ovarian endometriosis also associated with an ovarian carcinoma. Associating clinical history with HPV-positive endometriosis and control tissues, all patients had a prior HPV cervical infection. CONCLUSION(S): HPV infection in endometriosis lesions including control tissues supports spreading of the virus or HPV-infected endometrial cells via retrograde menstruation. Owing to an association of HPV in carcinomas, we propose that persistent HPV infection of endometriosis lesions could contribute to malignant progression.

Matrix metalloproteinases with gelatinolytic activity induced by Paracoccidioides brasiliensis infection.

Matrix metalloproteinases (MMPs) modulate extracellular matrix turnover, inflammation and immunity. We studied MMP-9 and MMP-2 in experimental paracoccidioidomycosis. At 15 and 120 days after infection (DAI) with virulent Paracoccidioides brasiliensis, MMP-9 was positive by immunohistochemistry in multinucleated giant cells, in mononuclear cells with macrophage and lymphocyte morphologies and also in fungal cells in the lesions of susceptible and resistant mice. Using gelatin zymography, pro- and active MMP-9 and active MMP-2 were detected in all infected mice, but not in controls. Gelatinolytic activity was not observed in P. brasiliensis extracts. Semiquantitative analysis of gelatinolytic activities revealed weak or absent MMP-2 and strong MMP-9 activity in both mouse strains at 15 DAI, declining at 120 DAI. Avirulent P. brasiliensis-infected mice had residual lesions with MMP-9-positive pseudoxantomatous macrophages, but no gelatinase activity at 120 DAI. Our findings demonstrate the induction of MMPs, particularly MMP-9, in experimental paracoccidioidomycosis, suggesting a possible influence in the pattern of granulomas and in fungal dissemination.

Sterile intra-abdominal fluid collection associated with seprafilm use.

Postoperative abdominal adhesions are a significant cause of morbidity and expenditure of healthcare resources. As a result, numerous substances have been studied in an effort to reduce the incidence of adhesive disease. Seprafilm, a hyaluronate-based bioresorbable membrane, has been the subject of considerable research and has been found to be both safe and effective in reducing postoperative adhesions. We report three cases of the development of sterile abdominal fluid collection after the use of Seprafilm in colorectal surgery.

Dialyzer reactions in a patient switching from peritoneal dialysis to hemodialysis.

Many terms have been used to describe the collection of signs and symptoms triggered by the initial use of dialyzers. These reactions can be divided into Type A (hypersensitivity reactions, with the incidence of 4/100,000) and Type B (nonspecific reactions, incidence 3-5/100). Many different mechanisms have been postulated, including complement activation, pulmonary leukostasis, hypersensitivity to ethylene oxide, interaction between the AN69 membrane and angiotensin-converting enzyme inhibitors, and dialysate contamination. An unusual case of dialyzer reactions is presented here, involving a patient who had to discontinue peritoneal dialysis when she was admitted with fungal peritonitis. Upon initiation of hemodialysis, she experienced dyspnea and burning sensation and demonstrated significant leukopenia, thrombocytopenia, and oxygen desaturation. These reactions persisted despite double-rinsing of the dialyzers and the use of several different dialyzers with synthetic membranes (polysulfone and AN69), and a variety of sterilization methods (electron beam and gamma radiation). In the end, a simple measure was found to be effective in preventing further dialyzer reactions in this fascinating case.

Coccidioidomycosis mimicking ovarian cancer.

BACKGROUND: Dissemination of coccidioidomycosis to the abdominal cavity is rare. No previous case of peritoneal coccidioidomycosis has presented as an adnexal mass. CASE: We report a case of peritoneal coccidioidomycosis mimicking ovarian carcinoma. The patient presented with a complex ovarian mass, ascites, omental caking, and an elevated CA 125. The ultimate diagnosis was not made until frozen section histopathology was performed at staging laparotomy. CONCLUSION: Peritoneal coccidioidomycosis can present with the clinical, radiographic, and serologic features of ovarian cancer. Although essential for diagnosis and staging, radiographic studies and tumor markers have limited specificity. Coccidioidomycosis now joins other benign conditions that comprise the differential diagnosis of patients who present with what seems to be advanced ovarian carcinoma. Infectious diseases consultation is recommended for the management of peritoneal coccidioidomycosis.