A rare case of peritoneal tuberculosis mimicking peritoneal carcinomatosis: the ongoing challenge.

Tuberculosis (TB) is a serious infection that can involve any organ system and present in various forms. About one-third of the world's population are carriers of latent TB. Although most cases are from a pulmonary origin, there is a rising prevalence of abdominal TB. Patients with pulmonary or extrapulmonary TB are treated similarly through the use of pharmacological therapy. Nonspecific clinical manifestations of TB have made it difficult for clinicians to diagnose. Peritoneal tuberculosis (PTB) is a serious concern as its symptoms overlap with that of many other chronic conditions, especially in those who are immunocompromised. The lack of highly sensitive and specific testing methods has made early intervention difficult, therefore a high index of suspicion is crucial in the progression of the disease. Here, we present a case of a 71-year-old female with a history of abdominal pain, fever, and weakness. Initial investigation with computed tomography (CT) imaging revealed omental fat stranding that pointed towards peritoneal carcinomatosis (PC) from possible recurrence of her ovarian cancer. Further investigation with a peritoneal biopsy was remarkable for caseating granulomas with fat necrosis confirming extrapulmonary TB. This report highlights a rare case of PTB mimicking PC in an elderly patient who is immunocompromised from the use of long-term corticosteroids who continued to decline after pharmacological treatment of the disease.

CT texture analysis for differentiating between peritoneal carcinomatosis and peritoneal tuberculosis: a cross-sectional study.

PURPOSE: Peritoneal carcinomatosis (PC) and peritoneal tuberculosis (PTB) have similar clinical and radiologic imaging features, which make it very difficult to differentiate between the two entities clinically. Our aim was to determine if the CT textural parameters of omental lesions among patients with PC were different from those with PTB. METHODS: All patients who had undergone omental biopsy at our institution from January 2010 to December 2018 and had a tissue diagnosis of PC or PTB were eligible for inclusion. Patients who did not have a contrast-enhanced CT abdomen within one month of the omental biopsy were excluded. A region of interest (ROI) was manually drawn over omental lesions and radiomic features were extracted using open-source LIFEx software. Statistical analysis was performed to compare mean differences in CT texture parameters between the PC and PTB groups. RESULTS: A total of 66 patients were included in the study of which 38 and 28 had PC and PTB, respectively. Omental lesions in patients with PC had higher mean radiodensity (mean difference: +32.4; p = 0.001), higher mean entropy (mean difference: +0.11; p < 0.001), and lower mean energy (mean difference: -0.024; p = 0.001) compared to those in PTB. Additionally, omental lesions in the PC group had lower gray-level co-occurrence matrix (GLCM) homogeneity (mean difference: -0.073; p < 0.001) and higher GLCM dissimilarity (mean difference: +0.480; p < 0.001) as compared to the PTB group. CONCLUSION: CT texture parameters of omental lesions differed significantly between patients with PTB and those with PC, which may help clinicians in differentiating between the two entities.

Abdominal visceral tuberculosis: a malignancy mimic.

The purpose is to discuss abdominal tuberculosis mimicking malignancy involving the abdominal viscera. TB of the abdominal viscera is common, especially in countries where tuberculosis is endemic and in pockets of non-endemic countries. Diagnosis is challenging as clinical presentations are often non-specific. Tissue sampling may be necessary for definitive diagnosis. Awareness of the early and late disease imaging appearances of abdominal tuberculosis involving the viscera that can mimic malignancy can aid detecting TB, providing a differential diagnosis, assessing extent of spread, guiding biopsy, and evaluating response.

Differentiating peritoneal tuberculosis and peritoneal carcinomatosis based on a machine learning model with CT: a multicentre study.

PURPOSE: It is still a challenge to make early differentiation of peritoneal tuberculosis (PTB) and peritoneal carcinomatosis (PC) clinically as well as on imaging and laboratory tests. We aimed to develop a model to differentiate PTB from PC based on clinical characteristics and primary CT signs. METHODS: This retrospective study included 88 PTB patients and 90 PC patients (training cohort: 68 PTB patients and 69 PC patients from Beijing Chest Hospital; testing cohort: 20 PTB patients and 21 PC patients from Beijing Shijitan Hospital). The images were analyzed for omental thickening, peritoneal thickening and enhancement, small bowel mesentery thickening, the volume and density of ascites, and enlarged lymph nodes (LN). Meaningful clinical characteristics and primary CT signs comprised the model. ROC curve was used to validate the capability of the model in the training and testing cohorts. RESULTS: There were significant differences in the following aspects between the two groups: (1) age; (2) fever; (3) night sweat; (4) cake-like thickening of the omentum and omental rim (OR) sign; (5) irregular thickening of the peritoneum, peritoneal nodules, and scalloping sign; (6) large ascites; and (7) calcified and ring enhancement of LN. The AUC and F1 score of the model were 0.971 and 0.923 in the training cohort and 0.914 and 0.867 in the testing cohort. CONCLUSION: The model has the potential to distinguish PTB from PC and thus has the potential to be a diagnostic tool.

Pretreatment CT differential diagnosis of tuberculous peritonitis from peritoneal carcinomatosis of advanced epithelial ovarian cancer.

Delayed diagnosis of female genital tuberculosis (FGTB) can lead to inappropriate treatment and unnecessary surgical procedures rather than standard anti-TB medication. We tried to evaluate the use of computed tomography (CT) imaging to differentiate TB peritonitis from peritoneal carcinomatosis of advanced epithelial ovarian cancer (AEOC). We investigated women who underwent CT to distinguish between TB peritonitis and peritoneal carcinomatosis of AEOC. We evaluated various CT imaging features to identify differences between the two diseases. In addition, we performed univariate and multivariate logistic regression analyses to identify the independent imaging parameters associated with TB peritonitis and evaluated the diagnostic performance of the combined imaging parameters. We also performed the histopathological analysis of the available salpinx specimens of TB peritonitis. We included 25 women with TB peritonitis and 34 women with peritoneal carcinomatosis of AEOC. A multivariate analysis of the discriminant CT imaging features between the two diseases revealed that changes in fallopian tubes and peritoneal micronodules were independent parameters associated with TB peritonitis (p ≤ 0.012). Combining the two imaging parameters showed an area under the receiver operating characteristic curve of 0.855, a sensitivity of 88.0%, and a specificity of 67.7% for differentiating TB peritonitis from peritoneal carcinomatosis. Furthermore, changes in fallopian tubes were correlated with histopathological abnormalities in salpinx specimens. Pretreatment CT evaluation with useful imaging features could help differentiate TB peritonitis from peritoneal carcinomatosis of AEOC.

Peritoneal tuberculosis mimicking colonic carcinomatosis.

Pulmonary Tuberculosis (TB) has increased in Spain in recent years due to multiple factors. Peritoneal tuberculosis represents the sixth cause of extrapulmonary tuberculosis, accounting for 11% of tuberculosis cases. We report a 28-year-old male from Mali, who arrived at our hospital with an acute abdomen due to intestinal perforation with a computed tomography scan (CT) performed peritoneal tuberculosis mimicking primary carcinomatosis. This presents a diagnostic and therapeutic challenge, since the surgical approach differs in both cases, and the prognosis is very different between them.

Is MDCT an accurate tool to differentiate between benign and malignant etiology in diffuse peritoneal disease?

PURPOSE: There is often considerable overlap of imaging findings in benign and malignant peritoneal diseases. We evaluated patients with diffuse peritoneal disease, to assess the diagnostic value of MDCT in predicting benign or malignant etiology in patients with unknown etiology, by analyzing the various patterns of involvement, particularly tuberculosis (TB) vs malignancy. METHODS: One hundred and thirty-six patients with diffuse peritoneal disease who had abdominal CT and subsequently underwent omental biopsies were included in the study. Peritoneal, mesenteric and omental involvement by disease was evaluated on CT using specific parameters. The presence of lymphadenopathy, ascites, scalloping of organs, involvement of liver and spleen, were also compared between benign and malignant conditions using histopathology as the gold standard. RESULTS: In 136 patients, 72 benign and 64 malignant pathologies were classified as per histopathology. Higher age (p < 0.001), increasing omental thickness (mean 25.2 mm, p = 0.004), omental caking (p < 0.001), > 10 mm mesenteric/peritoneal nodules (p < 0.03), visceral scalloping (p = 0.001), free ascites (p = 0.003), serosal involvement (p = 0.004) and bilateral pleural effusion (p = 0.02) were associated with malignant etiology. Mesenteric thickening/stranding (p = 0.02), mesenteric adenopathy (p < 0.001), necrotic nodes (p = 0.02), splenomegaly (p = < 0.001) and higher attenuation (> 20HU) of ascitic fluid (p < 0.001) were associated with benign etiology. The presence of mesenteric thickening or stranding (p = 0.01), splenomegaly (p = 0.02), higher ascitic fluid attenuation > 20HU (p = < 0.01), mesenteric adenopathy (p < 0.01), necrotic nodes (p = 0.03) favored tuberculosis. CT had diagnostic accuracy (79.3, 86.7%), sensitivity (79.2, 74.6%) and specificity (79.4, 97%) for observers 1 and 2, respectively (Kappa 0.713). CONCLUSION: Contrast-enhanced MDCT has good sensitivity, specificity and accuracy in differentiating benign and malignant etiologies of diffuse peritoneal disease. Multiple common parameters can be used to differentiate between tuberculous peritonitis and peritoneal carcinomatosis.

Diagnostic accuracy of computed tomography in differentiating peritoneal tuberculosis from peritoneal carcinomatosis.

INTRODUCTION: Peritoneal tuberculosis is difficult to diagnose as it may mimic peritoneal carcinomatosis, which has similar symptomatology. We sought to determine the diagnostic accuracy of computed tomography in differentiating peritoneal tuberculosis versus peritoneal carcinomatosis. MATERIALS AND METHODS: The associations of radiological findings in 124 patients with peritoneal carcinomatosis (n = 55) or tuberculosis (n = 69) were determined using Chi-square test. Sensitivity, specificity, positive and negative predictive value, and total diagnostic accuracy of CT imaging, with histopathology as gold standard, was determined. Subgroup analyses to determine these parameters by age (>40 years and ≤40 years) and gender (male and female) were performed. RESULTS: Mean age of study population was 44.1 ± 13.2 years with 61 males (49.2%) and 63 females (50.8%). The most common radiological abnormality in both peritoneal carcinomatosis (90.9%) and peritoneal tuberculosis (89.9%) was omental smudging, followed by presence of extraperitoneal mass (81.8%) in carcinomatosis and presence of micro-nodules in tuberculosis (88.4%). The findings significantly different in both the carcinomatosis and tuberculosis groups were high-density ascites, splenic calcification, splenomegaly, lymph node calcifications, micro-nodules, and macro-nodules. The diagnostic accuracy of CT in differentiating peritoneal tuberculosis from peritoneal carcinomatosis was 83.8%; sensitivity and specificity for peritoneal tuberculosis were 88.4% and 78.2%, respectively. CONCLUSION: The diagnostic accuracy of CT in differentiating peritoneal tuberculosis from peritoneal carcinomatosis revealed an overall diagnostic accuracy of 83.8%. Subgroup analysis revealed that CT may be a more specific diagnostic tool to predict peritoneal tuberculosis in female patients and in those over 40 years old.

Diagnostic yield and safety of percutaneous CT-guided biopsy of retroperitoneal lesions and analysis of imaging features.

BACKGROUND: Computed tomography (CT)-guided biopsy is emerging as a preferred method for obtaining tissue samples from retroperitoneal lesions due to clear visualization of needle and vessels. PURPOSE: To assess diagnostic yield and safety of CT-guided biopsy of retroperitoneal lesions and compare CT findings in different disease categories. MATERIAL AND METHODS: This retrospective analytical study included 86 patients with retroperitoneal lesions who underwent CT-guided biopsy from December 2010 to March 2020. All procedures were performed with co-axial technique and multiple cores were obtained and subjected to histopathology. Additional tests like immunohistochemistry or microbiological analysis were done depending on clinical suspicion. Diagnostic yield calculation and comparison of imaging findings was done by one-way ANOVA, chi-square, and Fisher's exact tests. RESULTS: CT-guided biopsy was technically successful in all cases with a diagnostic yield of 91.9%. Minor complications in the form of small hematomas were seen in two patients. Major disease categories on final diagnosis were lymphoma, tuberculosis, and metastases. A variety of malignant and benign soft-tissue neoplasms were also noted less commonly. With help of immunohistochemistry, lymphoma subtype was established in 88.8% of cases. Addition of microbiological tests like the GeneXpert assay helped in the diagnosis of tuberculosis in some cases. A mass-like appearance and vascular encasement was common in metastatic group and lymphoma. CONCLUSION: Percutaneous CT-guided biopsy is a safe method for the sampling of retroperitoneal lesions with high diagnostic yield. Imaging findings are mostly overlapping; however, some features are more common in a particular disease condition.

Characterizing omental PET/CT findings for differentiating tuberculous peritonitis from peritoneal carcinomatosis.

PURPOSE: To characterize and investigate PET/CT findings in the omentum in the differentiation of tuberculous peritonitis (TBP) and peritoneal carcinoma (PC). METHODS: Thirty-nine patients with TBP and 113 patients with PC who underwent PET/CT were retrospectively enrolled. The omental uptake intensity, distribution characteristics, contracture, size and boundary of soft-tissue lesions, and CT patterns were reviewed. RESULTS: Absent and focal FDG uptake in the lesser omentum was more common in the PC patients (P = 0.034 and P = 0.017, respectively), and diffuse FDG uptake in the lesser omentum was more common in the TBP patients (P < 0.001). An apron-like pattern in the greater omentum commonly occurred in the TBP patients (P = 0.004). Micronodules (< 5 mm) were more common in the TBP patients (P < 0.001), and masses (> 3 cm) were more common in the PC patients (P = 0.001). Smudged and nodular patterns occurred more frequently in the TBP patients than in the PC patients (P < 0.001 and P = 0.003, respectively), and the caked pattern occurred more frequently in the PC patients (P < 0.001). There was no significant difference in the FDG uptake intensity and the boundary of soft-tissue lesions between the TBP and PC patients (P = 0.191 and P = 0.061, respectively). CONCLUSION: Diffuse FDG uptake, an apron-like pattern, micronodules, and a smudged and nodular pattern might be significant differential features of TBP. Absent and/or focal FDG uptake, mass, and a caked pattern might be significant differential features of PC.

Diagnostic performance of CT for differentiating peritoneal tuberculosis from peritoneal carcinomatosis: a systematic review and meta-analysis.

AIM: To undertake a systematic review and meta-analysis of the diagnostic performance of CT for differentiating peritoneal tuberculosis (PTB) from peritoneal carcinomatosis (PC). MATERIAL AND METHODS: PubMed, Embase, the Web of Science, and the Cochrane Library were searched for papers published before 23 July 2019. The methodological quality of the studies was analysed. Overlapping descriptors used in different studies to denote the same image finding were subsumed under a single CT feature. Sensitivity, specificity, and positive and negative likelihood ratios were pooled. A summary receiver operating characteristic curve (sROC) was constructed and the area under the curve (AUC) of the included studies was calculated when possible. RESULTS: Six studies were included and 17 CT features were analysed. The pooled sensitivity and specificity of smooth peritoneal thickening were 59% (95% CI: 52-66%) and 84% (95% CI: 79-88%), respectively. The AUC of smooth peritoneal thickening was 0.83. Omentum line/rim, lymph node necrosis or calcification, and mesenteric macro nodules had a pooled specificity ranging from 95% to 100% and a pooled sensitivity ranging from 12% to 67%. The other 12 signs had a pooled sensitivity ranging from 21% to 79% and a pooled specificity ranging from 19% to 81%. Omentum involvement (cake-like pattern) showed a threshold-effect, so only the AUC (=0.70) was calculated. CONCLUSIONS: Smooth peritoneal thickening shows fairly good diagnostic accuracy, while omentum rim/line, lymph nodes necrosis or calcification, mesenteric macro nodules have good specificity but limited sensitivity. The informative features summarised in this study may aid clinical practice and future studies.

Female Peritoneal Tuberculosis with Ascites, Pelvic Mass, or Elevated CA 125 Mimicking Advanced Ovarian Cancer: A Retrospective Study of 26 Cases.

This study aimed to summarise the clinical experience of peritoneal tuberculosis (TB). Clinical data of 26 patients admitted and diagnosed with peritoneal TB mimicking advanced ovarian cancer or peritoneal carcinoma between June 2008 and June 2017, was evaluated. The mean age was 35.92 ±15.30 years. The most common findings were abdominal mass (n=21, 80.77%) and elevated CA 125 levels (n=19, 73.08%). One patient underwent PET-CT and was diagnosed with peritoneal TB. Laparotomy was performed in 14 patients (70%) and laparoscopy in six patients (30%), out of whom two patients were converted to laparotomy due to severe adhesions. Meanwhile, mass puncture biopsy or small incision biopsy was the preferred method for diagnosing peritoneal TB, while PET-CT was considered as a good diagnostic method.

Differentiation of peritoneal tuberculosis from peritoneal carcinomatosis by the Omental Rim sign. A new sign on contrast enhanced multidetector computed tomography.

INTRODUCTION: Peritoneal TB (PTB) is the commonest presentation of abdominal TB. One of its close mimics is peritoneal carcinomatosis (PC). We present a new sign of PTB on contrast enhanced multidetector computed tomography (CT) called the Omental Rim (CT-OR) sign which helps to accurately differentiate PTB from PC. MATERIALS AND METHODS: A prospective study was performed from 2014 to 2018 on patients referred for CT at a tertiary referral hospital. The study group consisted of consecutive 85 patients, 52 men and 33women, with PTB. The control group consisted of 168 consecutive patients, 96 men and 72 women, with PC. The images were analysed for omental thickening and enhancement, peritoneal thickening and nodules, mesenteric thickening and nodules, presence, quantity, loculation and density of ascites, presence of nodes, bowel and other organ involvement as well as a new sign called the CT-OR sign. RESULTS: The CT-OR sign could identify 85% of patients with PTB. It was absent in 96% of patients with PC and was effective in ruling out PC (p < 0.001). The sign had a sensitivity of 85%, specificity of 96%, positive predictive value of 92%, negative predictive value of 93% and accuracy of 92%. CONCLUSION: The new CT-OR sign is a sensitive and specific sign for PTB. It helps to rule out majority of PC.

Common and uncommon imaging features of abdominal tuberculosis.

Despite the advances in the medical care, tuberculosis (TB) still remains an important health problem. This is particularly relevant to the developing countries as well as the immunocompromised population in the developed world. Multidrug resistance poses another challenge and may be responsible for increasing incidence of TB, to some extent. The respiratory system is the most commonly involved, although any organ system may be affected. Abdominal involvement occurs in 11-12% of the patients with extrapulmonary TB. The clinical features of abdominal TB are nonspecific. Imaging plays an important role in the diagnosis of abdominal TB. Although a few imaging features strongly favour the possibility of TB, abdominal TB is a greater masquerader. In this review, we highlight the entire spectrum of the manifestations of abdominal tuberculosis (excluding the genitourinary involvement) with an emphasis on imaging findings.

Tuberculosis Mimicking Disseminated Peritoneal Carcinomatosis of a Sigmoid Carcinoma.

BACKGROUND: A 76-year-old Moroccan patient with a medical history of sigmoid carcinoma suffered from weight loss of 15 kg and abdominal pain. Laparoscopy showed disseminated miliary peritoneal lesions, prima vista suspicious for disseminated peritoneal cancer spread. METHODS: Patient's medical history was reprocessed and compared to recent literature via PubMed. RESULTS: Pathological evaluation revealed granulomas and an infection with miliary intraabdominal tuberculosis (TB) was proven. CONCLUSION: Symptoms of TB may vary and findings can be misleading. An interdisciplinary approach is needed for diagnosis and treatment.

Tuberculous peritonitis following intestinal perforation in malignancy.

Tuberculous peritonitis is one of the most common causes of exudative ascites, especially in the young, and is an important cause of extra-pulmonary disease. However, tuberculous peritonitis is challenging to diagnose because there are no pathognomonic clinical features or imaging findings. Therefore, it is commonly misdiagnosed as another type of peritoneal disease, especially so in elderly patients with malignant disease. In this report, we described two cases of tuberculous peritonitis that were observed after intestinal perforation in elderly patients with malignancies. These diagnoses were established by laparoscopic peritoneal biopsy or AFB cultures of the ascitic fluid. Both patients were treated with anti-TB medications.