Atypical cutaneous tuberculosis with an unusual course.

Cutaneous tuberculosis represents the fifth extrapulmonary form in Morocco after pleural, lymph node, urogenital, and intestinal tuberculosis. It is recognized to form a continuous immunopathologic spectrum, ranging from a high intensity to a low intensity of cell-mediated immunity, which explains the multiplicity and heterogeneity of anatomo-clinical forms. Association of multiple forms in the same patient is really rare. In this regard, we report a case of scrofuloderma on axillary tuberculosis adenitis associated to a lupus vulgaris in an immunocompetent patient, which was confirmed by histology, QuantiFERON-TB Gold test, and polymerase chain reaction. He received an antituberculous therapy with clinical regression of the lesions. In conclusion, cutaneous tuberculosis is still endemic in developing countries.The diagnosis is difficult because of its clinical polymorphism. That's why it's should be suspected clinically in the presence of any destructive or verrucous skin lesion evolving without healing for a long period and confirmed by bacteriological examinations and histology.

Expression of Adenosine Deaminase and NLRP3 Inflammasome in Tuberculous Peritonitis and Their Relationship with Clinical Efficacy.

Objective: Tuberculous peritonitis (TP) can cause multiple infections of surrounding organs and tissues, leading to organ failure and endangering life safety. In this research, the relationship between adenosine deaminase (ADA), NLRP3 inflammasome, and TP and its clinical significance will be deeply explored, so as to provide new directions and reliable reference opinions for future clinical diagnosis and treatment. Methods: Altogether, 59 TP patients (research group, RG) and 52 non-TP patients (control group, CG) who were admitted to our hospital from May 2014 to June 2018 were regarded as research objects. Ascites samples of RG before treatment (admission) and one month after treatment and CG before treatment were obtained, and the ADA and NLRP3 levels were tested to evaluate the clinical and prognostic significance of the two in TP. Results: Before treatment, ADA and NLRP3 in RG were higher than CG (P < 0.05), and the sensitivity and specificity of combined detection of the two in predicting TP occurrence were 89.83% and 73.08% (P < 0.05). In addition, ADA and NLRP3 in RG patients were positively correlated with the disappearance time of abdominal pain and ascites (P < 0.05) and had excellent predictive effect on the adverse reactions during treatment (P < 0.05). After treatment, both in RG patients decreased, which was inversely proportional to the clinical efficacy (P < 0.05). Prognostic follow-up manifested that ADA and NLRP3 in relapse patients were higher than those without recurrence after treatment (P < 0.05). Conclusion: The increase of ADA and NLRP3 in TP is relevant to the adverse reactions during treatment, clinical efficacy, and prognosis recurrence after treatment. It can be used as a disease marker to confirm, intervene, and evaluate TP progression promptly.

The Clinical Utility of the Neutrophil-to-Lymphocyte Ratio as a Discriminatory Test among Bacterial, Mycobacterium Tuberculosis, and Nontuberculous Mycobacterium Peritoneal Dialysis-Related Peritonitis.

Background: Distinguishing Mycobacterium tuberculosis (TB) and nontuberculous Mycobacterium (NTM) from bacterial peritoneal dialysis (PD)-related peritonitis (peritonitis) is often very challenging and can lead to a significant delay in diagnosis and treatment. The neutrophil-to-lymphocyte ratio (NLR) is readily calculable and has been shown to be useful in differentiating pulmonary TB from bacterial pneumonia. We are the first group to demonstrate the predictive efficacy of peritoneal dialysate (PDE) NLR in distinguishing TB/NTM peritonitis from bacterial causes in the PD population. Methods: We retrospectively reviewed the clinical and laboratory characteristics of all patients with TB/NTM peritonitis, methicillin-sensitive Staphylococcus aureus (MSSA) peritonitis, and culture-negative peritonitis in our tertiary center between July 2000 and July 2020. The diagnostic ability of the blood and PDE NLR for differential diagnosis was evaluated. Results: In total, 258 episodes, 38 episodes, and 27 episodes were caused by MSSA, TB, and NTM species, respectively; 364 episodes were culture negative. The PDE NLR level taken at presentation were lowest in the TB peritonitis, followed by the NTM, culture-negative, and MSSA groups, (9.44±13.01, 16.99±23.96, 36.63±32.33, 48.51±36.01; P<0.001, respectively). The area under the receiver operating characteristic curve for the NLR taken at presentation was 0.83 (95% confidence interval, 0.77 to 0.89; P<0.001). A PDE NLR <15 was an optimal cut-off value with sensitivity, specificity, positive predictive value, and negative predictive values of 81%, 70%, 97%, and 22%, respectively. Conclusions: The PDE NLR obtained at presentation is a useful and easily accessible marker to discriminate TB/NTM peritonitis from bacterial peritonitis, especially in areas with intermediate TB/NTM burden. The NLR may enable early prompting of TB/NTM peritonitis, allowing specific investigation and treatment to be instigated earlier.

[Peritoneal tuberculosis in a postmenopausal woman with progressive ascites]. / Peritoneale tuberculose.

BACKGROUND: The non-specific symptomatology in peritoneal tuberculosis often results in a delay in the diagnosis. Due to clinical overlap symptoms may be confused with metastatic ovarian carcinoma. This can lead to delayed treatment, unnecessary surgical interventions and a deteriorated prognosis. CASE DESCRIPTION: A 75-year-old female of Moroccan descent was referred to the gastroenterology department with increasing ascites and weight loss. Based on the clinical picture metastatic ovarian cancer was suspected. However, repeatedly no malignant cells were found in both ascitic fluid and tissue biopsies. Peritoneal tuberculosis was considered and ovarian malignancy could not be excluded. A diagnostic laparoscopyand biopsy was considered necessary. The laparoscopic view was pathognomic for tuberculosis after which antituberculosis treatment was started with good result. CONCLUSION: Peritoneal tuberculosis should be included in the differential diagnosis in women from endemic areas with symptoms of abdominal pain, ascites, weight loss and/or increased CA-125. Laparoscopy should be considered if less invasive tests are inconclusive about the diagnosis.

Tuberculous peritonitis complicated by immunologic cerebral vasculitis.

A 53-year-old female was admitted with ascites for 3 weeks, decreased response, and weakness of right upper and lower limbs for 1 day. Peritoneal biopsy showed necrotizing granulomatous inflammation, and cartridge-based nucleic acid amplification test for tuberculosis (TB) of biopsy was positive without rifampicin resistance. Magnetic resonance imaging brain showed multiple foci of diffusion restriction in bilateral cerebral hemisphere and cerebellum, suggestive of acute infarcts. After ruling out the secondary causes of cerebral infarction by appropriate tests and demonstrating that there was no evidence for tuberculous meningitis or direct injury, it was concluded that the reason for multiple cerebral infarctions in this patient is likely to be immunologic injury secondary to TB. Multiple cerebral infarctions secondary to immunologic injury in TB were reported only once previously.

Fever, abdominal pain, and lymphocytic ascites in a young immigrant from western Africa.

Tuberculous peritonitis is an uncommon disease in countries with low tuberculosis (TB) incidence, most often affecting non-white race, foreign-born individuals. We describe a case of TB with peritoneal involvement in a 32-year-old man immigrated to Italy from Burkina Faso, who presented with a history of fever, malaise, abdominal pain and abdominal swelling. Due to its nonspecific clinical presentation and paucibacillary nature, diagnosis of tuberculous peritonitis can be challenging, and requires a high index of suspicion. This report highlights the diagnostic challenges posed by tuberculous peritonitis and emphasizes the importance of imaging (computed tomography, CT) in identifying typical findings, and the value of histological examination of tissue specimens from peritoneum or any site of suspected TB as a tool for diagnosis confirmation.

Jejunal multiple perforations for combined abdominal typhoid fever and miliary peritoneal tuberculosis.

Typhoid fever and tuberculosis, considered rare diseases in western countries, is still considered a notable problem of health issue in developing countries. The gastrointestinal manifestations of typhoid fever are the most common and the typhoid intestinal perforation (TIP) is considered the most dangerous complication. Abdominal localization of tuberculosis is the 6th most frequent site for extra pulmonary involvement, it can involve any part of the digestive system, including peritoneum, causing miliary peritoneal tuberculosis (MPT). This is the case report of a 4 years old girl with multiple jejunal perforations in a setting of contemporary miliary peritoneal tuberculosis and typhoid fever occurred in "Hopital Saint Jean de Dieu" in Tanguietà, north of Benin. The patient was admitted in the emergency department with an acute abdomen and suspect of intestinal perforation, in very bad clinical conditions, underwent emergency laparotomy. The finding was a multiple perforations of the jejunum in a setting of combined abdominal typhoid fever and miliary peritoneal tuberculosis. Typhoid intestinal perforations and peritoneal tuberculosis are a very rare cause of non-traumatic peritonitis in western country, but still common in developing country. Considering the modern migratory flux and the diffusion of volunteer missions all around the world, the western surgeon should know this pathological entities, and the best treatments available, well known by surgeons with experience of working in developing countries. The combination of both TIP and MPT in the same patient, is a very rare finding which can worsen the outcome of the patient itself.

Chylous ascites, anti-interferon-gamma autoantibody, and angioimmunoblastic T-cell lymphoma: a rare but intriguing connection over Mycobacterium avium.

We report a case of non-AIDS (acquired immunodeficiency syndrome), non-CAPD (Continuous Ambulatory Peritoneal Dialysis), non-cirrhotic, Mycobacterium avium peritonitis, which is a rare form of mycobacterial infection. A 66-year-old Japanese man who had been treated previously for angioimmunoblastic T-cell lymphoma (AITL), had developed disseminated M. avium infection. Antimycobacterial regimen improved his symptoms; however, following an interruption in treatment, he developed chylous ascites. The patient died of uncontrolled peritonitis despite intensive treatment. Anti-interferon-γ autoantibody was positive, and AITL was presumed to be involved in autoantibody production. A rare coexistence of chylous ascites, autoantibody, and AITL taught us an intriguing lesson on the pathogenesis of M. avium infection. Particularly, we conclude that treatment strategies for M. avium infection should aim to restore immunity.

Transvaginal natural orifice transluminal endoscopic surgery in the diagnosis of ascites of unknown origin.

BACKGROUND AND AIMS: Natural orifice transluminal endoscopic surgery (NOTES) has been established in animal models and human studies, but few clinical studies have investigated transvaginal NOTES in the diagnosis of unexplained refractory ascites. We aimed to assess the feasibility, efficacy, and safety of transvaginal NOTES for the diagnosis of unexplained ascites in female patients. METHODS: A prospective study was done involving 3 female patients with unexplained ascites. After general anesthesia and disinfection, a 1.0-cm incision was made in the posterior fornix of the vagina. A gastroscope was inserted into the abdominal cavity through the transvaginal incision and an artificial pneumoperitoneum was created; NOTES peritoneoscopy was performed to scrutinize the pathologic changes. Endoscopic biopsy specimens were obtained for pathologic examination. The transvaginal incision was closed by direct suturing. RESULTS: Transvaginal NOTES for diagnostic peritoneoscopy was successfully performed in 3 patients. The mean operative time was 61 minutes. The estimated blood loss was 5 to 10 mL. The pathologic diagnoses were tuberculosis for all patients, and the symptoms and ascites disappeared after antituberculosis therapy. During the 4-year follow-up, no clinically significant adverse events occurred in any patient after NOTES. No patient experienced an annex inflammation, vaginitis, dyspareunia, or sexual dysfunction. All patients were comfortable and satisfied with the nonscarring surgical procedure. CONCLUSIONS: Transvaginal NOTES for the diagnosis of unexplained ascites is feasible, effective, and safe. This method had no long-term effect on female sexual function and is particularly suitable for women who have special aesthetic requirements. (Clinical trial registration number: ChiCTR-TRC-10001053.).

Fitz-Hugh-Curtis syndrome associated with tuberculous salpingitis and peritonitis: a case presentation and review of literature.

BACKGROUND: Fitz-Hugh-Curtis syndrome or acute perihepatitis is considered a rare complication of pelvic inflammatory disease, mostly associated with chlamydial or gonococcal salpingitis. Peritoneal tuberculosis is a rare site of extra-pulmonary infection caused by Mycobacterium tuberculosis. Infection usually occurs after reactivation of latent tuberculous foci in the peritoneum and more seldom after contiguous spread from tuberculous salpingitis. CASE PRESENTATION: We describe a case of a 21-year old female of Somalian origin diagnosed with Fitz-Hugh Curtis syndrome associated with tuberculous salpingitis and peritonitis, presenting with new onset ascites. Acid fast stained smear and polymerase chain reaction for Mycobacterium tuberculosis on ascitic fluid, endocervical culture and tuberculin skin test were all negative. Eventually, the diagnosis was made laparoscopically, showing multiple peritoneal white nodules and perihepatic "violin string" fibrinous strands. CONCLUSIONS: To our knowledge, this is the first case where Fitz-Hugh-Curtis syndrome is associated with both peritoneal and genital tuberculosis and where ascites was the primary clinical finding. Female genital tuberculosis has only rarely been associated with Fitz-Hugh-Curtis syndrome and all cases presented with chronic abdominal pain and/or infertility. Ascites and peritoneal involvement was not present in any case. Moreover, most patients with Fitz-Hugh-Curtis syndrome show no evidence of generalized intra-abdominal infection and only occasionally have concomitant ascites.