Tuberculous peritonitis in patients on peritoneal dialysis: a 35-year experience from a large medical center in Northern Taiwan.

INTRODUCTION: Tuberculous peritonitis (TBP) is a rare but fatal complication in patients on peritoneal dialysis (PD). In this study, we aimed to determine the demographic features, clinical features, laboratory parameters, and clinical outcomes of PD patients with TBP and to clarify possible risk factors for mortality. MATERIALS AND METHODS: We retrospectively reviewed 2084 PD patients from January 1985 to December 2019. The diagnosis of TBP was established by positive peritoneal fluid culture for Mycobacterium tuberculosis. RESULTS: 18 patients were diagnosed with TBP. The incidence was 2.029 episodes per 1000 patient-years. The most common symptom was fever (94.4%), followed by cloudy effluent (83.3%) and abdominal pain (83.3%). The average peritoneal dialysis effluent (PDE) white blood cell (WBC) count was 172.7 cells/µL. Nine patients (50%) had WBC counts lower than 100 cells/µL and 13 patients (72.2%) had neutrophilic predominant WBC counts. Acid fast stain (AFS) was positive in 7 patients (38.9%). Only 2 patients (11.1%) continued with PD after TB infection, while 10 patients (55.6%) changed to hemodialysis. Seven patients (38.9%) died within 1 year. Significant differences were observed in sex (p = 0.040), the presence of diabetes mellitus (p = 0.024), and PD catheter removal (p < 0.001) between TBP patients with and without mortality. However, none of them was a significant factor for 1-year mortality in multivariate Cox regression model. CONCLUSION: Physicians should pay attention to the unusual presentations of peritonitis, especially if symptoms include fever or an initial low PDE WBC count. Catheter removal is not mandatory if early diagnosis and appropriate therapy are available.

Mycobacterium tuberculosis peritonitis in peritoneal dialysis patients: A scoping review.

BACKGROUND: The clinical syndrome of Mycobacterium tuberculosis (M. tuberculosis) peritoneal dialysis (PD) peritonitis is poorly understood. Whether local tuberculosis (TB) patterns modify the clinical syndrome, and what factors associate with poor outcomes is also unknown. METHODS: A scoping review identified published cases of TB PD peritonitis. Cases from low- and high-TB burden areas were compared, and cases that did or did not suffer a poor clinical outcome were compared. RESULTS: There were 216 cases identified. Demographics, presentation, diagnosis, treatment and outcomes were described. Significant delays in diagnosis were common (6.1 weeks) and were longer in patients from low-TB burden regions (7.3 vs. 3.7 weeks). In low-TB burden areas, slower diagnostic methods were more commonly used like PD fluid culture (64.3% vs. 32.7%), and treatment was less likely with quinolone antibiotics (6.9% vs. 34.1%). Higher national TB incidence and lower GDP per capita were found in cases that suffered PD catheter removal or death. Diagnostic delays were not longer in cases in which a patient suffered PD catheter removal or death. Cases that suffered death were older (51.9 vs. 45.1 years) and less likely female (37.8% vs. 55.7%). Removal of PD catheter was more common in cases in which a patient died (62.0% vs. 49.1%). CONCLUSIONS: Outcomes in TB PD peritonitis are best predicted by national TB incidence, patient age and sex. Several unique features are identified to alert clinicians to use more rapid diagnostic methods that might enhance outcomes in TB PD peritonitis.

Non-tuberculous and tuberculous mycobacterial peritonitis in peritoneal dialysis patients.

INTRODUCTION: Peritoneal dialysis (pd)-associated mycobacterium peritonitis is an important clinical entity in patients with end stage renal disease. They present a significant diagnostic and therapeutic challenge for clinicians because clinical findings and laboratory investigations can not be differentiated from symptoms caused by non-tuberculous mycobacterium (ntm), Mycobacterium tuberculosis (tb) or other bacteria. The aim of the present article is to know the differences between the clinical manifestations and laboratory investigations, the appropriate diagnosis, treatment strategies and prognosis for tb and ntm disease in patients with pd-associated mycobacterial infections. METHODS: This was a retrospective observational study conducted over a period of 25 years. Out of 1737 patients, only 7 were diagnosed with mycobacterial peritonitis. RESULT: Evaluable data showed that there were three patients diagnosed with ntm peritonitis and four patients with tuberculous peritonitis. The mean age of the patients was 53.9 ± 11.8 years. Although all patients developed abdominal pain and cloudy dialysate, only four patients (57.1%) had fever. Two patients (28.6%) suffered severe sepsis and septic shock. Therefore, the patient survival rates for ntm and tuberculous peritonitis were 100.0% and 75.0%, respectively. Two patients were shifted to long-term hemodialysis; therefore, the technical survival rates for ntm and tuberculous peritonitis were 66.7% and 50.0%, respectively. Notably, recurrence of mycobacterial infection was found in one patient with both pulmonary tuberculosis and tuberculous peritonitis. CONCLUSION: The diagnosis of mycobacterial peritonitis remains a challenge to medical staffs because of its insidious nature, the variability of its presentation and the limitations of available diagnostic test.

Tuberculous peritonitis during pegylated interferon plus ribavirin combination therapy in a patient with chronic hepatitis C.

A woman in her 70s with fever and abdominal distension was referred to our hospital for investigation. She had just finished a course of pegylated interferon and ribavirin combination therapy for chronic hepatitis C. Abdominal computed tomography revealed peritoneal thickening and ascites. QuantiFERON(®)-TB Gold was positive, ascitic adenosine deaminase was high, and fluorine-18-fluorodeoxyglucose positron emission tomography (FDG-PET) showed diffuse accumulation in the peritoneum. Although these findings suggested tuberculous peritonitis, we did not detect Mycobacterium tuberculosis in any bacterial cultures, ascites, or other specimens. However, laparoscopic peritoneal biopsy demonstrated a large number of miliary white nodules in the parietal and visceral peritonea. Pathological examination of these nodules revealed epidermoid granuloma with giant Langhans' cells and caseous necrosis. Finally, the diagnosed of tuberculous peritonitis was established. It is important to consider tuberculosis in patients presenting with new symptoms while receiving interferon therapy.

Mycobacterium abscessus peritonitis associated with laparoscopic gastric banding.

BACKGROUND: Mycobacterium abscessus is a rapidly growing Mycobacterium that is a common water contaminant in the environment. We report a case of M. abscessus infection with band erosion following laparoscopic gastric banding. CASE PRESENTATION: A 34-year-old woman developed insidiously progressing abdominal distension over a period of 1 year associated with abdominal pain, fatigue, night sweating and anorexia 4 years after laparoscopic gastric banding for obesity. Investigation revealed significant ascites with caseating granuloma in peritoneal biopsies from which M. abscessus was isolated. Band erosion with infection and multiple abdominal adhesions were confirmed during laparoscopic removal of the gastric band. To the best of our knowledge, this is the first reported case of M. abscessus infection after laparoscopic gastric banding surgery. We discuss the possible sources of infection, its indolent presentation, and therapeutic challenges. CONCLUSION: It is important to consider environmentally acquired infection in patients with signs and symptoms of infection in the presence of surgical prosthesis.

Rapid T-cell-based immunodiagnosis of tuberculous peritonitis in a peritoneal dialysis patient.

Tuberculous peritonitis is a rare complication during peritoneal dialysis (PD). This report presents the case of a patient with clinical signs and symptoms indicative of bacterial peritonitis, but without culture growth of conventional bacteria or fungi. Cytokine flow cytometry after overnight stimulation of cells from peripheral blood and the peritoneal dialysate with Mycobacterium tuberculosis (MTB)-specific antigens revealed a 40-fold increase in MTB-specific CD4 + T cells expressing interferon-γ (IFN-γ) in peritoneal fluid compared with blood, which was indicative of active tuberculosis (TB). The presence of TB was later confirmed by polymerase chain reaction and growth of MTB in culture of the dialysate. The case illustrates the usefulness of MTB-specific immunodiagnosis for the rapid identification of peritoneal TB in PD patients.

[Peritoneal tuberculosis and HIV infection in adults: 32 cases in Lome (Togo)]. / Tuberculose péritonéale et infection par le VIH de l'adulte: 32 observations à Lomé (Togo).

The purpose of this prospective study is to describe a series of adult HIV-infected patients treated for peritoneal tuberculosis over a 36-month period in Lome, Togo. A total of 32 cases were included. Mean patient age was 38 years (range, 20 to 69). The M/F sex ratio was 0.52. Ascites with fever was observed in all cases. Ascitic fluid was exsudative in 10.6% of cases and lymphocytic in 93.7%. Peritoneal tuberculosis was isolated in 27 patients, associated with pleural involvement in 15.6 % of cases, hematological in 75% and hepatic in 21.9%. Patients responded poorly to therapy and prognosis was unfavorable with a mortality rate of 12.5%. HIV infection substantially alters the epidemiological, clinical and therapeutic profile of peritoneal tuberculosis.

[Tuberculous peritonitis in HIV-infected patients]. / Peritonitis tuberculosa en pacientes infectados por el virus de la inmunodeficiencia humana.

UNLABELLED: In order to describe the clinical and laboratory findings of Mycobacterium tuberculosis peritonitis M. tuberculosis in HIV+ patients, we conducted a retrospective analysis of the medical records of HIV+ patients with isolation of M. tuberculosis from ascitic fluid (AF), assisted at Hospital Muñiz, Buenos Aires, Argentina (1996-2005). RESULTS: 21 patients were included. Median age: 33, male sex: 52%; peripheral blood CD4-T lymphocyte count (median): 85/mm3; prior history of tuberculosis: 40%; cirrhosis: 65%; enolism: 45%; HCV coinfection: 85%. The most frequent symptoms were abdominal distension (71%), fever (62%) and abdominal pain (19%). The chemical characteristics of the AF were (median): leukocyte count: 751/mm3 (mononuclear predominance: 79%), protein: 3.1 g/dl, LDH: 351 IU/l. AF samples positive for acid fast bacilli at direct microscopic examination: 14%. Infection with multidrug resistant M. tuberculosis (TB-MR): 20%. M. tuberculosis was isolated from other clinical samples in 79%. Fifteen patients received treatment for tuberculosis; in 30% of cases, it was not appropriate due to the susceptibility of the isolated strain. Overall mortality was 66.4%. CONCLUSION: high mortality was observed, which may be attributable to the high frequency of TB-MR, the level of immunosuppression and the prevalence of cirrhosis secondary to enolism and/or HCV coinfection.

[Ratio of serum levels of 1,25-dihydroxyvitamin D3 and parathyroid hormone for the diagnosis and treatment of tuberculous peritonitis in a chronic kidney disease patient: a case report].

An 80-year-old man was admitted to our hospital because of exacerbation of preexisting chronic kidney disease (CKD). On admission, he showed elevated levels of serum creatinine (6.37 mg/dL) and corrected calcium (13.7 mg/dL). Although the serum levels of intact parathyroid hormone (I-PTH) and parathyroid hormone-related peptide(PTITH-rP)were low, the serum 1,25-dihydroxyvitamin D3 (1,25 (OH)2D3)levels were high. Computed tomography (CT) revealed ascites, and the ascitic fluid was exudative and serous with predominance of lymphocytes. The levels of adenosine deaminase (ADA) in the ascitic fluid were also elevated, and the results of QuantiFERON-TB2G (QFT-2G)assay were positive, indicating tuberculous peritonitits. Ascites resolved rapidly after initiation of the antituberculosis therapy. The elevated levels of serum calcium and 1,25 (OH) 2D3 returned to below-normal levels; however, serum i-PTH levels increased from 8.9 pg/ mL to 432 pg/mL. Diagnosis of extrapulmonary tuberculosis is often difficult in CKD patients. CKD patients show abnormal vitamin D activation, so these patients usually have low levels of serum 1,25(OH)2D3. On the other hand, in our patient, 1,25(OH)2D3 was extrarenally produced from tuberculous granuloma and therefore, he showed high levels of serum 1,25(OH)2D3 and correspondingly, low levels of serum i-PTH. We observed that the ratio of 1,25 (OH) 2D3:i-PTH decreased due to antituberculosis therapy. This ratio facilitated the diagnosis and evaluation of treatment for this condition.

[Miliary tuberculosis and tuberculous peritonitis during infliximab treatment for rheumatoid arthritis].

A 55-year-old woman treated with infliximab for rheumatoid arthritis was admitted due to progressive ascites. A CT scan showed massive ascites, bilateral pleural effusion, disseminated granular shadows in the lung, and multiple swollen mediastinal lymph nodes. A FDG-PET/CT scan showed increases of FDG uptake in the mesentery and peritoneum, mimicking peritoneal carcinomatosis. Subsequent pleural and peritoneal fluid analysis showed elevated adenosine deaminase activity levels with no malignant cells. A right pleural biopsy specimen revealed Langhans giant cells and granulomas. Finally, a diagnosis of miliary tuberculosis was established because cultures of the sputum and gastric fluid were positive for Mycobacterium tuberculosis. Several weeks after a standard anti-tuberculosis regimen with 4 drugs was initiated, her clinical condition and radiological findings ameliorated. Since the initial manifestations of tuberculosis tend to be more severe during treatment of rheumatoid arthritis with tumor necrosis factor-alpha inhibitors such as infliximab due to immune suppression, we should pay closer attention to the possibility of tuberculosis infection in these patients.

Peritoneal tuberculosis and granulomatous hepatitis secondary to treatment of bladder cancer with Bacillus Calmette-Guérin.

Intravesical administration of Bacillus Calmette-Guérin is used as a treatment method in superficial bladder cancer. While it is generally well tolerated, serious side effects may develop. Granulomatous hepatitis cases have been previously reported; however, only one case with tuberculous peritonitis exists in the current literature. We hereby present two cases, one of which is the second tubercular peritonitis case following Bacillus Calmette-Guérin treatment to be reported, and the other a case with granulomatous hepatitis. Complete cure was achieved in both cases with specific therapy. In the patient who developed peritonitis, intravesical Bacillus Calmette-Guérin therapy was recommenced after antituberculosis treatment, and completed without further complications.

Tuberculous peritonitis.

Compared with the general population, dialysis patients are at higher risk of acquiring mycobacterial infections. The aim of the present article is to review case reports and studies published since the report by Talwani and Horvath (2000) and to discuss the main problems that arise in daily practice. After a comprehensive review of the literature, cumulative data about peritoneal dialysis and peritoneal tuberculosis from reports of 98 patients in 21 papers were analyzed. The clinical and laboratory findings of peritoneal tuberculosis are nonspecific. Diagnosis requires a high index of suspicion. The most difficult cases present as culture-negative peritonitis or culture-positive peritonitis resistant to appropriate antibiotics without any additional clues of tuberculosis. The sensitivity of smears and cultures can be enhanced by centrifuging a 50 - 150 mL dialysate sample.

[Tuberculous peritonitis in peritoneal dialysis]. / Peritonitis tuberculosa en diálisis peritoneal.

We report a patient in Automatic Peritoneal Dialysis (APD) with tuberculous peritonitis by possible peritoneal infection due to the proximity between fallopian tube and the left ovary, a peritoneal liquid culture was constantly negative. The patient presented a bad clinic evolution. Her only medical history was hypercalcemia six months before developing a peritonitis and occasionally nausea and vomits To confirm the diagnosis it was needed a peritoneal biopsy by means of a laparoscopy with a removal of the peritoneal catheter and left anexectomy. Now, the patient is asintomatic in daily home hemodialysis.

Tuberculous peritonitis during infliximab therapy.

Reactivation of tuberculosis is a severe side effect of anti-TNF treatment. Especially extrapulmonary forms of tuberculosis may occur, which are difficult to diagnose. The diagnosis may be obtained by a thorough search for Mycobacterium tuberculosis. We describe two patients who developed tuberculous peritonitis after infliximab therapy that was prescribed for treatment of rheumatoid arthritis. These cases illustrate that tuberculous peritonitis has a nonspecific clinical manifestation and that Mycobacteria can be difficult to find in ascites fluid. For this reason, tuberculostatic therapy has to be started in case of clinical suspicion. Before starting infliximab therapy, the patient must be thoroughly screened for the presence of (latent) tuberculosis.

[Peritoneal tuberculosis as a complication in a case of unclassifiable myelodysplastic/myeloproliferative disease]. / Tuberculosis peritoneal como complicación en un caso de síndrome mielodisplásico/mieloproliferativo inclasificable.

We report the case of a 68-year-old male with a diagnosis of unclassifiable myelodysplatic/myeloproliferative disease (WHO classification), under prolonged steroid treatment and unsuccesful chemotherapy response, who developed progressive asthenia, thoracic pain, minimal efforts dyspnea, and abdominal distension, that initially was suspicious of splenic rupture. Exploratory laparotomy showed multiple peritoneal implants, and a diagnosis of peritoneal tuberculosis was obtained from local biopsy. Definitive diagnosis included a positive result to culture and PCR urine test, together with a possible pleural and splenic tuberculous affectation. Response to tuberculostatic treatment was successful. To the best of our knowledge, this is the first reported case with such characteristics.

[Intestinal tuberculosis of the terminal ileum causing obstructive ileus and tuberculous peritonitis and presenting numerous peritoneal small red nodules: a case report].

A 38-year-old woman suffering from lower abdominal pain was referred to our hospital. Abdominal computed tomography showed marked thickening of the terminal ileum to the cecum, localized collection of ascites, and multiple mesenteric lymphadenopathy. A barium contrast small bowel series showed solitary severe stenosis of the terminal ileum with marked swelling of the ileocecal valve, where colonoscopy could not pass through, suggesting that ileal stenosis was caused by intestinal tuberculosis. She also showed strongly positive tuberculin skin test. Laparoscopy-assisted ileocecal resection was performed for confirmation of diagnosis and removal of the stenotic intestinal lesion. Laparoscopically, numerous small red nodules scattered on the stenotic ileal serosa, peritoneum, and mesenterium. Histopathological examination revealed ileal tuberculosis causing ulcerative stricture, and mesenteric tuberculous lymphadenitis. The small red nodules were formed of hemorrhagic tuberculous nodules.

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.

Pulmonary and peritoneal tuberculosis in a CAPD patient.

Patients with chronic renal failure have an increased incidence of tuberculosis due to decreased cellular immunity. More than half of the tuberculosis infection in these patients presented with extrapulmonary involvement. Tuberculous peritonitis is an important problem in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). Simultaneous pulmonary and peritoneal tuberculosis is a very rare condition. We describe a 39-year-old man with culture negative CAPD peritonitis. In spite of conventional antimicrobial therapy the patient had persistent fever, weight loss, and night sweats. Approximately after one month from starting treatment, both sputum specimen and peritoneal fluid were positive for mycobacterium. Quadruple therapy for tuberculosis has been started. The response to treatment was promptly. He is still on treatment for six months and receiving CAPD. Tuberculous peritonitis should always be considered when patients on CAPD develop culture negative peritonitis treated with conventional antibiotics without improvement. In addition, the existence of extraperitoneal tuberculosis, especially pulmonary disease must be investigated.