Abdominopelvic tuberculosis mimicking advanced ovarian cancer and pelvic inflammatory disease: a series of 28 female cases.

OBJECTIVE: To present and discuss 28 female cases with abdominopelvic tuberculosis (TB) and abnormal CA125 levels to better distinguish this disease from advanced ovarian cancer (AOC) and pelvic inflammatory disease (PID). Abdominopelvic tuberculosis (APTB) is one of the extrapulmonary tuberculosis (TB) sites, usually misdiagnosed as AOC and PID and then has to undergo surgery. However, the treatment of APTB is totally based on medical therapy other than surgery except biopsy. This article aims to present and discuss 28 female APTB cases with abnormal CA125 levels to better distinguish this disease from AOC and PID so as to find out non-invasive APTB diagnosis methods. METHODS: 28 APTB patients diagnosed between January 2000 and January 2010 in our gynecologic department of Nanjing Jinling hospital were reviewed retrospectively and compared with AOC and PID. RESULTS: The mean age was 38.24 ± 11 (range 15-64) years. Elevated levels of serum CA125 were determined in all 28 patients (100%). Other common findings were ascites in 20 (71.43%, 20/28), pelvic mass in 21(75%, 21/28), slight fever with night sweat in 13 (46.43%, 13/28), cough and pleural effusion in nine (32.14 %, 9/28), high fever more than 39 °C combined with abdominal pain and elevated white blood count in five (17.86%, 5/28), weight loss more than 5 kg at admission in six (21.43%, 6/28). Diagnoses were made based on biopsy from laparotomy in 14 (50%) patients, from laparoscopy in nine (32.14%), from diagnostic curettage because of primary infertility in two (7.14%), and only from clinical suspicion in three patients. Histopathology revealed that caseating granulomatous lesions were seen in 25 patients, positive anti-acid staining in 11 patients. Totally 26 patients completed anti-TB therapy successfully and were cured, two patients died of the disease because of long-term immune inhibitor used. CONCLUSION: Although it is difficult to exactly distinguish APTB from AOC and PID without operation, it is important because the treatment of APTB is totally based on medical therapy other than surgery. Some difference may be found out if clinical manifestation, physical examination, laboratory tests and imaging findings are carefully analyzed to avoid unnecessary extensive surgery and improve the prognosis.

Extrapulmonary tuberculosis: 7 year-experience of a tertiary center in Istanbul.

BACKGROUND: Although a decreasing trend of tuberculosis (TB) was reported in Turkey, higher proportion of extrapulmonary tuberculosis (EPT) was revealed. MATERIAL AND METHODS: In this retrospective study, clinical and laboratory data of 141 EPT patients were evaluated for a seven-year period by using descriptive statistics, and parametric and non-parametric tests where appropriate. RESULTS: The most frequent types of EPT were meningeal TB (23%) and TB lymphadenitis (21%), respectively. Other types of EPT were skeletal, miliary, peritoneal, abscess, genitourinarial, cutaneous and gastrointestinal involvement which ranged between 18% and 1%. Mean age was 42 and female/male ratio was almost equal. All patients were born in Turkey. Although all of them were permanent residents of Istanbul, 73% of the patients came from East and Southeast Region of Turkey. For the patients, being older than 40 years old (p<0.01), having miliary TB (p<0.05) and high CRP levels (p<0.05) were found to be associated with mortality. CONCLUSIONS: EPT still remains as a significant morbidity and mortality reason in lower income populations and developing countries. In our study, although all patients were residents of Istanbul approximately two thirds of them have migrated from East and Southeast parts of the country. The relatively high prevalence of tuberculosis cases in Istanbul may be due to the permanent migration from other parts of the country. Early diagnosis and initiation of appropriate treatment are the keys for reducing morbidity and mortality in patients with EPT, particularly in the cases of older ages.

Tuberculous peritonitis-associated mortality is high among patients waiting for the results of mycobacterial cultures of ascitic fluid samples.

We identified 60 cases of tuberculous peritonitis during the past 12 years at our health care center. Most of the patients had severe underlying medical conditions, such as cirrhosis, renal failure, diabetes mellitus, and malignancy. Abnormal chest radiograph findings, ascitic fluid lymphocytosis, and biochemical findings for exudates could only identify 33%, 37%, and 53% of the cases, respectively. On the other hand, peritoneal biopsy allowed early definitive diagnosis for 9 patients. Thirty-one patients died, 26 of whom died < or =6 weeks after their initial presentation, often before the result of mycobacterial culture was available. Only 8 patients died of advanced disease after antituberculous therapy was started. Univariate analysis showed that advanced age, underlying diagnosis, and delayed initiation of therapy were associated with higher mortality rates. Standard antituberculous chemotherapy is highly effective. However, conventional microbiologic diagnostic methods are slow and not sensitive enough for establishing a diagnosis of tuberculous peritonitis.

Tuberculosis infection in Chinese patients undergoing continuous ambulatory peritoneal dialysis.

A retrospective study of the prevalence and pattern of tuberculosis in patients undergoing continuous ambulatory peritoneal dialysis (CAPD) was performed. Thirty-eight cases of tuberculosis were diagnosed among 790 patients (18 men, 20 women; mean age, 58 +/- 12.6 years) between July 1994 and June 2000. The interval between the initiation of CAPD and onset of tuberculosis ranged from 1 to 168 months (median, 22 months). There were 18 cases of pulmonary tuberculosis, 14 cases of tuberculous peritonitis, 5 cases of tuberculous lymphadenitis, and 1 case of tuberculous synovitis. Patients with pulmonary tuberculosis usually presented with fever, constitutional symptoms, and pleural effusion or pulmonary infiltrates on chest radiograph. Abdominal pain and turbid dialysate were the main presenting symptoms in patients with tuberculous peritonitis. Diagnosis was established by positive culture in 20 patients, typical histological characteristics on a tissue biopsy specimen in 10 patients, and response to empirical antituberculous treatment in 8 patients. The duration of symptoms before the diagnosis of tuberculosis and initiation of antituberculous treatment ranged from 7 to 57 days (median, 30 days). Antituberculous treatment consisted of isoniazid, rifampicin, pyrazinamide, and ofloxacin for 9 to 15 months. Antituberculous treatment generally was well tolerated. Twenty-seven patients (71%) completed antituberculous treatment. No recurrence of tuberculosis was observed after a mean follow-up of 19.8 months. Eleven patients (29%) died while on antituberculous treatment; none of the deaths appeared to be directly caused by tuberculosis. We conclude that: (1) tuberculosis is prevalent among CAPD patients in our locality; (2) extrapulmonary tuberculosis, particularly tuberculous peritonitis, is common; and (3) a high index of suspicion for tuberculosis among CAPD patients is warranted to ensure early diagnosis and prompt initiation of treatment.

Optimal treatment and long-term outcome of tuberculous peritonitis complicating continuous ambulatory peritoneal dialysis.

A retrospective study of the treatment and short- and long-term outcomes of tuberculous peritonitis (TBP) complicating continuous ambulatory peritoneal dialysis (CAPD) among our dialysis patients over a 6-year period was performed. Ten cases of TBP complicating CAPD were identified among 601 dialysis patients between January 1988 and December 1994. There were four male and six female patients. The most common clinical features were abdominal pain, fever, and cloudy peritoneal fluid (PDF). Two patients had concurrent bacterial peritonitis. Extraperitoneal tuberculosis was not observed. The majority of the patients showed neutrophil predominance in the PDF. Only one patient had a positive acid-fast bacilli smear of the PDF. The acid-fast bacilli culture of the PDF was positive in all patients. The patients were treated with isoniazid, rifampicin, and pyrazinamide for 9 to 12 months (mean, 11 months). Continuous ambulatory peritoneal dialysis was continued in all patients. Two patients died, one from multiorgan failure at 2 months and the other from sudden cardiac death at 9 months. Two patients were converted to hemodialysis at 3 months. Six patients continued to receive CAPD after completion of the antituberculous treatment. Four of these six patients were still alive 5 years after the TBP. Three patients were still undergoing CAPD with satisfactory ultrafiltration and solute clearance. None of the patients developed relapse of TBP. We concluded that (1) TBP is a rare but important complication of CAPD, (2) removal of the Tenckhoff catheter is not mandatory in the management of TBP complicating CAPD, and (3) long-term continuation of CAPD is possible after TBP.

[Gastrointestinal tuberculosis. 10 years experience in a surgical university clinic]. / Gastrointestinale Tuberkulose. 10 Jahre Erfahrung einer chirurgischen Universitätsklinik.

Between 1982 and 1992 a total of 38 patients were treated for primary peritoneal tuberculosis in the medical faculty Cerrapasah, University of Istanbul. Ten patients were operated on as emergency cases because of bowel obstruction, the remaining 28 had elective procedures. Seven patients had a diagnosis made laparoscopically, 31 with a laparotomy. In the latter group 13 patients underwent a laparotomy with biopsy without any morbidity or mortality. On the other hand there was no morbidity or mortality after laparoscopic diagnosis and these patients had an average admission time of 3.5 days. The morbidity and mortality rates of the entire laparotomy group were 6.4 and 3.2% respectively. And the average length of admission was 13.6 days. In view of our results we would favour laparoscopy as the best diagnostic method for intraabdominal tuberculosis in patients with unspecific abdominal pain and no endoscopically proven cause.

Tuberculous peritonitis: a study comparing cirrhotic and noncirrhotic patients.

Tuberculous peritonitis is a rare disease, which often goes unrecognized because of the subtle clinical clues and its insidous onset. We retrospectively analyzed the records of 37 cases of tuberculous peritonitis diagnosed over a 15-year period, and compared the clinical and diagnostic features of cirrhotic and noncirrhotic patients. In cirrhotic patients, tuberculous peritonitis can simulate ascites from liver disease or spontaneous bacterial peritonitis. The diagnosis is difficult in these patients because the ascitic fluid may not be of the exudative type as a result of the low albumin level in serum, and lymphocytes do not predominate in all cases. Adenosine deaminase (ADA) activity in ascitic fluid was elevated (higher than 40 U/L) in all 11 patients (four patients with hepatic cirrhosis). The time required to achieve a correct diagnosis was significantly longer in cirrhotic than in noncirrhotic patients. The overall mortality was 13%, with deaths occurring exclusively among cirrhotic patients. We emphasize that tuberculous peritonitis in cirrhotic patients can present an atypical picture. A considerable element of suspicion is necessary.

Tuberculous peritonitis: 43 years' expereince in diagnosis and treatment.

The clinical course of 70 patients with tuberculous peritonitis seen over a 43 year period has been reviewed. Thirty-seven patients were diagnosed prior to the advent of anti-tuberculous chemotherapy and 33 after. Clinical manifestations remained unchanged over the period of study. Abdominal pain (93%), fever (63%), gastrointestinal upset (60%), weight loss (60%), and ascites (59%) continue to be the most common findings. Females outnumbered males 2:1. In 89% of patients the duration of symptoms prior to diagnosis was a week or longer, and in 47% it was longer than a month. Diagnosis was confirmed by histologic examination of intra-abdominal tissue in 44% of cases, by clinical suspicion with an extraperitoneal site of tuberculosis in 29%, by bacteriology of peritoneal fluid in 24%, and by autopsy alone in 3%. An extraperitoneal site of tuberculsis was present in 83% of patients. The importance of obtaining a definitive diagnosis, and of instituting immediate antimicrobial therapy is emphasized by the mortality of 49% in the pre-antibiotic era, and of 7% in patients receiving anti-microbial therapy. The conclusions from this review are that: 1) with suggestive clinical manifestations and bacteriologic proof of active tuberculosis anywhere in the patient, operation is not mandated; 2) in the presence of the above clinical manifestations, and in the absence of definitive bacteriologic proof, exploratory laparotomy is indicated for diagnostic purposes; 3) antituberculous chemotherapy is highly effective, and is the treatment of choice.