Incidental detection of disseminated peritoneal tuberculosis-varied presentation.

BACKGROUND: Incidental peritoneal tuberculosis represents an uncommon variety of peritoneal tuberculosis and surgeons must be aware of this entity particularly in tuberculosis endemic zones. METHODS: We prospectively analysed cases of incidental peritoneal tuberculosis detected during surgery over a period of last six months. RESULTS: We herein describe three such cases of incidental peritoneal TB detected during surgical exploration for other reasons. CONCLUSION: Diagnosis of disseminated peritoneal tuberculosis often remains a challenging task owing to its non specific clinical presentation and difficulty arises on seeing such a picture intraoperative and raises a question whether to proceed with the decided surgery or not. Frozen section can help in guiding further management but it is not definitive.

Massive infected ascites in an immunocompetent patient with gastrointestinal tuberculosis.

Mycobacterium tuberculosisis highly endemic in the Philippines. The diagnosis is challenging with its non-specific presentation and the organism could extend to any of the organs. Interestingly, bacterial peritonitis arising spontaneously from gastrointestinal tuberculosis (TB) in an otherwise healthy, non-cirrhotic patient is quite unusual. In this paper, we discuss the case of a 27-year-old HIV-seronegative woman with massive intraperitoneal mixed bacterial and tuberculous abscess presenting 20 months after being diagnosed with bacteriologically confirmed gastrointestinal TB. Repeated large-volume paracentesis was done to drain out the infected ascites instead of inserting a percutaneously implanted catheter. Clinical improvement was noted and she was discharged after 12 days of intravenous antibiotics. She had completed 6 months of antituberculosis therapy and been well since then. The case has demonstrated that repeated paracentesis along with appropriate antibiotic regimen, may be a viable option for patients with TB and bacterial coinfected peritonitis. And possibly, peritoneal TB may increase the risk for (spontaneous) bacterial peritonitis.

Tuberculosis peritoneal. Diagnóstico diferencial con carcinomatosis de origen ovárico / Peritoneal tuberculosis. Differential diagnosis with ovarian carcinomatosis

Mujer de 35 años, con antecedente de espondilitis anquilosante en tratamiento con antifactor de necrosis tumoral. Consulta por dolor abdominal, náuseas, vómitos, deposiciones semilíquidas, anorexia y pérdida de 5 kg en un mes. Analíticamente, presenta elevación del CA 125 y de la proteína C reactiva,y la tomografía computarizada informa de un pequeño derrame pleural derecho, engrosamiento peritoneal, ascitis leve y engrosamiento parietal del intestino delgado, todo ello compatible con carcinomatosis peritoneal. El Mantoux fue negativo. En la laparotomía exploradora se observa siembra miliar abdominal con abundantes adherencias. La anatomía patológica informó de peritonitis granulomatosa con necrosis caseosa, indicativa de tuberculosis miliar peritoneal (AU)

A 35-year-old woman with previous ankylosing spondylitis treated with anti-tumor necrosis factor presented with abdominal pain, nausea, vomiting, semiliquid stools, anorexia and weight loss of 5 kg in a month. A blood test showed an increase of CA 125 and C-reactive protein, and a computed tomography scan showed a small right pleural effusion, peritoneal thickening, mild ascites, and thickening of the small intestine wall, compatible with peritoneal carcinomatosis. The Mantoux test was negative. The exploratory laparotomy showed abdominal miliary seeding with abundant adhesions. Pathological analysis revealed granulomatous peritonitis with caseous necrosis, suggestive of miliary peritoneal tuberculosis(AU)

Unmasking tuberculosis-associated immune reconstitution inflammatory syndrome in HIV-1 infection after antiretroviral therapy.

The exaggerated immune response to the subclinical opportunistic microorganisms or their antigens can be found in HIV-1 infected patients after receiving antiretroviral (ARV) therapy. We report a case of unmasking tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS) in the HIV-1 infected patient who had no previous history of mycobacterial infection. She had tuberculosis of intestines, peritoneum and mesenteric glands within 2 months of ARV. However, her sputum acid-fast bacilli stain, sputum, blood and cervical lymph node aspiration cultures for mycobacterium were negative. Her CD4 cell count increased of from 46 cells/microL at baseline before receiving ARV to 155 cells/microL at month 6 of ARV. In addition, her plasma pro-inflammatory (IFN-gamma and TNF-alpha) and anti-inflammatory (IL-10) cytokine measurement was supported the occurrence of immune restoration reaction. Therefore, the changing in these cytokine profiles may be an important marker of developing unmasking TB-IRIS.

Solución del caso 22. Peritonitis tuberculosa / No disponible

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Study of biochemical parameters of ascitic fluid in exudative ascites with special reference to tuberculous peritonitis.

In an attempt to differentiate between three important but clinically similar conditions of exudative ascites like tuberculous peritonitis, spontaneous bacterial peritonitis (SBP) and malignant ascites, we evaluated the biochemical parameters of ascitic fluid as a diagnostic aid. The serum ascitic albumin gradient (SAAG), lactate dehydrogenase (LDH), pH, adenosine deaminase(ADA), carcino-embryonic antigen (CEA) and carbohydrate antigen (CA-125) levels were measured in 36 patients with tuberculous peritonitis, 30 patients with SBP and 30 patients with ascites due to malignant disorders. The LDH level was significantly lower in tuberculous peritonitis patients than in malignant and SBP groups. A value of < 110 U/l gave the assay a sensitivity of 94% and a specificity of 93%, positive predictive value of 89% and negative predictive value of 96% for tuberculous peritonitis. The ADA activity was significantly higher in tuberculous peritonitis group than in the other two groups. A cut off value > 33 U/l gave the ADA test a sensitivity of 89%, specificity of 100%, positive predictive value of 100 % and a negative predictive value of 94% for tuberculosis. A pH value of <7.26 with high SAAG (>11 g/l) predicted SBP with reasonable accuracy. Elevated ascitic fluid CEA (>2 ng/ml) and CA - 125(> 35 U/l) was found exclusively in cases of malignant ascites with a single case of tuberculous peritonitis showing CA-125 value > 35 U/l. All these tests are rapid, non-invasive, and easily reproducible and offer good predictive accuracy which is comparable to that of more invasive procedures like peritoneoscopy and biopsy.

Abdominal tuberculosis: imaging features.

LEARNING OBJECTIVES: Radiological findings of abdominal tuberculosis can mimic those of many different diseases. A high level of suspicion is required, especially in high-risk population. In this article, we will describe barium studies, ultrasound (US) and computed tomography (CT) findings of abdominal tuberculosis (TB), with emphasis in the latest. We will illustrate CT findings that can help in the diagnosis of abdominal tuberculosis and describe imaging features that differentiate it from other inflammatory and neoplastic diseases, particularly lymphoma and Crohn's disease. As tuberculosis can affect any organ in the abdomen, emphasis is placed to ileocecal involvement, lymphadenopathy, peritonitis and solid organ disease (liver, spleen and pancreas). A positive culture or hystologic analysis of biopsy is still required in many patients for definitive diagnosis.

Computed tomography findings of peritoneal tuberculosis: systematic review of seven patients diagnosed in 6 years (1996-2001).

OBJECTIVE: The aim of this study was to describe the computed tomography (CT) findings in patients with demonstrated peritoneal tuberculosis (TB) and their concordance with the three types from the traditional classification (wet, fibrotic, and dry plastic). METHODS: We reviewed the CT images of all patients with microbiologically proven peritoneal tuberculosis over a 6-year period (1996-2001). RESULTS: Seven patients were included. Ascites was present in 5 patients (free ascites in 3 patients and loculated in 2). Involvement of the mesentery was found in 5 patients, the omentum in 4, and the parietal peritoneum in 3. Tuberculous lymphadenitis was the most common associated finding (6 patients). Two patients had hepatic lesions. The fibrotic type was found in all the patients, and 5 patients had an association of the fibrotic and wet types. None of the patients had lesions consistent with the dry plastic type. CONCLUSION: Peritoneal tuberculosis is best described as a combination of ascites, peritoneal lesions, and lymphadenopathy, rather than the three types from the traditional classification.

Abdominal tuberculosis--a study of 25 cases.

Abdominal tuberculosis is one of the common extra pulmonary tubercular infections. Its clinical presentation is protean and it has diagnostic dilemma, as most of the investigations are non-specific and less sensitive. Therefore this study was undertaken to define the most suggestive clinical features of abdominal tuberculosis, to find out the efficacy of most commonly available investigations and also to evaluate the response of abdominal tuberculosis to conventional antitubercular therapy. Twenty five cases of either sex were studied in department of gastroenterology in BSMMU (earlier IPGMR), Dhaka from January 2001 to June 2003. All patients were clinically evaluated and were investigated by available tests. Eighteen patients were diagnosed by investigations (One by detecting AFB, 9 with caseating granuloma in biopsy specimen and 8 with suggestive radiological findings). Diagnosis of 7 patients were made from the common clinical features (fever, weight loss, altered bowel habit, abdominal pain and distension, positive non-specific findings and from response by antitubercular therapy. All patients received conventional 9 month anti-tubercular treatment with Rifampicin, Isoniazide and Pyrazinamide and were followed up clinically during and one year after completion of treatment. All patients were improved with minimum side effects of drug. Therefore, it is observed that a representative tissue biopsy (when approachable) and radiological findings are good method of diagnosis of abdominal tuberculosis. Strongly suggestive clinical features with positive non specific investigation findings are also an indication for anti tubercular treatment in all endemic countries like Nepal, Bangladesh and India. Treatment of abdominal tuberculosis is in no way different from that of other conventional anti-TB therapy.

Pelvic tuberculosis mimicking signs of abdominopelvic malignancy.

We discuss the clinical presentation and consequences of pelvic tuberculosis in the context of 3 cases having developed typical signs and symptoms of ascites and abdominal mass. These cases are reported to emphasize the difficulty of early diagnosis and treatment of the disease.

[Abdominal tuberculosis misdiagnosed as tumor].

OBJECTIVE: To evaluate the clinical and pathological features of abdominal tuberculosis (TB) in order to establish correct diagnosis. METHODS: Forty-five cases of abdominal TB, which were clinically misdiagnosed as tumor (misdiagnosed as malignant tumor in 31 cases) between 1962 and 1997 were reviewed. The diagnosis was confirmed histopathologically after the operation. RESULTS: Most of the patients with abdominal TB were young in age (< 40 years in 29 cases, 64%) and females (28 cases, 62%). The main clinical manifestations were abdominal mass (37 cases, 82%), abdominal pain (30 cases, 67%), fever (17 cases, 38%), abdominal distension, constipation or diarrhea (15 cases, 33%) and weight loss (14 cases, 29%). The finding during operation showed multiple massive lesions involving intestine, peritoneum and lymph nodes in all the cases, which mimicked those with abdominal tumor. Under microscopy, proliferative type of lesions were found in 29 cases, caseous necrosis type in 11 cases and mixed type in 5 cases. CONCLUSIONS: It is showed that the clinical manifestations of abdominal TB mimic those in abdominal tumor. It is recommended that clinicians should improve understanding of clinical and pathological features of the abdominal TB and that exploratory laparotomy biopsy should be performed on those with suspected abdominal TB.

Tuberculous peritonitis in patients undergoing continuous ambulatory peritoneal dialysis: case report and review.

A case of tuberculous peritonitis complicating continuous ambulatory peritoneal dialysis (CAPD) in a 37-year-old man who presented with fever, abdominal pain, and a malfunctioning Tenckhoff catheter is reported. The patient was initially treated for presumed bacterial peritonitis but remained febrile and had persistent abdominal pain and peritoneal fluid pleocytosis, despite broad-spectrum antibiotic therapy. Mycobacterium tuberculosis was isolated in a culture of peritoneal fluid, and the patient responded promptly to antituberculous therapy. More than 50 cases of tuberculous peritonitis complicating CAPD that have been reported in the English-language literature since the initial case was reported in 1980 are reviewed. The most common symptoms are fever (78%), abdominal pain (92%), and cloudy dialysate (90%); 76% of cases had a predominance of polymorphonuclear cells in peritoneal fluid. A smear for acid-fast bacilli or a culture was positive in 73% of cases. The peritoneal dialysis catheter was removed in 53% of cases, although this was rarely considered necessary for cure of tuberculosis. The attributable mortality rate is 15%, with the most significant factor being treatment delay (mean time from presentation to initiation of treatment, 6.74 weeks). We conclude that tuberculosis is an important diagnostic consideration for CAPD patients with peritonitis that is refractory to broad-spectrum antibiotics.

Tuberculous peritonitis in 11 children: clinical features and diagnostic approach.

BACKGROUND: Tuberculous peritonitis (TBP) is a rare manifestation of childhood tuberculosis characterized by long-lasting abdominal symptoms and exudate and lymphocytes in the ascitic fluid. The diagnosis of TBP is rarely established unless a high index of suspicion is maintained. METHODS: The diagnostic features of 11 cases who were hospitalized with TBP in the Pediatric Infectious Diseases Ward of Dicle University Hospital, Turkey, were evaluated retrospectively. RESULTS: Seven cases were male and the ages of all cases ranged between 1 and 11 years. The onset of symptoms was 1-12 months (mean +/- SD 3.1 +/- 2.7 months) prior to the admission time. Nine patients gave a history of familial tuberculosis. Three cases had Bacillus Calmette-Guérin (BCG) scars and the results of five tuberculin unit (TU) tests in cases without and with BCG were over 10 and 15 mm, respectively. The most common presenting clinical symptoms and signs at admission were abdominal distention and ascites (100%), fever (27%) and loss of weight (18%). One case had accompanying tuberculous meningitis and two cases had concomitant pulmonary tuberculosis. Only one of 11 samples of ascitic fluid yielded Mycobacterium tuberculosis by the polymerase chain reaction method and no other microbiologic evidence was obtained in culture specimens. Ultrasonographic and computed tomographic imagings revealed high-density ascites that contributed well to the diagnosis. The diagnosis in two patients was proven histopathologically via peritoneoscopy and laparoscopy. All cases were treated with isoniazide, rifampisin for 9 months and pyrazinamide for the first 2 months. CONCLUSIONS: Radiologic diagnostic techniques, positive skin tests and a history of exposure to tuberculosis may contribute to the diagnosis of TBP, helped by clinical symptoms and findings, particularly when invasive diagnostic methods via peritoneoscopy and laparoscopy are not available in developing countries.

Aspectos do diagnóstico por imagem da tuberculose peritoneal / Aspects of diagnosis imaging of peritoneal tuberculosis. Review articles and case report

Os autores apresentam o caso de paciente etilista crônico com tumor abdominal e ascite. Este estudo mostra as dificuldades diagnósticas na primeira fase da investigaçäo. A avaliaçäo ultra-sonográfica, associada à tomografia computadorizada do abdome, mostrou espessamento peritoneal difuso. Este achado foi de fundamental importância para o diagnóstico clínico e etiológico da tuberculose peritoneal. Além da apresentaçäo do caso, os autores revisam a literatura sobre o assunto.

Malabsorption syndrome complicating tuberculous peritonitis.

A 22-year-old Nepali man presented with a 2-month history of fever, ill health, anorexia, loss of weight and diarrhoea. Apart from an ill-defined lower abdominal mass, physical examination was unremarkable. Investigations showed the picture of malabsorption syndrome with no evidence of structural gastro-intestinal tract involvement on barium meal, small bowel and large bowel enema, upper gastro-intestinal endoscopy, colonoscopy and mucous membrane biopsy. Laparoscopy showed typical features of tuberculous peritonitis. Liver biopsy showed tuberculous granulomatous hepatitis, and peritoneal biopsy showed caseating granulomata. The patient responded rapidly to antituberculosis chemotherapy.