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.

Clinicopathological profile of peritoneal tuberculosis and a new scoring model for predicting mortality: an international ID-IRI study.

Existing literature about peritoneal tuberculosis (TBP) is relatively insufficient. The majority of reports are from a single center and do not assess predictive factors for mortality. In this international study, we investigated the clinicopathological characteristics of a large series of patients with TBP and determined the key features associated with mortality. TBP patients detected between 2010 and 2022 in 38 medical centers in 13 countries were included in this retrospective cohort. Participating physicians filled out an online questionnaire to report study data. In this study, 208 patients with TBP were included. Mean age of TBP cases was 41.4 ± 17.5 years. One hundred six patients (50.9%) were females. Nineteen patients (9.1%) had HIV infection, 45 (21.6%) had diabetes mellitus, 30 (14.4%) had chronic renal failure, 12 (5.7%) had cirrhosis, 7 (3.3%) had malignancy, and 21 (10.1%) had a history of immunosuppressive medication use. A total of 34 (16.3%) patients died and death was attributable to TBP in all cases. A pioneer mortality predicting model was established and HIV positivity, cirrhosis, abdominal pain, weakness, nausea and vomiting, ascites, isolation of Mycobacterium tuberculosis in peritoneal biopsy samples, TB relapse, advanced age, high serum creatinine and ALT levels, and decreased duration of isoniazid use were significantly related with mortality (p < 0.05). This is the first international study on TBP and is the largest case series to date. We suggest that using the mortality predicting model will allow early identification of high-risk patients likely to die of TBP.

Frequency, outcomes, and need for intervention in stricturing gastrointestinal tuberculosis: a systematic review and meta-analysis.

BACKGROUND: Gastrointestinal strictures impact clinical presentation in abdominal tuberculosis and are associated with significant morbidity. AIM: To conduct a systematic review of the prevalence of stricturing disease in abdominal and gastrointestinal tuberculosis and response to antitubercular therapy (ATT). METHODS: We searched Pubmed and Embase on 13th January 2022, for papers reporting on the frequency and outcomes of stricturing gastrointestinal tuberculosis. The data were extracted, and pooled prevalence of stricturing disease was estimated in abdominal tuberculosis and gastrointestinal (intestinal) tuberculosis. The pooled clinical response and stricture resolution (endoscopic or radiologic) rates were also estimated. Publication bias was assessed using the Funnel plot and Egger test. The risk of bias assessment was done using a modified Newcastle Ottawa Scale. RESULTS: Thirty-three studies reporting about 1969 patients were included. The pooled prevalence of intestinal strictures in abdominal tuberculosis and gastrointestinal TB was 0.12 (95%CI 0.07-0.20, I2 = 89%) and 0.27 (95% CI 0.21-0.33, I2 = 85%), respectively. The pooled clinical response of stricturing gastrointestinal tuberculosis to antitubercular therapy was 0.77 (95%CI 0.65-0.86, I2 = 74%). The pooled stricture response rate (endoscopic or radiological) was 0.66 (95%CI 0.40-0.85, I2 = 91%). The pooled rate of need for surgical intervention was 0.21 (95%CI 0.13-0.32, I2 = 70%), while endoscopic dilatation was 0.14 (95%CI 0.09-0.21, I2 = 0%). CONCLUSION: Stricturing gastrointestinal tuberculosis occurs in around a quarter of patients with gastrointestinal tuberculosis, and around two-thirds of patients have a clinical response with antitubercular therapy. A subset of patients may need endoscopic or surgical intervention. The estimates for the pooled prevalence of stricturing disease and response to ATT had significant heterogeneity.

Clearing the clouds: Case-report and review of the literature.

In peritoneal dialysis (PD), a cloudy dialysate is an alarming finding. Bacterial peritonitis is the most common cause, however, atypical infections and non-infectious causes must be considered. A 46-year-old man presented with asthenia, paraesthesia, foamy urine and hypertension. Laboratory testing revealed severe azotaemia, anaemia, hyperkalaemia and nephrotic-range proteinuria. Haemodialysis was started through a central venous catheter. Later, due to patient preference, a Tenckhoff catheter was inserted. Conversion to PD occurred 3 weeks later, during hospitalization for a presumed central line infection. A month later, the patient was hospitalized for neutropenic fever. He was diagnosed an acute parvovirus infection and was discharged under isoniazid for latent tuberculosis. Four months later, the patient presented with fever and a cloudy effluent. Peritoneal fluid (PF) cytology was suggestive of infectious peritonitis, but the symptoms persisted despite antibiotic therapy. Bacterial and mycological cultures were negative. No neoplastic cells were detected. Mycobacterium tuberculosis eventually grew in PF cultures, despite previous negative molecular tests. Directed therapy was then initiated with excellent response. Thus, facing a cloudy effluent, one must consider multiple aetiologies. Diagnosis of peritoneal tuberculosis is hampered by the lack of highly sensitive and specific exams. Here, diagnosis was only possible due to positive mycobacterial cultures.

'Rollover' abdominal paracentesis versus standard technique: protocol of a crossover randomized comparative trial.

The sensitivity of single abdominal paracentesis for diagnosis of peritoneal carcinomatosis in patients with malignant ascites is 40-70%. Tumor cells shed from the peritoneum settle preferentially in certain recesses of the peritoneum. We aim to compare the standard technique of abdominal paracentesis versus a rollover technique in a randomized crossover study to assess the cytological yield in patients suspected to have peritoneal carcinomatosis. Each patient will serve as their own control and the outcome assessor (cytopathologist) will be blinded to the method of paracentesis performed. The primary objective will be to compare the tumor cell positivity between the standard paracentesis group and the rollover group among enrolled patients. Clinical Trial registration: CTRI/2020/06/025887 and NCT04232384.

Lay abstract Existing methods of diagnosing cancer-related ascites are dependent on microscopic evaluation of fluid obtained from the ascites. However, this may not diagnose all such cases because the fluid may not contain many tumor cells. This may be due to the settling of tumor cells in certain inaccessible locations of the peritoneum (the lining of the abdominal cavity). This trial will look at whether rolling the patient from side to side could be helpful in increasing the chances of finding tumor cells in the ascites.

[Tuberculous abdominal cocoon as a rare variant of peritonitis]. / Osumkovyvayushchii tuberkuleznyi perivistserit kak redkii variant peritonita.

OBJECTIVE: To study and systematize clinical symptoms of tuberculous perivisceritis, to clarify diagnostic value of laboratory and instrumental survey in these patients and to identify the features of surgical treatment. MATERIAL AND METHODS: There were 8 patients with tuberculous perivisceritis. Examination included computed tomography of the abdominal cavity and chest, ultrasound, laparoscopy. All patients underwent surgical treatment with histological, cytological, microbiological and molecular genetic analysis of peritoneal exudate and biopsy of peritoneal specimens. RESULTS: Clinical picture of tuberculous perivisceritis is variable and non-specific. Periods of exacerbation are replaced by periods of prolonged remission. The complex of radiological survey used in verification of perivisceritis does not allow accurate determining the nature of disease. However, peritoneal tuberculosis may be suspected as a rule considering signs of thickening of the peritoneum. Objective confirmation of perivisceritis is possible only during surgical intervention. In this case, etiological factor can be established only after a thorough histological examination of resected fibrous capsule. CONCLUSION: Clinical picture of tuberculous perivisceritis does not have specific symptoms. The disease is characterized by prolonged and undulating course. Acute peritonitis and acute intestinal obstruction may be suspected during exacerbation of the pathological process. Laparotomy followed by complete excision of fibrous capsule and adhesiolysis is preferred.

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.

Evaluating the clinical significances of serum HE4 with CA125 in peritoneal tuberculosis and epithelial ovarian cancer.

This study aimed to evaluate the clinical significances of human epididymis protein 4 (HE4) with cancer antigen 125 (CA125) in differential diagnosis between epithelial ovarian cancer (EOC) and peritoneal tuberculosis (PTB). We retrospectively reviewed data of 31 patients suspected preoperatively as having EOC but whose pathological results revealed PTB. The concentrations of serum HE4 and CA125 in PTB were significantly lower than that in EOC. The optimal cutoffs to differentiate EOC from PTB were HE4 > 151.4 pmol/l and CA125 > 563.5 U/ml, which means EOC may be considered if HE4 or CA125 was greater than the cutoff, otherwise, PTB should not be neglected. Furthermore, the specificity and accuracy for differentiating PTB form EOC could be improved when combination HE4 and CA125. Conclusively, the combination of HE4 and CA125 may be recommended as potential biomarkers in the preliminary differential diagnosis of PTB from EOC before the "golden standard" of pathologic diagnosis finally obtained.

Intermittent Directly Observed Therapy for Abdominal Tuberculosis: A Multicenter Randomized Controlled Trial Comparing 6 Months Versus 9 Months of Therapy.

BACKGROUND: The duration of treatment of gastrointestinal tuberculosis continues to be a matter of debate. The World Health Organization advocates intermittent directly observed short-course therapy (DOTs), but there is a lack of data of its efficacy in abdominal tuberculosis. We therefore conducted a multicenter randomized controlled trial to compare 6 months and 9 months of antituberculosis therapy using DOTs. METHODS: One hundred ninety-seven patients with abdominal tuberculosis (gastrointestinal, 154; peritoneal, 40; mixed, 3) were randomized to receive 6 months (n = 104) or 9 months (n = 93) of antituberculosis therapy using intermittent directly observed therapy. Patients were followed up 1 year after completion of treatment to assess recurrence. Patients were evaluated for primary endpoint (complete clinical response, partial response, and no response) and secondary endpoint (recurrence of the disease at the end of 1 year of follow-up). RESULTS: Baseline characteristics were similar between the 2 randomized groups. There was no difference between the 6-month group and 9-month group in the complete clinical response rate on per-protocol analysis (91.5% vs 90.8%; P = .88) or intent-to-treat analysis (75% vs 75.8%; P = .89). Only 1 patient in the 9-month group and no patients in the 6-month group had recurrence of disease. Side effects occurred in 21 (21.3%) and 16 (18.2%) patients in the 6-month and 9-month groups, respectively. CONCLUSIONS: There was no difference in efficacy of antituberculosis therapy delivered for either 6 months or 9 months in either gastrointestinal or peritoneal tuberculosis, confirming the efficacy of intermittent directly observed therapy. CLINICAL TRIALS REGISTRATION: NCT01124929.

Female genital tract tuberculosis presenting as ovarian cancer.

BACKGROUND: Tuberculosis (TB) is still a major worldwide concern. There is no pathognomonic clinical feature or imaging findings for definite diagnosis of extra pulmonary TB. Therefore, TB involvement of Gastrointestinal or Genitourinary tract can be easily confused with peritoneal carcinomatosis and advanced ovarian carcinoma. Our aim is to emphasize the importance of considering the disease based upon the epidemiologic clues of the patients, while interpreting the positive results for a suspicious ovarian malignancy. CASES: This paper illustrates 8 cases of ovarian or peritoneal tuberculosis, whose initial diagnoses were malignant processes of the GU tract. CONCLUSION: Tuberculosis (TB) should be always being considered in the differential diagnosis of advanced ovarian cancer, especially in the regions that are endemic for 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.

Coexistence of ovarian cancer and peritoneal tuberculosis: a case report.

Peritoneal tuberculosis (TB) is known to mimic advanced ovarian cancer. In this case report, we describe a unique case of ovarian cancer (endometrioid carcinoma grade 3) at the International Federation of Gynecology and Obstetrics (FIGO) stage IC1 with pulmonary and peritoneal TB, which was suspected preoperatively to be a coexistence of advanced ovarian cancer and pulmonary TB. A 68-year-old woman presented with a prominent abdominal mass and fever. Laboratory investigations, imaging, and sputum analysis indicated a probable diagnosis of ovarian cancer at FIGO stage IIIC, characterized by peritoneal dissemination and para-aortic lymph node metastasis, which was further complicated by coexisting pulmonary TB. Surgical management included total abdominal hysterectomy, bilateral salpingo-oophorectomy, and partial omentectomy. Intraoperatively, the tumor was localized to the right ovary with significant peritoneal thickening and adhesions indicative of peritoneal TB. The surgery was completed without apparent complications. Postoperative histopathological evaluation confirmed grade 3 endometrioid carcinoma in the right ovary along with evidence of peritoneal TB. Given the extent of adhesions attributed to TB, lymph node dissection for staging was deemed challenging and was thus not pursued. Initiation of anti-TB treatment on postoperative day 2 resulted in marked regression of the preoperatively identified pulmonary nodules and para-aortic lymph node enlargement, suggesting their inflammatory origin from TB. Although postoperative chemotherapy is typically advocated for patients with stage IC1 endometrioid carcinoma grade 3, the patient opted against it. Consequently, no adjuvant therapy was administered and the patient remained under close observation.

Peritoneal tuberculosis with an atypical presentation. Surgical case report.

INTRODUCTION AND IMPORTANCE: 1-3% of tuberculosis cases are extrapulmonary, which 11-16% are abdominal. In recent years, a progressive increase in the number of peritoneal tuberculosis cases has been observed. Peritoneal tuberculosis accounts for only 1-2% of all cases of peritonitis. Historically it is known as "the great mimicker" since it can resemble a neoplastic, infectious or inflammatory intestinal disease. The most common triad of presentation is fever, weight loss and abdominal pain; ascites is also usually present. For diagnosis, computed tomography is the most sensitive technique and is complemented by elevation of CA 125 and Adenosine deaminase (ADA) but is confirmed by pathology study. Treatment is the same as the pulmonary presentation. CASE PRESENTATION: A 33-year-old man presented with acute complication appendicitis. A limited right hemicolectomy was performed due to the nature of the patient advanced disease. Multiple small tumor resembling peritoneal implant and a granuloma were identified has sampled during the patient's surgical procedure. Pathologic examination revealed peritoneal tuberculosis and medical therapy was initiated. Laboratory assays including CA 125 and adenosine deaminase (ADA) can be useful serum markers to follow during treatment if they are positive. DISCUSSION: The most common presentation of peritoneal tuberculosis is fever, weight loss and abdominal pain. Our patient did not have any of these symptoms, we founded granulomas in surgery of intestinal restitution. METHODS: The work has been reported in line with the SCARE criteria. CONCLUSIONS: This pathology should always be kept in mind as a differential diagnosis when faced with unexpected findings in surgery.

Peritoneal tuberculosis, an underestimated diagnosis: a case report.

Tuberculosis is an infectious disease that most often affects the lungs, caused by human-to-human transmission of Mycobacterium tuberculosis. Peritoneal tuberculosis is an extra-pulmonary form of the disease that usually manifests as an ascitic syndrome, with or without fever, in a context of altered general condition, often in endemic areas. The diagnosis of peritoneal tuberculosis is not always easy, as the clinical signs are often insidious and unspecific. We report a case of peritoneal tuberculosis in an 18-year-old female, who had presented for 10 days with a progressive increase in abdominal volume associated with vomiting and diarrhoea.

Partial adhesive small bowel obstruction due to peritoneal tuberculosis HIV/AIDS patient: A case report.

INTRODUCTION: Diagnosing peritoneal tuberculosis is challenging due to unspecific clinical manifestations, particularly in immunocompromised patients with HIV/AIDS and tuberculosis infections. PRESENTATION OF CASE: An Indonesian man, 26-years-old, complained of mid-abdominal colic and constipation. The patient's present state exhibited symptoms of weakness and paleness, oral candidiasis, a bloated abdomen, palpable discomfort, and shifting dullness. The ascitic fluid analysis showed increased ADA (709 U/L), and detected Mycobacterium tuberculosis using GeneXpert MTB/RIF. Radiographic examination from abdominal x-ray and CT scan revealed a small bowel obstruction. He received intestinal decompression, pain control, intravenous fluid resuscitation, and correction of electrolyte imbalance for small bowel obstruction without any indication for surgical intervention. He also receive first-line ATD for 2 months during intensive phase and 4 months for continuous phase. After a period of 2 weeks following the ATD administration, the patient began taking ARV medication on a daily basis. He showed a good prognosis 6 months following. DISCUSSION: The diagnosis of peritoneal tuberculosis is challenging due to its unspecific manifestation and some cases are identified when complications such as small bowel obstruction appear. The ADA test and GenExpert MTB/RIF are useful instruments for promptly diagnosing tuberculosis. It is suggested to use ARV treatment in individuals with HIV/AIDS who have peritoneal tuberculosis, starting 2 weeks following ATD treatments. CONCLUSION: Peritoneal tuberculosis with small bowel obstruction and HIV/AIDS infection is a rare case in which early diagnosis and monitoring play an important role in successful treatment.

A case of peritoneal Burkitt's lymphoma mimic of peritoneal tuberculosis.

Peritoneal lymphomatosis is a rare presentation of lymphoma that can mimic peritoneal tuberculosis. The computed tomography findings in both conditions include omental caking, thickening, and nodularity. We report the case of a 41-year-old man who presented with intermittent abdominal pain and distension. Abdominal CT initially suggested peritoneal tuberculosis due to the thickening of the peritoneum and greater omentum with multiple nodules. However, 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) images showed diffuse metabolic activity increase in the thickened peritoneum, omentum, and mesentery. An omental biopsy was performed under ultrasonography guidance, and histopathological examination revealed a high-grade Burkitt lymphoma. It is crucial to distinguish peritoneal lymphomatosis from tuberculosis, as the prognosis and management of the two conditions are vastly different.

Imaging of infra-thoracic tuberculosis.

Tuberculosis (TB) is a potentially curable disease that is a leading cause of death globally. While it typically affects the lungs, this disease may involve many extra-pulmonary sites, particularly in patients with risk factors. Extra-pulmonary TB often mimics a variety of different diseases, posing a diagnostic dilemma. Imaging aids in early diagnosis of TB, especially in patients with non-specific or atypical symptoms found at extra-pulmonary infra-thoracic locations. Imaging also helps guide appropriate laboratory investigation, monitor disease progress, and response to treatment. This review aims to highlight the imaging spectrum of TB affecting the infra-thoracic region, that is, gastrointestinal tract, abdominal lymph nodes, peritoneal cavity, intra-abdominal solid organs, and urogenital system.

Acute abdomen revealing abdominal tuberculosis complicated by a proximal jejunal perforation: Case report.

Abdominal tuberculosis (TB) remains a significant health concern globally, particularly in regions with high endemicity such as North Africa and Morocco. Despite advances in diagnostic modalities, the nonspecific presentation of abdominal TB poses challenges for timely diagnosis and management. Here, we report a case of abdominal TB in a critically state of a young man from Morocco, presenting with acute abdominal pain and signs of sepsis. Radiological investigations revealed features suggestive of intestinal perforation complicating peritoneal TB. Urgent laparotomy confirmed the diagnosis, yet the patient succumbed to advanced sepsis postoperatively. This case underscores the complexity of abdominal TB diagnosis and management, necessitating a high index of suspicion and multidisciplinary collaboration. With evolving surgical techniques and ongoing research efforts, optimizing strategies for early detection and treatment of abdominal TB remains imperative, particularly in endemic regions.

Peritoneal Tuberculosis in Western Countries: A Rare Case With Concurrent Helminthic Infection.

This case report presents a rare case of peritoneal tuberculosis (TB) coexisting with a helminthic infection in a 25-year-old female residing in Australia, highlighting the diagnostic challenges posed by abdominal TB. Despite the low incidence of TB in Western countries, abdominal TB remains a diagnostic dilemma due to its nonspecific symptoms and potential mimicry of other abdominal pathologies. The case highlights the importance of considering TB as a differential diagnosis of unexplained abdominal symptoms, particularly in individuals with a history of travel or previous residence in high-endemic regions. A multidisciplinary approach involving infectious disease specialists, radiologists, and surgeons is essential for comprehensive management. Prompt initiation of anti-TB therapy is recommended once diagnosis is confirmed.