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.

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.

Tuberculous peritonitis following intestinal perforation in malignancy

SUMMARY 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.

Peritoneal dialysis related peritonitis due to Mycobacterium spp.: A case report and review of literature.

Mycobacterium tuberculous peritonitis is a less common cause of peritoneal dialysis related infection in developed countries. As both CAPD and APD are being used as renal replacement therapy in developing countries of South Asia, Mycobacterium tuberculous peritonitis are being reported. Any culture negative peritonitis should be investigated for this entity. In this manuscript, we report an index case and our experience with literature review of Mycobacterium tuberculous peritonitis. The diagnostic techniques, management and outcome are described.

Mycobacterial Peritonitis in CAPD Patients in Limpopo: A 6-Year Cumulative Report from a Single Center in South Africa.

South Africa has one of the highest incidences of tuberculosis (TB) worldwide due to the ongoing human immunodeficiency virus (HIV) epidemic. There are, however, no reports on peritonitis in continuous ambulatory peritoneal dialysis (CAPD) patients due to Mycobacterium tuberculosis in South Africa. The aim of this study is to discuss our experience of tuberculous peritonitis in CAPD patients from a rural endemic area of South Africa. This is a retrospective descriptive study of CAPD patients diagnosed with mycobacterium peritonitis infection from January 2008 to August 2014 at the Limpopo Kidney and Dialysis Centre (LKDC) in South Africa. The diagnosis of peritonitis was based on the International Society for Peritoneal Dialysis (ISPD) 2010 recommendations. Peritoneal fluid samples were collected in BACTEC Myco/F Lytic Culture Vials (Becton, Dickinson and Company, Dublin, Ireland). Tenckhoff catheter tips were sent for acid-fast bacilli (AFB) smear and TB culture. Mycobacterium infection was considered in patients with clinical features of peritonitis if 1) AFB smear or TB culture was positive or 2) if the patient was smear- or culture-negative but had suggestive radiological features of TB in the lungs or abdomen or 3) if the patient improved clinically following treatment with anti-tuberculous drugs. Of 170 patients on CAPD for the period reviewed, 12 (7.1%) were diagnosed and treated for mycobacterial peritonitis. There was an equal number of males and females, and all the patients were Black Africans with a mean age of 35.4 years (17-51 years). Eight of the 12 patients (66.7%) had had previous episodes of non-tuberculous peritonitis. Four patients (33.3%) had elevated white blood cell count (WCC) while 9 had higher polymorph count in the PD fluid than lymphocyte count. Mycobacterial organism was confirmed in 9/12 (75%), while the diagnosis was made on clinical and radiological features in the remaining 3 patients. Seven patients (58.3%) died, 10 patients were permanently transferred to hemodialysis (HD), 1 patient returned to PD after a short stay on HD, 1 patient died after 2 years on HD due to lack of further access to dialysis, and in 1 patient, the catheter could not be removed before death. This case series corroborates findings from other previous series that mycobacterial infection in PD patients carries a high mortality and can often pose a diagnostic challenge to attending clinicians. Clinicians should have a high index of suspicion for mycobacterial peritonitis in CAPD patients with features of peritonitis who do not respond promptly to conventional anti-microbial agents. We feel that the recommendation about catheter removal during mycobacterial peritonitis should be revisited, as it had no impact on our patients' outcome.

Tuberculosis peritonitis with features of acute abdomen in HIV infection.

This case report introduces a 26-year-old male IV drug abuser with fever, abdominal pain and distension referred to the emergency ward. According to these findings, abdominal tenderness and involuntary guarding, an explorative laparotomy was performed. Multiple biopsies of omentum, peritoneum and liver were taken. Pathologic assessment of multiple biopsies confirmed intra-abdominal TB infection.

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.

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.

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.

Mycobacterium tuberculous peritonitis in CAPD patients: a report of 11 patients and review of literature.

BACKGROUND: The aims of the present report were to document our experience of the prevalence of tuberculous peritonitis in continuous ambulatory peritoneal dialysis (CAPD) patients, mode of presentation, diagnosis and outcome and to discuss the current published data about catheter removal. METHODS: A retrospective study of CAPD patients with tuberculous peritonitis was done. A minimum of three specimens of peritoneal fluid were examined for acid-fast bacilli smears. The BACTEC 9000 Blood Culture Series of instruments were used for the culture of Mycobacterium tuberculosis. After 2005, patients were treated with anti-tuberculous treatment, and catheter retention was started in our patients. RESULTS: There were eleven patients (2.6 %) with tuberculous peritonitis among 414 CAPD patients. M. tuberculosis accounted for 4.47 % of all peritonitis episodes. The incidence of tuberculous peritonitis was 1/794 months. There were eight males and three females. The mean age was 49 years. Intestinal obstruction was reported in two patients, and two patients were treated for antecedent peritonitis. One of them had a simultaneous fungal peritonitis. One patient each developed a peritoneo-cutaneous fistula and ultrafiltration failure. Three were successfully treated without the removal of catheter. CONCLUSION: Based on the analysis of all published reports of tuberculous peritonitis, there was no significant difference in patient survival between patients in whom CAPD catheter was removed or retained. Tuberculous peritonitis should be considered in patients with neutrophilic 'sterile' peritonitis with no response to antibacterial medications, predominance of lymphocytic peritonitis and in bacterial peritonitis not responding to antibiotics. After an early diagnosis, with close monitoring, an effort to retain the catheter after 5 days of anti-tuberculous therapy may be attempted.

[Abdominal tuberculosis in a young immigrant patient: a clinical case]. / Tubercolosi addominale in un giovane paziente extracomunitario: descrizione di un caso clinico.

In developing countries, tuberculosis (TBC) is commonly associated with inadequate socio-economic and sanitary conditions. Currently, in Western countries, TBC is often linked with HIV infection, an ageing population or trans-global migration. Approximately two out of ten TB cases worldwide are extra-pulmonary, of which abdominal tuberculosis accounts for 11%-16%. The Mycobacterium tuberculosis complex involves the abdomen as primary or secondary localization (hematogenous spread or from pulmonary foci or infected neighbouring organs). Abdominal TBC can infect the gastrointestinal tract, peritoneum, mesentery, abdominal lymph nodes, liver, spleen, and pancreas. Diagnosis of abdominal tuberculosis is difficult because of vague and non-specific clinical features and due to the differential diagnosis with other granulomatous diseases such as Crohn's Disease. It is of great importance for clinicians to pay great attention to tubercular aetiology as a possible cause of gastrointestinal symptoms. Here we describe the clinical case of a young immigrant patient with intestinal TB for whom the wrong initial diagnosis led to a delay in the correct diagnosis and a worsening of the already serious general conditions.

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.

Tumoral calcinosis, calciphylaxis, hyperparathyroidism and tuberculosis in a dialysis patient.

Tumoral calcinosis and calciphylaxis are uncommon but severe complications in uremic patients. They occur generally after long-term hemodialysis (HD) treatment explained by advanced secondary hyperparathyroidism and longstanding high calcium phosphorus product (Ca × P). Other factors such granulomatous diseases may worsen the calcium phosphate homeostasis alterations. We report a young male patient treated by HD for 6 years who developed tuberculosis in addition to tumoral calcinosis and calciphylaxis.

[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.

Haemophilus paraphrophilus peritonitis followed by tuberculous peritonitis and Pott's disease.

Patients with alcoholic cirrhosis who have ascites have a high risk of developing spontaneous bacterial peritonitis (SBP). The authors report a case of SBP caused by Haemophilus paraphrophilus, the first-reported SBP in literature with this pathogen. Later on, the patient also developed tuberculous (TB) peritonitis associated with thoracic Pott's disease, a combination never reported before. The diagnoses were confirmed by positive mycobacterium cultures of both omental tissues and vertebral tissues. This report also illustrates prominent computed tomography findings of TB peritonitis and magnetic resonance imaging of spinal cord compression of Pott's disease. Tuberculosis is a treatable and curable disease and should be considered as a potential offending pathogen on differential diagnosis in SBP of alcoholic cirrhotic patients. Timely biopsy and surgical intervention with these kinds of TB are needed to lead early diagnosis and result in an excellent outcome.

[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.