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.

[Tuberculous peritonitis. 'Forgotten' disease]. / Tuberkuleznyi peritonit. 'Zabytaia' bolezn'.

AIM: To analyze diagnosis and treatment of patients with tuberculous peritonitis, to develop the algorithms for instrumental examination and differential diagnosis. MATERIAL AND METHODS: There were 48 patients with tuberculous peritonitis. The examination included radiography, abdominal and thoracic computed tomography, ultrasound, and laparoscopy. All patients underwent histological, cytological, microbiological and molecular-genetic analysis of abdominal exudate and peritoneal biopsy. Exclusion criterion was signs of secondary peritonitis. RESULTS: Clinical picture of tuberculous peritonitis was accompanied by nonspecific symptoms. Previously identified pulmonary tuberculosis and HIV-infection were present in 93.8 and 70.8% of patients. Diagnostic laparoscopy of abdominal cavity as the main method of instrumental diagnosis together with cytological, molecular-genetic and microbiological research of peritoneal exudate and tissue specimens were useful to determine diagnosis in 87.2-95.8% of cases. CONCLUSION: Tuberculous peritonitis may be assumed in patients with previous tuberculosis of lungs or other localizations, HIV-infection. Computed tomography is the most informative method to diagnose tuberculous peritonitis. Diagnostic laparoscopy is indicated for suspected tuberculous peritonitis. This procedure is supplemented by peritoneal biopsy, cytological, molecular-genetic and microbiological examination of peritoneal exudate and tissue specimens.

Paediatric abdominal tuberculosis in developed countries: case series and literature review.

OBJECTIVE: To provide an insight into the presentation, diagnosis and management of paediatric abdominal tuberculosis (TB) in developed countries. METHODS: The records of all children at the Montreal Children's Hospital (MCH) admitted with abdominal TB between 1990 and 2014 were reviewed. An automated and manual literature search from 1946 to 2014 was performed. RESULTS: (1) CASE SERIES: six cases were identified at the MCH. All were male between 5 and 17 years of age. All were from populations known to have high rates of TB (aboriginal, immigrant). Three underwent major surgical interventions and three underwent ultrasound (US) or CT aspiration or biopsy for diagnosis. (2) LITERATURE REVIEW: 29 male (64%) and 16 female subjects (36%) aged between 14 months and 18 years were identified, including the MCH patients. All patients except one were from populations with a high incidence of TB. Most presented with a positive tuberculin skin test (90%), abdominal pain (76%), fever (71%) and weight loss (68%). On imaging, 22 (49%) were classified with gastrointestinal TB with colonic wall irregularity (41%) and 19 (42%) with peritoneal TB with ascites (68%). A positive culture was obtained in 33 (73%) patients. Three cases used CT- or US-guided aspiration or biopsy to obtain tissue samples. A surgical intervention was performed in 34 (76%) children; 13 (38%) of these were for diagnosis. CONCLUSIONS: Diagnosis based on clinical features (abdominal pain, fever and weight loss) and CT- or US-guided aspiration or biopsy may encourage physicians to adopt a more conservative approach to abdominal TB.

Tuberculosis peritoneal con presentación clínica como cáncer ovárico avanzado: revisión de la literatura / Peritoneal tuberculosis with clinical presentation as advanced ovarian cancer

Se presenta el caso de paciente con ascitis, masa pelviana y CA 125 elevado, sugerentes de cáncer ovárico avanzado. Se realizó laparoscopía que demostró lesiones compatibles con tuberculosis peritoneal. La biopsia laparoscópica de las lesiones demostró granulomas, por lo que no se realizó más cirugía y se inició tratamiento antituberculoso específico con buena respuesta clínica. Se revisa en la literatura tuberculosis peritoneal y su dificultad con el diagnóstico diferencial con cáncer de ovario avanzado.

It is presented the case of a patient with ascites, pelvic mass and elevated CA 125, all suggested of advanced ovarian cancer. It was made a laparoscopy that evidenced lesions of peritoneal tuberculosis. The laparoscopic biopsy of the lesions demostrated granulomas, for that there was no more surgery made and antituberculosis specific treatment was started, with good clinical response. It is revisited in the literature peritoneal tuberculosis and its difficult differential diagnoses with advanced ovarian cancer.

Can D-dimer levels predict the treatment outcome in a patient with tuberculosis?

Tuberculous peritonitis is a leading cause of mortality and morbidity particularly in the developing world. Delay in initiation of treatment distinctively increases mortality. Treatment response to anti-tuberculosis drugs is usually observed by regression of symptoms and clearance of ascites. With initiation of treatment, laboratory values including CA-125 levels generally return to normal levels in 3 months. However, there is still no consensus about treatment response during the follow-up period. Serum D-dimer level is used as an inflammation marker in some cases. A case with Tuberculous peritonitis successfully monitorised by serum D-dimer levels is presented.

Analysis of cases with tuberculous peritonitis: a single-center experience.

BACKGROUND/AIMS: Tuberculous peritonitis (TP) is a rare form of tuberculosis and is caused by peritoneal involvement with Mycobacterium tuberculosis. A distinctive correlation exists between socioeconomic state and disease prevalence. We aimed to evaluate the clinical, laboratory, and radiological findings of patients with TP. MATERIALS AND METHODS: We conducted a retrospective study in patients with peritoneal tuberculosis from January 2004 to October 2008 at Yuzuncu Yil University Medical School Education and Research Hospital. During this time, the data of 21 patients (17 females) with TP were reviewed. RESULTS: Fever, abdominal pain, and anorexia were the most common symptoms. An analysis of ascites showed lymphocyte predominance and low albumin gradient in all patients. Patients with TP had a median ascites adenosine deaminase (ADA) level of 139 U/L (range, 25 to 303U/L). Peritoneal involvement (wet peritonitis) was seen in all the cases. Following 6-month administration of combined anti-TBC treatment, mean serum CA-125 levels were within the normal range among patients who had previously higher serum CA-125 level. Mortality rate in the total cases was 4.6%. CONCLUSION: Peritoneal tuberculosis should be considered in the differential diagnosis of exudative ascites in eastern Turkey. A high level of suspicion is required, especially in high-risk populations living in rural areas. ADA seems to be a sufficient, safe, and inexpensive method to perform the diagnosis of peritoneal tuberculosis. Serum CA-125 levels may play a key role to support the diagnosis as well as disease management of TP.

Laparoscopic management of midgut malrotation and tuberculous peritonitis in an adolescent boy.

An unusual case of miliary plastic peritonitis associated with midgut malrotation in an adolescent in whom various diagnostic investigations, medical management and staged initial laparoscopic diagnostic followed by therapeutic procedure was curative have been presented. Tuberculous miliary plastic peritonitis causes dense adhesions between bowel loops and prevents midgut volvulus in a pre-existing malrotation. Diagnosis can be a challenge and threshold for diagnostic laparoscopy should be low. Interval correction of malrotation by laparoscopy after complete resolution of tuberculosis is easy, safe and effective, and cosmetically more pleasing. Midgut malrotation is a congenital anomaly referring to either lack of or incomplete rotation of fetal axis around the axis of superior mesenteric artery during fetal development. Most patients present with bilious vomiting in the first month of life because of duodenal obstruction or a volvulus. This is an unusual case of midgut malrotation in association with tuberculous peritonitis in an adolescent boy.

Peritoneal tuberculosis due to multidrug-resistant Mycobacterium tuberculosis.

The emergence of drug-resistant Mycobacterium tuberculosis has been widely reported throughout the world, but there are very few data regarding children. We describe the case of a 14-year-old Peruvian adolescent who had been living in Italy since the age of 8 years and was diagnosed as having peritoneal tuberculosis (TB). While she was receiving first-line anti-TB therapy, she developed pyrazinamide-associated thrombocytopenia and cultures revealed a multidrug-resistant strain of Mycobacterium tuberculosis. Pyrazinamide, rifampicin and isoniazid were replaced by moxifloxacin, which was continued for 9 months together with ethambutol. The patient recovered without experiencing any drug-related adverse event or the recurrence of TB in the following year. In conclusion, this case illustrates some of the problems that can arise when multidrug-resistant TB has to be treated in children and adolescents, and also highlights the fact that further studies are needed to clarify which drugs should be used and for how long.

Tuberculosis: experience in a low endemic area Australian tertiary hospital.

BACKGROUND: Abdominal tuberculosis (ATB) poses a significant diagnostic, management, and resource challenge. In Australia, an increasing number of tuberculosis (TB) cases are being reported, and we describe our experience of ATB in an Australian tertiary institution. METHODS: All diagnosed cases of tuberculosis (TB) at the Royal North Shore tertiary hospital campus of the University of Sydney are entered prospectively into a central registry. Cases of ATB encountered between September 1991 and November 2011 were identified and retrospectively reviewed. RESULTS: In all, 841 cases of TB were identified, of which 20 were abdominal (2.4 %). Median age at presentation was 34 years (range: 22-79 years), and 55 % of patients were women. None of the patients were born in Australia and 11 patients were of South Asian origin. The most common presenting symptom was abdominal pain (65 %). Diagnosis was based primarily on histology (90 % sensitivity), and the sensitivity of PCR analysis in this series was low (44 %). Eleven of the patients required laparoscopy or laparotomy. 40 % of cases involved the peritoneum, and disease was also seen in solid organs (liver, spleen, pancreas, adrenal gland) and bowel (esophagus, small bowel, colon). CONCLUSIONS: In our local experience ATB was seen exclusively in the immigrant population. The presentation of ATB varies greatly, necessitating a high index of suspicion within the context of abdominal symptoms in high-risk groups. The role of surgical involvement is indispensable for both diagnosis and management of ATB-related complications. Surgeons should remain mindful of the diagnosis in an age of increasing worldwide incidence.

[Extrapulmonary tuberculosis]. / La tuberculose extrapulmonaire.

Extrapulmonary tuberculosis represents an increasing proportion of all cases of tuberculosis reaching 20 to 40% according to published reports. Extrapulmonary TB is found in a higher proportion of women, black people and immunosuppressed individuals. A significant proportion of cases have a normal chest X-Ray at the time of diagnosis. The most frequent clinical presentations are lymphadenitis, pleuritis and osteoarticular TB. Peritoneal, urogenital or meningeal tuberculosis are less frequent, and their diagnosis is often difficult due to the often wide differential diagnosis and the low sensitivity of diagnostic tests including cultures and genetic amplification tests. The key clinical elements are reported and for each form the diagnostic yield of available tests. International therapeutic recommendations and practical issues are reviewed according to clinical presentation.

Umbilical signs of peritoneal tuberculosis in children.

OBJECTIVES: To report the observation of involvement of the umbilicus with alteration of its morphology in association with peritoneal tuberculosis. METHODS: This is a retrospective observational case series of abdominal tuberculosis (ATB) in children, treated in the department of pediatric surgery of a tertiary-care children's hospital in the period from January 2004 through April 2010. RESULTS: Out of a total of 38 cases of ATB in children, 22(57.9%) were of the peritoneal type, 14(36.8%) were of the intestinal type, and 2(5.3%) involved the mesenteric lymph nodes. Of the patients manifesting with peritoneal tuberculosis, 11 cases (50%) had involvement of the umbilicus with changes in the umbilical shape and appearance. In seven cases the umbilicus was found retracted and transversely oriented (a slit-like "smiling" appearance) with loss of the umbilical hollow. In two cases there was puckering of the umbilicus. Other findings included umbilical erythema with inflammation in one patient and a fecal fistula at the umbilicus in another patient. While seven cases responded to treatment with antituberculous therapy (ATT), four cases underwent surgery (two laparotomy and two laparoscopy). Findings were similar in all four patients, consisting of adhered dilated bowel loops studded with tubercles which also covered the parietal peritoneum and the falciform ligament. All four cases responded to postoperative ATT. CONCLUSIONS: Morphological changes of the umbilicus can provide an additional clue to the diagnosis of peritoneal tuberculosis in children.

Comparison between laparoscopy and noninvasive tests for the diagnosis of tuberculous peritonitis.

BACKGROUND: Despite recent progress, the fast and accurate diagnosis of tuberculous peritonitis (TBP) continues to be a challenge, mainly because of the lack of specific clinical features and the difficulty in isolating the M. tuberculosis. The present study aimed to investigate the role of laparoscopy in the diagnosis of TBP, compared to noninvasive tests. METHODS: We retrospectively studied 60 patients who had diagnostic laparoscopy for suspected TBP between January 2002 and June 2010. RESULTS: Forty-one patients were diagnosed with TBP. In terms of accuracy and predictive value, the visual diagnosis via laparoscope was the most diagnostic test. In the noninvasive tests, both the ascitic adenosine deaminase (ADA) level over 30 U/l, and the ascitic lactate dehydrogenase (LDH) level over 90 U/l had relatively high positive, as well as negative, predictive values. The overall morbidity and mortality rates for laparoscopy were 5 and 5%, respectively. CONCLUSIONS: Laparoscopy is a rapid and accurate diagnostic test for TBP. However, complications may occur. In older patients with associated conditions, a combination of various noninvasive tests and empirical treatments is needed prior to laparoscopy.

Peritoneal tuberculosis.

The peritoneum is one of the locations outside the most common pulmonary tuberculosis. Peritoneal tuberculosis poses a public health problem in endemic regions of the world. The phenomenon of migration, the increased use of immunosuppressive therapy and the epidemic of AIDS have contributed to a resurgence of this disease in regions where it was previously controlled. The aim of this review is to expose the clinical, biologic end radiologic futures of the peritoneal tuberculosis and to present the methods of diagnosis and treatment. The diagnosis of this disease is difficult and still remains a challenge because of its insidious nature, the variability of presentation and limitations of available diagnostic tests. The disease usually presents a picture of lymphocytic exudative ascites. There are many complementary tests with variable sensitivities and specificities to confirm the diagnosis of peritoneal tuberculosis. Isolation of mycobacteria by culture of ascitic fluid or histological examination of peritoneal biopsy ideally performed by laparoscopy remains the investigation of choice. The role of PCR, ascitic adenosine deaminase, interferon gamma and the radiometric BACTEC system can improve the diagnostic yield. An antituberculous treatment with group 1 of the WHO for 6 months is sufficient in most cases.

Conservative management of a high output enterocutaneous fistula in abdominal tuberculosis.

A 25-year-old lady with a high-output, tuberculous, entero-cutaneous fistula was managed successfully by conservative means in a teaching hospital in Nairobi, Kenya.