A Critical Appraisal of Clinicopathological, Imaging, and GeneXpert Profiles of Surgical Referrals with Pediatric Abdominal Tuberculosis.

Abstract

To study the clinicopathological, imaging, and GeneXpert profiles of surgical referrals with abdominal tuberculosis (TB) and to compare the utility of GeneXpert versus conventional diagnostic armamentarium. This cohort study which was conducted over a study period of 8 years (2011-18) included seventy-seven children operated with a provisional diagnosis of abdominal TB and those who had either histological (n = 58; 75.3%) or GeneXpert (n = 9) confirmation or had miliary tubercles on exploration with supportive clinical and imaging findings (n = 17; 22.1%). GeneXpert testing was added to the diagnostic armamentarium only in the latter half of the study (2016-18, n = 31). Demographic details, symptomatology, prior antitubercular treatment, GeneXpert positivity, imaging, operative, and histological findings were recorded and analyzed using mean, standard deviation, and range for continuous variables and proportion for categorical variables. Perforation peritonitis (n = 26; 33.8%) and unrelieved obstruction (n = 51; 66.2%) were the main surgical indications. The mean age at presentation was 9.5 ± 3.6 years with a distinct female preponderance. The presence of right lower abdomen lump (n = 23; 29.9%), alternate diarrhea and constipation (n = 34; 44.1%), tubercular toxemia (n = 38; 49.4%), positive history of contact (n = 20; 25.9%), tuberculin positivity (n = 38; 49.4%), fibrocavitary pulmonary lesion (5.2%), clumped bowel loops with pulled-up cecum (n = 23; 29.9%), septated ascites (n = 17), mesenteric lymphadenopathy and omental thickening (n:18; 23.4% each) were the supportive tell-tale signs of the disease. The hallmark of pathological diagnosis was caseous necrosis with epithelioid granulomas (n = 43; 55.8%), nongranulomatous caseation (n = 15; 19.5%), and acid-fast bacilli positivity in 27.3% of patients. GeneXpert was positive in only nine patients with an overall sensitivity of 29% as compared to 75.3% for histopathology. Bacteriological and histological confirmation of the disease eluded us in a significant proportion of patients, requiring a very high index of clinical suspicion to clinch the diagnosis. The current version of GeneXpert has low sensitivity in diagnosing pediatric abdominal TB.