Diagnosis Of Tuberculous Peritonitis Research Articles

#593 Prevalence and outcomes of tuberculous peritonitis among CAPD patients in National Kidney and Transplant Institute from January 2016 to January 2023

Abstract Background Continuous ambulatory peritoneal dialysis is a cost effective and efficient modality of renal replacement therapy. However, infectious processes such as peritonitis may lead to peritoneal membrane failure necessitating shift to hemodialysis. Tuberculous peritonitis is an unusual cause of peritonitis, which may lead to risk of hospitalization and significant morbidity and mortality. Aims To determine the prevalence and outcomes of tuberculous peritonitis among patients on continuous ambulatory peritoneal dialysis Method A retrospective, descriptive study of patients on continuous ambulatory peritoneal dialysis with tuberculous peritonitis from January 2016 to January 2023 in National Kidney and Transplant Institute. Demographic, clinical and laboratory data of patients with TB peritonitis were collected via chart review. Results Among 1182 patients on continuous ambulatory peritoneal dialysis, 2.03% had tuberculous peritonitis. Average length of time from development of symptoms to diagnosis is 24.5 days. Majority of presenting symptoms were hazy drain and abdominal pain. 66.7% retained their peritoneal dialysis catheter. PD catheter was removed in 33% of TB peritonitis due to peritoneal dialysis failure and unresolving peritonitis. Mortality was 37.5% after diagnosis of tuberculous peritonitis. Only significant factor associated with mortality was length of time on continuous ambulatory peritoneal dialysis to development of TB peritonitis (p = 0.0332). Conclusion Relative high prevalence of tuberculous peritonitis could be related to high background occurrence of tuberculosis in the country. Majority of cases had resolution of symptoms and effective dialysis during course of anti-tuberculous treatment and did not warrant peritoneal dialysis catheter removal.

Tense Ascites in a Young Man Aged 24 Years Due to TB Peritonitis: Case Report

Tuberculous peritonitis is parietal or visceral peritoneal inflammation caused by Mycobacterium tuberculosis bacteria. Pathogenesis Tuberculous peritonitis is preceded by M. tuberculosis infection followed by spread to the peritoneum. This is a report from a young male patient with the main complaint of an increasingly enlarged stomach in 2 weeks and weight loss accompanied by other symptoms such as fever, nausea, vomiting, difficulty breathing. Investigation showed anemia, the results of Adenosine deaminase (ADA) ascitic fluid: 36.3 U/L. Radiological examination. Thorax photo showed Sinistra pleural effusion. Abdominal ultrasound found ascites. Then an ascitic puncture of approximately 2600 cc of greenish fluid was carried out. The diagnosis of tuberculous peritonitis is based on the Adenosine deaminase (ADA) test. Next, the patient received Fixed Drug Combination (FDC) therapy consisting of Rifampicin, Isoniazid, Pyrazinamide, and Ethambutol for 2 months, followed by a combination of Rifampicin and Isoniazid for 7-10 months. The prognosis of tuberculous peritonitis is fair if diagnosis is prompt and the patient is treated adequately.

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.

Acid fast bacillus smear, mycobacterial culture and Xpert MTB/RIF assay for the diagnosis of tuberculous peritonitis in patients with and without end stage renal failure.

Introduction. Diagnosis of tuberculous peritonitis (TBP) requires a high index of suspicion.Hypothesis /gap statement. Information about the diagnostic features of TBP among patients with end-stage renal failure (ESRF) from India is limited.Aim. To assess the utility of the Gene Xpert MTB/RIF assay in the diagnosis of TBP in patients with end-stage renal failure (ESRF), compared with those without ESRF.Methodology. This prospective observational single centre cohort study was performed at a tertiary care centre in Northern India. Ascitic fluid and/or whole continuous ambulatory peritoneal dialysis (CAPD) bag with effluent from 300 clinically suspected cases of TBP were included in the study. Diagnosis was based on detection of Mycobacteria on smear, Xpert MTB/RIF assay and/or culture. Cell counting was done in a Neubauer chamber. Cell predominance was seen by Giemsa stain. Line probe assay (LPA) for drug susceptibility testing was performed on all positive cultures.Results. TBP was diagnosed in 168 cases. Diabetes mellitus was a significant risk factor for developing TBP in patients with ESRF (P value<0.01). Lymphocytic predominance was seen in 21 patients without ESRF (P value 0.033) while majority of the patients in both groups had neutrophils in their ascitic and peritoneal fluids (138/168; P value 0.033). We recovered 15 cases of laboratory diagnosed TBP (11 without ESRF and four with ESRF). Microscopy was positive in two cases while ten isolates were recovered on culture. The Xpert MTB/RIF assay was positive in seven ascitic fluid samples out of which three were rifampicin resistant. All these were patients without renal failure (P value 0.010). Eight culture positive samples tested by the line probe assay did not detect any resistance to either rifampicin or isoniazid.Conclusion. The GeneXpert MTB/RIF assay has a limited value in the diagnosis of TBP in patients with ESRF.

Tuberculous peritonitis in peritoneal dialysis: report of three cases

Tuberculous peritonitis is a rare but dreaded complication in peritoneal dialysis.&#x0D; We report three cases of tuberculous peritonitis diagnosed in our PD center at over a period of 15 years.&#x0D; They are a woman and two men aged 50, 45 and 64 respectively.&#x0D; The diagnosis of tuberculous peritonitis was suspected in front of a many of clinical (AEG, abdominal pain, cloudy liquid), biological (inflammatory syndrome, the dialysate liquid with lymphocyte predominance and negative culture) and or radiological (abdominal lymphadenopathy) arguments.&#x0D; It was confirmed by the demonstration of Mycobacterium Tuberculosis in the dialysate by GeneXpert or by culture on LOWENSTEIN Jensen medium in 2 cases, and the characteristic appearance on anatomopathological examination in only 1 case.&#x0D; The evolution under antituberculous treatment was favorable, with recourse to the ablation of&#x0D; The diagnosis of tuberculous peritonitis in peritoneal dialysis is difficult and often late because the clinical signs is non-specific. It should be considered in the presence of any culture-negative peritonitis that is refractory to empirical treatment.&#x0D; Bacteriological or histological confirmation should not delay the start of anti-tuberculosis treatment because early diagnosis and rapid initiation of treatment are the keys to recovery and the only guarantee of a good prognosis.

Tuberculous peritonitis during pregnancy: Case report

Introduction: Tuberculous Peritonitis (TP) in pregnancy is a rare condition, and the diagnosis can be deleyed because of the symptoms non specificity. Case report: 31-year-old parturient primigravidia at 34 weeks of amenorrhea presented diffuse and intense abdominal pain with vomiting. Examination found abdominal distention with ascites. Investigations did not lead to a precise diagnosis, therefore, an exploration by laporotomy with cesarean delivery were performed. The diagnosis of Tuberculous peritonitis on histopathologic examination was confirmed. Discussion: Tuberculous peritonitisis extremely rare in pregnancy, and the rate of TP among all forms of tuberculosis varies from 0.1% to 0.7% worldwide. Gold standards for the diagnosis of TP are the identification of M. tuberculosis in ascites and peritoneal biopsy findings compatible with tuberculosis. Bacteriologic examination of the biopsy specimen should be performed, because this could be positive for tuberculosis when histological examination is negative. Conclusion: The early diagnosis and treatment of TP in pregnancy are important to prevent obstetric and neonatal morbidities. Keywords: tuberculous peritinitis; pregnancy; rare; delayed diagnosis.

Value of gamma interferon enzyme-linked immunospot assay in the diagnosis of peritoneal dialysis-associated tuberculous peritonitis

BackgroundTuberculous peritonitis is the most common form of extrapulmonary tuberculosis infection in peritoneal dialysis patients. However, diagnosing tuberculous peritonitis quickly and early has always been a challenge for nephrologists. Mycobacterium tuberculosis antigen-specific gamma interferon enzyme-linked immunospot (IFN-γ ELISPOT) assay has been widely used in the clinical diagnosis of tuberculous pleurisy and peritonitis, but its use has not been reported for uremia.MethodsThis study mainly verified the feasibility of using the M. tuberculosis antigen-specific IFN-γ ELISPOT assay in the diagnosis of continuous ambulatory peritoneal dialysis (CAPD) patients with tuberculous peritonitis. Taking M. tuberculosis culture as the gold standard, the IFN-γ ELISPOT assay was used to analyze peripheral blood and peritoneal dialysis fluid of patients, and the receiver operating characteristic (ROC) curves in patients with tuberculous peritonitis (TBP) or non-tuberculous peritonitis (NTBP) were analyzed.ResultsThe area under the receiver operating characteristic curve (AUC) was 0.927 (95% CI 0.816–1.000, P = 0.001) for the ELISPOT assay with peritoneal fluid mononuclear cells (PFMC), which was higher than that for the ELISPOT assay with peripheral blood mononuclear cells (PBMC) (0.825, 95% CI 0.6490–1.000, P = 0.011). The cutoff value for the diagnosis of TBP was 40 spot-forming cells (SFCs)/2 × 105 for the ELISPOT with PBMC, with a sensitivity of 55.6%, a specificity of 92.3%, and a diagnostic efficiency of 77.3%. The cutoff value for the diagnosis of TBP was 100 SFCs/2 × 105 for the ELISPOT on PFMC, with a sensitivity, specificity, and diagnostic efficiency 77.8%, 84.6%, and 81.8%, respectively. Parallel and serial testing algorithms appeared more accurate than single ELISPOT assays with PBMC, but ELISPOT assays with PFMC.ConclusionsThe IFN-γ release test can be used for the early diagnosis of CAPD-related TBP; compared with peripheral blood, peritoneal fluid may be a more effective and accurate medium to diagnose CAPD complicated with tuberculous peritonitis.

Visual PET/CT scoring of mesenteric fdg uptake to differentiate between tuberculous peritonitis and peritoneal carcinomatosis.

We aimed to differentiate tuberculous peritonitis (TBP) from peritoneal carcinomatosis (PC) using a visual positron-emission tomography/computed tomography (PET/CT) scoring system based on mesenteric fluorodeoxyglucose (FDG) uptake. PET/CT scans from 31 patients with TBP and 92 patients with PC were retrospectively reviewed. A visual PET/CT scoring system for mesenteric FDG uptake was used according to the following characteristics: FDG uptake intensity (low = 0, moderate = 1, high = 2), FDG uptake deposits (uniform = 0, irregular = 1, ascitic = 2), FDG uptake focality (diffuse = 0, segmental = 1, focal = 2), nodularity on the corresponding CT (nonnodular = 0, micronodular = 1, macronodular = 2) and mesenteric lymphadenopathy (absent = 0, lymphadenopathy without FDG uptake = 1, lymphadenopathy with FDG uptake = 2). The FDG uptake intensity, deposits, focality, nodularity and mesenteric lymphadenopathy scores between TBP and PC were compared using chi-square tests. The diagnostic performance of this scoring system for differentiating TBP from PC was analyzed using a receiver operating characteristic (ROC) curve. P < 0.05 was considered statistically significant. Twenty-four patients with TBP (77.4%) and 56 patients with PC (60.9%) had mesenteric FDG uptake (P = 0.095) and were included for evaluation with the visual PET/CT scoring system. PC lesions scored higher than TBP lesions in FDG uptake deposits (P < 0.001), focality (P < 0.001) and nodularity (P < 0.001). No significant differences were observed between PC and TBP lesions in FDG uptake intensity (P = 0.396) and lymphadenopathy (P = 0.074). The total score that combined deposits, focality and nodularity had significant value for differentiating TBP from PC (area under the curve (AUC) = 0.869, P < 0.001), and a cutoff > 1 had a sensitivity (the accuracy for diagnosis of PC) of 80.4% and a specificity (the accuracy for diagnosis of TBP) of 75.0%. A visual PET/CT scoring system based on mesenteric FDG uptake performed well in differentiating between TBP and PC.

P1217VALUE OF MYCOBACTERIUM TUBERCULOSIS SPECIFY ELISOPT IN THE DIAGNOSIS OF PERITONEAL DIALYSIS-ASSOCIATED TUBERCULOUS PERITONITIS PATIENTS

Abstract Background and Aims Patients with ESRD undergoing chronic dialysis are 6 to 25 times more likely to develop tuberculosis (TB) than the general population. Tuberculous peritonitis is the most common form of tuberculosis infection in peritoneal dialysis patients. However, diagnosing active TB infection can be challenging, early and rapid diagnosis of tuberculous peritonitis has always been a challenge for nephrologists. M.tuberculosis antigen-specific IFN-γ production by peripheral blood mononuclear cells (PBMC) was determined by using an in-house ELISPOT assay by Institute of Hepatology of Shenzhen Third Hospital.In this study, we evaluated diagnostic performance of an M.tuberculosis antigen-specific gamma interferon enzyme-linked immunospot (ELISPOT) assay in continuous ambulatory peritoneal dialysis (CAPD) patients with tuberculous peritonitis. Method There were nine patients (1.29%) with tuberculous peritonitis among 700 CAPD patients. M. tuberculosis accounted for 2.84 % of all peritonitis.IFN-γ response in peripheral blood and peritoneal fluid were determined in 9 patients with tuberculous peritonitis(TBP),at the same time, 13 cases diagnosed with non-tuberculous peritonitis(NTBP) were enrolled.All patients were examined for tuberculosis-specific IFN-γ ELISPOT in peripheral blood and peritoneal dialysis fluid. Results 22 patients were recruited into this study, 9 were classified with confirmed tuberculosis peritonitis, 13 patients with bacterial or fungal peritonitis were enrolled as controls during the same period, in this patients, 3 were caused by Gram positive bacteria, 3 were caused by Gram negative bacteria, 3 were caused by fungus, 4 patients were negative athogenic bacteria culture .The AUC of ROC curve was 0.927 (95%CI:0.816–1.000,P=0.001) for ELISPOT on PFMC, which was higher than that of ELISPOT on PBMC (0.825,95%CI: 0.6490–1.000,P=0.011).When the cutoff value for the diagnosis of TBP was 40.5 SFCs/2 × 105 for ELISPOT on PBMC, with a sensitivity of 55.6%, a specificity of 92.3%,a diagnostic efficiency of 77.3%,The positive predictive value was83.3%, with negative predictive value of 75%,positive likelihood ratio of 7.2, and negative likelihood ratio of 0.48.The sensitivity, specificity,diagnostic efficiency,PPV, NPV, LR+, and LR- of the ELISPOT assay for the diagnosis of active TBP when performed on the PFMC were 77.8%, 84.6%, 81.8%, 77.8%, 84.6%, 5.05 and 0.26, respectively.Receiver operating characteristic(ROC) curves were used to estimate the diagnostic values of Elispot on PFMC and PBMC in 22 patients with confirmed TBP or NTBP. Conclusion IFN-γ release test can be used for early diagnosis of CAPD-related TBP; compared with peripheral blood, peritoneal dialysate may be a more effective and accurate way to diagnose CAPD complicated with tuberculous peritonitis.

Transabdominal ultrasound as a screening stage for the diagnosis of tuberculous peritonitis

За последние годы отмечен рост числа случаев туберкулезного перитонита. Туберкулез брюшины — сложный объект для диагностики и нередко верификация диагноза происходит со значительными задержками. В клинической практике предложен непродолжительный и доступный метод лучевой диагностики при подозрении на туберкулезный перитонит — ультразвуковое исследование (УЗИ). Целью работы было описать эхо-семиотику туберкулезного перитонита с созданием интегральной шкалы оценки значимости отдельных эхо-симптомов туберкулеза брюшины и определить роль УЗ-сканирования в верификации диагноза. Произведен ретроспективный анализ инвазивной и УЗ-диагностики 37 пациентов с подтвержденным туберкулезным перитонитом в период с 2009 по 2019 г. В качестве группы сравнения использовали такие же данные исследований у 28 больных с заболеваниями, часто имитирующими туберкулезный перитонит (канцероматозом и саркоидозом брюшины, неспецифическим асцитом). Выделены прямые и косвенные признаки поражения брюшины при туберкулезе, на основании этого создана интегральная шкала оценки значимости отдельных эхо-симптомов. С этой целью каждому эхо-симптому присваивали от 0 до 3 баллов. При оценке визуализации описанных эхо-признаков возможно прогнозировать вероятность туберкулезной этиологии заболевания. Получены следующие статистические данные: низкая вероятность наличия туберкулезного перитонита при оценке визуализации всех описанных эхо-симптомов — до 4 баллов, средняя — от 5 до 8 баллов, высокая 9 и более баллов. Разработанная интегральная схема оценки УЗ-признаков позволяет клиницисту на основании эхографического исследования верифицировать туберкулезный перитонит или выбрать дальнейшую тактику в диагностическом поиске.

Transabdominal ultrasound as a screening stage for the diagnosis of tuberculous peritonitis

In recent years, the incidence of tuberculous peritonitis increased. Peritoneal tuberculosis is difficult to diagnose, and often the diagnosis is verified with significant delay. In clinical practice, a quick and affordable diagnostic radiology method, ultrasonography (USG), is proposed for patients with suspected tuberculous peritonitis. The study was aimed to describe the sonographic semiology of tuberculous peritonitis, to create the integrated scale for the individual peritoneal tuberculosis sonographic symptoms significance assessment, and to determine the role of ultrasound imaging in the diagnosis verification. Retrospective study of the invasive and ultrasound investigation results of 37 patients with confirmed tuberculous peritonitis was carried out in 2009–2019. Similar data obtained by investigation of 28 patients with the disorders which often mimic the tuberculous peritonitis (peritoneal carcinomatosis and sarcoidosis, non-specific ascites) were used as a comparison group. Direct and indirect signs of peritoneal lesion in patients with tuberculosis were identified. On the basis of that, an integral scale for the individual sonographic symptoms significance assessment was created. Each sonographic symptom received a 0–3 score. Assessment of those sonographic signs visualization allowed us to evaluate the probability of the disorder’s tuberculous etiology. The following data were obtained: score under 4 corresponded to low probability, score 5–8 corresponded to medium probability, and score over 9 corresponded to high probability of tuberculous peritonitis based on the visualization of all described songraphic symptoms. The proposed integrated scale for the sonographic signs assessment allows the clinician to verify the tuberculous peritonitis diagnosis based on the ultrasound imaging data or to select the further tactics of diagnosis.

Multicenter evaluation of the acid-fast bacillus smear, mycobacterial culture, Xpert MTB/RIF assay, and adenosine deaminase for the diagnosis of tuberculous peritonitis in China

BackgroundThe aim of this study was to assess the validity of GeneXpert MTB/RIF (Xpert) and adenosine deaminase (ADA) in the diagnosis of tuberculous peritonitis (TBP). MethodsThe laboratory results of peritoneal effusion (PE) specimens from patients with symptoms suggestive of TBP, attending three TB specialized hospitals between January 2016 and December 2018, were included retrospectively. Clinically diagnosed TBP was set as the gold standard to evaluate the performance of these methods. ResultsIn total, 191 individuals presenting with symptoms suggestive of TBP were included for analysis. The sensitivities of MGIT culture and Xpert were 17.2% and 18.3%, respectively. In addition, the TBP cases (69.8±6.0U/l) had higher amounts of ADA in their PE samples than the non-TBP cases (12.6±1.6U/l; p<0.01). Using a threshold of 31.5U/l to differentiate the TBP group from non-TBP group, the ADA assay provided a sensitivity of 89.6% and a specificity of 92.1%. The mean ADA concentration was significantly higher in bacteria-positive cases than in bacteria-negative cases (p<0.01). ConclusionsIn conclusion, the study data demonstrate the high sensitivity and specificity of the ADA test for the early diagnosis of TBP. In addition, the ADA concentration is directly correlated with the mycobacterial load.

Tuberculous peritonitis diagnosed using laparoscopy with assistance of a central venous catheter.

Laparoscopy with peritoneal biopsy is a tool for rapid and accurate diagnosis of tuberculous peritonitis (TBP). However, laparoscopic procedures are not risk-free; complications include injuries to the gastrointestinal tract and major blood vessels. The purpose of the present study was to introduce a novel method for safe and straightforward laparoscopic diagnosis of TBP. A case series of 12 patients with TBP diagnosed between October 2012 and November 2013 at our hospital is presented. The patients underwent a novel method of laparoscopy involving the use of a central venous catheter (CVC). The diagnosis was confirmed by biopsy and histology. The efficacy of the method for TBP diagnosis was evaluated by the time taken for the procedure and the rate of successful completion. The safety of the method was evaluated by recording all intra- and post-operative adverse events encountered. The mean age of the patients was 41 years and 33% were male. The mean operation time was 50.6 min and the median duration of hospital stay was 7 days. In all cases, diagnostic laparoscopy was successfully performed. Targeted biopsies were taken from all of the patients and revealed caseous granulomatous inflammation. All patients tolerated the procedure without significant bleeding or digestive tract perforation. In conclusion, the present case series demonstrated a novel method of diagnostic laparoscopy with CVC that is a feasible and straightforward procedure for TBP diagnosis.

GeneXpert Technique a New Diagnostic Modality for Diagnosis of Tuberculous Peritonitis in Patients on CAPD with a Review of Literature

Tuberculous peritonitis is largely an undetected entity in developing countries among patients on CAPD. GeneXpert is a newer tool used in the diagnosis of Mycobacterial tuberculous peritonitis. This paper presents a report on the application of GeneXpert as a rapid and useful diagnostic tool in the diagnosis of Mycobacterial tuberculous peritonitis. After initiation of antituberculous therapy, the use of GeneXpert for the response to treatment is discussed. We used GeneXpert as a rapid diagnostic tool in four patients for the diagnosis or exclusion of MTB peritonitis. One diabetic male patient tested positive for GeneXpert; in other three patients, GeneXpert test was negative. After initiation of antituberculous therapy in the patient with positive GeneXpert, the dialysis effluent became clear within 3 days and repeat GeneXpert tested after 10 days was reported negative. A second patient had smear positive with refractory peritonitis due to co infection with Coagulase negative staphylococcus and budding yeast. In the other two suspected patients, GeneXpert, AFB smear, and Mycobacterial culture were negative. GeneXpert contributes to rapid diagnosis of Mycobacterium tuberculous complex and also in the identification of rifampicin resistance in two hours, whereas conventional tuberculosis culture takes 3-8weeks to show a positive result. However, Mycobacterial culture remains the gold standard for the diagnosis of mycobacterial tuberculous peritonitis as GeneXpert has not been widely applied for diagnosis of peritonitis in chronic peritoneal dialysis patients.

A case of tuberculous peritonitis diagnosed by way of laparoscopy

Objective: Tuberculous peritonitis (TBP) is a rare form of extrapulmonary tuberculosis. The diagnosis of TBP is particularly challenging in children. Herein, we present a child who had been admitted with ascites and diagnosed as TBP by way of laparoscopy. Case report: A previously healthy 3-year-old girl was presented with newly onset fever and abdominal pain. She had abdominal distention and generalized tenderness on palpation. Abdominal percussion revealed dullness on nonspesific locations. Abdominal ultrasonography showed diffuse ascites with multiple septations, and paracenthesis performed detected exudative material with plenty of polmorphonuclear leukocytes. She was started on antibiotherapy. Lymphocytic pleocytosis persisted on control peritoneal lavage sample. Acid- resistant bacteria were not seen in the peritoneal fluid, tuberculous polymerase chain reaction test and tuberculous cultures were negative. Cytopathologic examination was not suggestive of malignancy. Diagnostic laparoscopy was compatible with TBP. Adenosine deaminase (ADA) level in peritoneal fluid was increased. She was started on quadruple antituberculous treatment including isoniazid (INH), rifampicin (RIF), pyrazinamide and ethambutol. On the 2nd month of antituberculous therapy, abdominal circumference showed obvious regression. She continued on INH-RIF therapy and is still being followedup in our outpatient clinic. Conclusion: Explorative laparoscopy and peritoneal fluid ADA level are very helpful in the diagnosis of TBP

腹腔鏡下手術が結核性腹膜炎の診断に有用であった1例－結核性腹膜炎の診断と感染対策－

A 79-year-old woman who had diabetes mellitus, dementia, and breast cancer was referred to our hospital because of ascites. She had no respiratory syndrome. Blood tests revealed an elevated CA125 level (1,224 U/mL), but other tumor markers were within their normal limits. Chest radiography and abdominal computed tomography (CT) detected no signs of malignancy or tuberculosis, but positron emission tomography/CT disclosed abnormal FDG uptake in the omentum, mediastinal lymph node, and diaphragm. Microbiological testing and cytological examination of ascites yielded negative results. We conducted diagnostic laparoscopy while wearing N95 masks and found numerous tiny nodular lesions on the peritoneal surfaces. Pathological examination showed epithelioid granuloma and Langhans giant cells with caseous necrosis, which are characteristic to tuberculosis. Although the Ziehl-Neelsen staining result was negative, interferon-gamma release assays were positive. Tuberculous peritonitis (TBP) was diagnosed, and a combination drug regimen of isoniazid, rifampicin, and pyrazinamide was administered. She has been free from recurrence since the completion of chemotherapy. Throughout the clinical course, Mycobacterium tuberculosis was undetected. TBP is a form of abdominal and pelvic tuberculosis that accounts for about 0.04% of all cases of tuberculosis. The risk is increased in patients with cirrhosis, acquired immune deficiency syndrome, diabetes mellitus, steroid use, or underlying malignancy, and those undergoing continuous ambulatory peritoneal dialysis. TBP, which might be confused with widespread ovarian cancer, should be included in the differential diagnosis of ascites. Because preoperative diagnosis of TBP is difficult, laparoscopic surgery is helpful to distinguish TBP from ovarian cancer. We also suggest the importance of assessing the risk of infectiousness of TBP patients.

Role of ascitic fluid adenosine deaminase (ADA) and serum CA-125 in the diagnosis of tuberculous peritonitis.

This cross sectional study was carried out in the department of gastroenterology, BIRDEM, Dhaka from January 2010 to May 2011 to determine the role of ascitic fluid ADA and serum CA-125 in the diagnosis of clinically suspected tubercular peritonitis. Total 30 patients (age 39.69 ± 21.26, 18M/12F) with clinical suspicion of tuberculosis peritonitis were included in this study after analyzing selection criteria. Laparoscopic peritoneal biopsy with 'histopathological diagnosis' was considered gold standard against which accuracics of two biomarkers (ADA & CA-125) were compared. Cut off value of ADA and CA-125 are 24 u/l, 35 U/ml respectively. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of ADA as a diagnostic modality in tuberculos peritonitis were 87.5%, 83.33%, 95.45%, 62.5% and 86.67% respectively where as CA-125 was found to have 83.33% sensitivity, 50% specificity, 86.9% positive predictive value, 42.85% negative predictive value and 76.6% accuracy. Both biomarkers are simple, non-invasive, rapid and relatively cheap diagnostic test where as laparoscopy is an invasive procedure, costly & requires trained staff and not without risk and also not feasible in all the centre in our country. So ascitic fluid ADA and serum CA-125 are important diagnostic test for peritoneal tuberculosis.

Ancillary tests to improve the accuracy of laparoscopy in the diagnosis of tuberculous peritonitis

It has been suggested in your journal that laparoscopy and biopsy should be deployed to diagnose tuberculous peritonitis.1 In 1993, the World Health Organization took an unprecedented step and declared tuberculosis (TB) a global emergency.2 The prevalence of extrapulmonary TB is rising, possibly related to coinfection with HIV. In patients with extrapulmonary TB, the abdomen is involved in 11% of patients.2 Tuberculous peritonitis is believed to exhibit a female predominance; other causes of abdominal pain may delay diagnosis. Over a 2-year period, we carried out a prospective study of 92 patients admitted to the Government Medical College at Srinagar with the clinical suspicion of abdominal TB. Of these patients, 50 were subsequently proven by biopsy to have peritoneal TB. All the patients underwent the following diagnostic tests after a thorough clinical examination: erythrocyte sedimentation rate (ESR); Mantoux test; ascitic fluid analysis for adenosine deaminase (ADA) levels, Ziehl–Neelsen staining and culture of mycobacterium tubercle bacilli (MTB); and contrast enhanced computed tomography (CT) of the abdomen. We then undertook diagnostic laparoscopy. Features of a positive laparoscopy included thickened peritoneum, adhesions and peritoneal tubercles, which were biopsied (Fig. 1). Our patients were mainly young adults from rural areas, with a slight female predominance. Patients presented with fever (50%), weigh loss (40%), aneroxia (74%), malaise/pain (80%), diarrhea (10%), vomiting (40%) and constipation (25%). Physical signs were palor (74%), tender abdomen (70%), abdominal distension (50%), abdominal mass (20%), ascitis (15%) and lymphadenopathy (8%). The Mantoux test was positive in 23 patients (46%). Anaemia was present in 84% of patients and the ESR was high in 90%. Fig. 1 Adhesions between the colon and the parietal peritoneum in a patient with tuberculous peritonitis. Diagnostic laparoscopy was positive in 46 of 50 patients with biopsy-proven peritoneal TB, with a sensitivity of 92%. Contrast enhanced CT of the abdomen detected 30 of 50 cases of abdominal TB with a sensitivity of 60% and specificity of 71.42%. Ziehl–Neelsen staining for MTB of ascitic fluid was positive in only 2 patients (4%) and culture for MTB was positive in 8 cases (16%), whereas ascitic fluid polymerase chain reation (PCR) for TB increased the sensitivity to 83.33%. Ascitic fluid analysis for ADA (> 33 U/L) showed a sensitivity and specificity of 100% and 96%, respectively. Diagnostic laparoscopy was falsely positive in 10 of 42 patients who did not have TB peritonitis. Difficulties in the diagnosis of TB peritonitis owe to its nonspecific associated clinical features, unhelpful laboratory tests and a high level of false-negative tests (i.e., Mantoux test, Ziehl–Neelsen staining and culture of ascitic fluid and false-negative imaging). High levels of ascitic ADA is associated with TB peritonitis.3 Ascitic fluid was found clinically in only 15% of our patients, but may be available at the time of operation. Histopathology of peritoneal lesions is appropriate for diagnosing TB and to rule out other diseases, such as cancer. In the past, this required laparotomy4 even though the potential for laparoscopy was known before the advent of video laparoscopy.5 We agree with the previous report1 on the value of laparoscopy, but we found a false-positive rate of 18%. We suggest that the laparoscopic diagnosis of TB peritonitis be confirmed by histopathology of peritoneal lesions or ascitic fluid analysis for ADA greater than 33 U/L, depending on the local availability of these tests.

Tuberculous Peritonitis Mimicking Primary Peritoneal Carcinoma

Tuberculous peritonitis is one of the most common extrapulmonary tuberculosis. The presenting signs and symptoms, together with the carbohydrate antigen (CA) 125 status and imaging findings may resemble the primary peritoneal carcinoma or ovarian carcinoma. We herein report a case on a 71-year-old woman who is presented with abdominal distension, abdominal pain, nausea, anorexia. Abdomino-pelvic computed tomography scans reveal large amounts of ascites and mottled omentum with diffuse nodular masses, and the serum CA 125 level is elevated. The initial clinical diagnosis is the primary peritoneal carcinoma, but the final histological diagnosis confirms the tuberculous peritonitis. Thus, we discuss the differential diagnosis of tuberculous peritonitis from primary peritoneal carcinoma and also the problems especially found in old aged patients. In conclusion, although the elderly patients are suspected with malignancy, we should keep in mind the possibility of curable diseases and perform laparoscopic biopsy during the early stage aggressively.

T-SPOT.TB in the diagnosis of tuberculous peritonitis

To evaluate the value of T-SPOT.TB in the diagnosis of tuberculous peritonitis (TBP). A total of 50 patients with clinically suspected TBP admitted from August 2011 to July 2012 from the Third Xiangya Hospital were enrolled in this prospective cohort study. Peripheral blood T-SPOT.TB, purified protein derivatives of tuberculin (PPD) skin test, serum tuberculosis antibody (TB-Ab) and ascitic adenosine deaminase (ADA) were measured in the 50 patients and we compared the diagnostic value of the 4 methods. According to the standard of diagnosis of TBP and grouping, 24 patients were diagnosed with TBP, 17 non-TBP and 9 undiagnosed in the end. The sensitivity of T-SPOT.TB for the diagnosis of TBP was 91.7% (22/24), with statistical significance when compared with PPD skin test 37.5% (9/24), serum TB-Ab 16.7% (4/24), and ascitic ADA 36.4% (8/22) (P<0.01). The specificity of T-SPOT.TB for the identification of non-TBP was 76.5% (13/17), without statistical significance when compared with PPD skin test 70.0% (7/10), serum TB-Ab 78.6% (11/14), and ascitic ADA 100% (14/14) (P>0.05). The positive prediction value of T-SPOT.TB for the diagnosis of TBP was 84.6% (22/26), without statistical significance when compared with PPD skin test 75.0% (9/12), serum TB-Ab 57.1% (4/7), and ascitic ADA 100%(8/8) (P>0.05). The negative prediction value of T-SPOT.TB for the identification of non-TBP was 86.7% (13/15), with statistical significance when compared with PPD skin test 31.8% (7/22), serum TB-Ab 35.5% (11/31), and ascitic ADA 50.0% (14/28) (P<0.05). Peripheral blood T-SPOT.TB for the diagnosis of TBP is highly sensitive, which is better than PPD skin test, serum TB-Ab, and ascitic ADA. T-SPOT.TB has an important reference for diagnosing suspected TBP quickly and accurately.