Diagnosis Of Tuberculous Peritonitis Research Articles

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.

Acute intestinal obstruction as the first manifestation of tuberculous peritonitis

A case of dynamic ileus resulting from tuberculous peritonitis (TBP) is presented, which was treated with exploratory laparotomy and administration of antituberculosis therapy. TBP accounts for 0.1–0.7% of all cases of TB and usually presents as a subacute disease. Acute abdomen sometimes complicates TB, mainly because of intestinal perforation or obstruction. A 20-year-old Pakistani male presented with symptoms and signs of intestinal obstruction. An exploratory laparotomy revealed ascites, small bowel distention due to adhesions around the terminal ileum, whitish nodules covering the inflamed peritoneum and omentum, enlarged mesenteric lymph nodes, and a saccular-shaped whitish mass measuring 11x7x5 cm at the right iliac fossa. Adhesiolysis, removal of the abovementioned mass, and an appendectomy was performed, and samples were obtained for microbiological and histological examination. The tuberculin skin test was positive, and since the intraoperative findings were highly suggestive of TBP, initiation of antituberculosis therapy on the 11th postoperative day was decided. Finally, the diagnosis of TBP was established both microbiologically and histologically. The patient successfully completed a 6-month regimen of antituberculosis drugs. Acute abdomen necessitating exploratory laparotomy is a rare first manifestation of TBP. Early initiation of antituberculosis therapy should take place if intraoperative findings strongly favour the diagnosis of TBP.

Assessment by meta-analysis of interferon-gamma for the diagnosis of tuberculous peritonitis

To investigate the performance and diagnostic accuracy of interferon-gamma (IFN-γ) for tuberculous peritonitis (TBP) by meta-analysis. A systematic search of English language studies was performed. We searched the following electronic databases: MEDLINE, EMBASE, Web of Science, BIOSIS, LILACS and the Cochrane Library. The Standards for Reporting Diagnostic Accuracy initiative and Quality Assessment for Studies of Diagnostic Accuracy tool were used to assess the methodological quality of the studies. Sensitivity, specificity, and other measures of the accuracy of IFN-γ concentration in the diagnosis of peritoneal effusion were pooled using random-effects models. Receiver operating characteristic (ROC) curves were applied to summarize overall test performance. Two reviewers independently judged study eligibility while screening the citations. Six studies met the inclusion criteria. The average inter-rater agreement between the two reviewers for items in the quality checklist was 0.92. Analysis of IFN-γ level for TBP diagnosis yielded a summary estimate: sensitivity, 0.93 (95%CI, 0.87-0.97); specificity, 0.99 (95%CI, 0.97-1.00); positive likelihood ratio (PLR), 41.49 (95%CI, 18.80-91.55); negative likelihood ratio (NLR), 0.11 (95%CI, 0.06-0.19); and diagnostic odds ratio (DOR), 678.02 (95%CI, 209.91-2190.09). χ(2) values of the sensitivity, specificity, PLR, NLR and DOR were 5.66 (P = 0.3407), 6.37 (P = 0.2715), 1.38 (P = 0.9265), 5.46 (P = 0.3621) and 1.42 (P = 0.9220), respectively. The summary receiver ROC curve was positioned near the desirable upper left corner and the maximum joint sensitivity and specificity was 0.97. The area under the curve was 0.99. The evaluation of publication bias was not significant (P = 0.922). IFN-γ may be a sensitive and specific marker for the accurate diagnosis of TBP. The level of IFN-γ may contribute to the accurate differentiation of tuberculosis (TB) ascites from non-TB ascites.

Peritoneal tuberculosis mimicking ovarian cancer

To evaluate the characteristics of 20 patients diagnosed as tuberculous peritonitis (TBP) mimicking ovarian cancer during a 10-year period at a single center. Among 612 operations for ovarian malignancy we retrospectively reviewed the surgical and pathological reports of 20 patients suspected preoperatively as having ovarian malignancy but whose pathological results revealed TBP, between 2000 and 2011 in a university clinic. Demographic characteristics, physical and pelvic examination, laboratory investigations and radiological imaging of the patients were evaluated retrospectively. Diagnostic laparotomy, laparoscopy and ultrasound guided tru-cut biopsy were performed in 11, 2 and 7 of the 20 patients, respectively. The mean age of the patients was 37.5 ± 17.3 years (range 16-70 years). The most common symptoms were abdominal pain (n=14%, 70%) and abdominal distension (n=13%, 65%). Serum CA 125 was elevated in 16 (80%) cases and the average CA 125 level was 289 ± 186.2 IU/ml. During ultrasonographic imaging and CT scans, ascites and a pelvic mass were detected in 19 (85%) and 12 (60%) patients respectively. TBP was suspected in 7 (35%) patients and ultrasound guided tru-cut biopsy was preferred as a first-line approach. Surgery was performed in 11 patients (55%) and during exploration widespread miliary nodules (n=9%, 81%), widespread adhesion (n=5%, 45%), adnexal mass (n=8%, 72%) and caseous necrotic substance (n=4%, 36%) were observed. Patients underwent unilateral (n=3% 27%) or bilateral (n=4%, 36%) salpingo-oophorectomy in seven (63%) cases. Since ovarian cancer is a serious condition and preoperative diagnosis of TBP is difficult, laparotomy is usually mandatory to distinguish these two entities. Ultrasound guided tru-cut biopsy is useful in selected patients and frozen section analysis avoids hazardous radical surgery at operation.

Role of ascites adenosine deaminase in differentiating between tuberculous peritonitis and peritoneal carcinomatosis

To investigate the usefulness of tumor markers and adenosine deaminase in differentiating between tuberculous peritonitis (TBP) and peritoneal carcinomatosis (PC). A retrospective analysis of data was performed on consecutive patients who underwent peritoneoscopic and abdominal computed tomography (CT) evaluations. Among 75 patients at the Seoul National University Hospital from January 2000 to June 2010 who underwent both tests, 27 patients (36.0%) and 25 patients (33.3%) were diagnosed with TBP and PC, respectively. Diagnosis was confirmed by peritoneoscopic biopsy. Serum c-reactive protein (7.88 ± 6.62 mg/dL vs 3.12 ± 2.69 mg/dL, P = 0.01), ascites adenosine deaminase (66.76 ± 32.09 IU/L vs 13.89 ± 8.95 IU/L, P < 0.01), ascites lymphocyte proportion (67.77 ± 23.41% vs 48.36 ± 18.78%, P < 0.01), and serum-ascites albumin gradient (0.72 ± 0.49 g/dL vs 1.05 ± 0.50 g/dL, P = 0.03) were significantly different between the two groups. Among tumor markers, serum and ascites carcinoembryonic antigen, serum carbohydrate antigen 19-9 showed significant difference between two groups. Abdominal CT examinations showed that smooth involvement of the parietal peritoneum was more common in the TBP group (77.8% vs 40.7%) whereas nodular involvement was more common in the PC group (14.8% vs 40.7%, P = 0.04). From receiver operating characteristic (ROC) curves ascites adenosines deaminase (ADA) showed better discriminative capability than tumor markers. An ADA cut-off level of 21 IU/L was found to yield the best results of differential diagnosis; sensitivity, specificity, positive predictive value, and negative predictive value were 92.0%, 85.0%, 88.5% and 89.5%, respectively. Besides clinical and radiologic findings, ascitic fluid ADA measurement is helpful in the differential diagnosis of TBP and PC.

Tuberculous Peritonitis: The Closer You Go, the More Confused You Get

We read the article entitled ‘‘Comparison between Laparoscopy and Noninvasive Tests for the Diagnosis of Tuberculous Peritonitis’’ by Hong et al. [1] with great interest. The authors presented a retrospective study of 60 patients who underwent diagnostic laparoscopy for either undiagnosed ascites (n = 19) or a condition that needed to be differentiated from peritoneal carcinoma (n = 41). Forty-one patients were diagnosed with tuberculous peritonitis (TBP). The positive and negative results of diagnostic laparoscopy were compared with ascitic deaminase levels [30 U/l and ascitic lactate dehydrogenase levels [90 U/l. The authors concluded that laparoscopy with combined biopsy is the most sensitive and the quickest method for diagnosing tubercular peritonitis. We would like to make the following observations regarding this article. The authors chose to present their results as mean ± SD. This method is always not representative, especially if data is nonuniform. This is apparent by looking at the duration of symptoms in the patients with TBP: 40 ± 57 (range, 3–360). Median ± interquartile range is a preferable method to represent the nonuniform data compared with mean ± SD [2]. The diagnosis of TBP was considered definitive by the authors, on the basis of either caseous granuloma or positive bacteriological results for M. tuberculosis. The diagnosis was considered probable in the presence of suggestive clinical and laparoscopic findings and noncaseous granuloma without positive bacteriologic findings. The authors did not mention how many patients were in the category of probable diagnosis or how many of them actually proved to be definitive case of TBP after favorable clinical response to antituberculosis therapy. The authors reported that biopsy tissues were deemed inadequate for the diagnosis in 12 of 60 cases. However, all of these patients were considered while assessing the presence of granuloma/caseous granuloma under the heading of laparoscopy in Table 4 [1]. This needs further clarification. The diagnosis of abdominal tuberculosis is classically based on microbiological confirmation [3]. Although the yield may be less, positive acid fast staining (AFB) and M. tuberculosis culture results confirm the diagnosis of tuberculosis unequivocally. The authors performed AFB of peritoneal biopsy specimen in 22 and culture for M. tuberculosis in 6 of 60 patients. Selective use of these investigations rules out the opportunity of exploring their full potential in the diagnosis of TBP. The authors mentioned that ascites was present in 92.7% (38/41) of patients of TBP. Table 2 shows that acid fast staining was conducted in 48 patients, and M. tuberculosis culture and PCR was undertaken in 48 and 39 patients respectively. The authors did not indicate why these investigations were selectively performed in a few patients and not in all patients. We believe that AFB staining, which is an inexpensive and freely available investigation, should be performed in the ascitic fluid of all patients suspected to have TBP. The authors stated that an abnormal chest X-ray was seen in 20 of 41 patients of TBP and active concomitant pulmonary disease was present in 8 patients (20%). It becomes imperative to know whether the sputum of these patients was examined for the presence of AFB. It will be interesting to know how many of these sputum AFBpositive patients were ultimately found to have TBP. P. K. Garg (&) B. K. Jain D. Mohanty Department of Surgery, University College of Medical Sciences and Guru Teg Bahadur Hospital, University of Delhi, Delhi 110095, India e-mail: dr.pankajgarg@gmail.com

Comparison between Laparoscopy and Noninvasive Tests for the Diagnosis of Tuberculous Peritonitis

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. We retrospectively studied 60 patients who had diagnostic laparoscopy for suspected TBP between January 2002 and June 2010. 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 30U/l, and the ascitic lactate dehydrogenase (LDH) level over 90U/l had relatively high positive, as well as negative, predictive values. The overall morbidity and mortality rates for laparoscopy were 5 and 5%, respectively. 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.

Tuberculous Peritonitis Mimicking Peritonitis Carcinomatosa

m s A immunocompetent man was referred to our department under the suspicion of disseminated peritonitis carcinomatosa. His physical examination was unremarkable except for slight abdominal distention. Contrastenhanced computed tomography (CT) revealed a small amount of ascites and diffusely thickened peritoneum with omental thickening (Figure A). F-18 fluorodeoxyglucose (FDG)-positron emission tomography (PET) also showed diffuse FDG uptake throughout the intraperitoneal cavity, including greater omentum and mesenterium, and slight uptake in the right supraclavicular lymph node, which strongly suggested the possibility of peritonitis carcinomatosa with metastasis to the supraclavicular lymph node (Figure B). Esophagogastroduodenoscopy and total colonoscopy showed no signs of malignancy at all. The amount of his ascites was too small for abdominal paracentesis. Exploratory laparoscopy was essential to obtain ascites intraoperatively and peritoneal biopsy specimens. Laparoscopy showed the diffusely thickened peritoneum with small white nodules, and intestines were strongly adhesive to the omentum and mesenterium (Figure C). A slight amount of yellowish serous ascites was also found in the Douglas’ pouch. The macroscopic appearance indicated tuberculosis rather than malignancy; however ascites cytology was negative. Peritoneal histology showed epitheloid granuloma formation but no findings of caseating granuloma. No signs of Mycobacterium infection were observed from the ascites culture or immunostaining specimens of the peritoneum. Therefore, the right supraclavicular lymph node was biopsied, which was enhanced in the FDG-PET/CT images. Granulomatous inflammation with necrosis was confirmed histopathologically. Mycobacterium tuberculosis infection was proved both from immunochromatography and liquid culture. We concluded that tuberculous peritonitis (TBP) caused the thickness and adhesion of the peritoneum. Quadruple drug therapy had been administered for 26 weeks. The CT scan showed remarkable improvement in the peritoneum immediately after the antituberculosis therapy. No recurrence had been observed at all since then. TBP is a well known site for extrapulmonary infection caused by Mycobacterium tuberculosis. TBP is the sixth most common extrapulmonary site in the United States.1 The risk is increased in patients with cirrhosis, HIV infection, and continuous peritoneal dialysis.2,3 However, there were no risk factors as described above in this case. Diagnosis of TBP remains a challenge because of its insidious nature. The gold standard for the diagnosis is laparoscopy and culture growth of Mycobacterium on peritoneal biopsy. The combination of acroscopic appearance and histologic findings has the senitivity of more than 90%,4 however we could not reach the final diagnosis after the laparoscopy and biopsy. Diagnostic therapy would be taken into consideration in this case, even if the cervical lymph node specimens showed no proof of tuberculosis infection.

Eosinophilic peritonitis: An unusual manifestation of tuberculous peritonitis in peritoneal dialysis patient

Eosinophilic peritonitis is an uncommon clinical entity with diagnostic considerations separate from those of tuberculous peritonitis. We report a patient on continuous ambulatory peritoneal dialysis (CAPD) with eosinophilic peritonitis resulting from tuberculous peritonitis. Acid-fast stain and mycobacterial culture of peritoneal dialysis effluent were both negative result. In the peritoneal dialysis effluent and blood samples, Mycobacterium tuberculosis was detected by polymerase chain reaction analyses. The initiation of antituberculous therapy resulted in resolution of the eosionphilia in the dialysis effluent. After 14 days of antituberculous therapy, the polymerase chain reaction analyses of tuberculosis were negative for both the blood and peritoneal dialysis effluents. Evaluation of tuberculosis infection is necessary if the CAPD-related peritonitis presents with an unusual and unexplained clinical course. Polymerase chain reaction can play an important role in the diagnosis of tuberculous peritonitis in patients undergoing CAPD.

Differentiation of tuberculous peritonitis from peritonitis carcinomatosa without surgical intervention

Background/Aim:Ascites of tuberculous peritonitis (TBP) is an exudative type and may well be misdiagnosed as carcinomatous peritonitis, especially in the elderly. The aim of this study was to identify independent predictors that can differentiate TBP from peritonitis carcinomatosa without surgical intervention.Patients and Methods:This prospective cohort study was performed on 75 subjects in the following groups: TBP (n=27) (TBP group), ovarian cancer complicated with ascites (n=24) (Ov Ca group), and gastric cancer complicated with ascites (n=24) (Ga Ca group). The frequency of clinical symptoms, laboratory parameters, and serum tumor markers levels were compared.Results:In univariate analysis; fever, night sweats, and abdominal pain were significantly more frequent in the TBP group compared to those in the Ov Ca group (P < 0.001, P < 0.001, and P = 0.035, respectively) and the Ga Ca group (P < 0.001, P < 0.001, and P = 0.015, respectively). Serum CA 19-9 and carcino embryonic antigen (CEA) levels were significantly lower in the TBP and Ov Ca group compared to the Ga Ca group (P < 0.001 and P < 0.001, respectively). Elevated serum CA 125 level was found in all patients with TBP and Ov Ca and in 86.6% of patients with Ga Ca. In the multivariate analysis, presence of fever (P < 0.001), night sweats (P < 0.001), age under 40 years (P = 0.008), and normal serum CA 19-9 level (P = 0.044) were independent predictor of diagnosis of TBP.Conclusion:The presence of fever, elevated serum CA 125 level, normal serum CA 19-9, and CEA associated with lymphocyte predominant benign ascites may establish the diagnosis of TBP.

Tuberculous peritonitis during etanercept therapy for rheumatoid arthritis

In August 2010, a 73-year-old woman with rheumatoid arthritis receiving etanercept (ETN) therapy for two years, developed high-fever and abdominal fullness. Though she had not been exposed to tuberculosis, isoniazid prophylaxis was administrated. Antibiotics were not effective. CT images revealed the massive ascites and peritonitis, and Ga scintigraphy demonstrated notable uptake in the peritoneum. Ascites analysis showed an elevated adenosine deaminase activity value (104.9 IU/l) without malignant cells. Moreover, PCR and culture for Mycobacterium tuberculosis were positive. Finally, a diagnosis of tuberculous peritonitis was established. After initiating a standard anti-tuberculosis regimen with four drugs, her clinical condition ameliorated and ascites promptly regressed. Although the tuberculous peritonitis during ETN therapy is rare, this report emphasized the importance of initial suspicion of tuberculosis in these patients with tumor necrosis factor inhibitors such as ETN.

Diagnosis of tuberculous peritonitis using endoscopic ultrasound-guided fine-needle aspiration biopsy of the peritoneum

Tuberculous peritonitis is prevalent in developing countries and its diagnosis is still challenging due to the lack of specific clinical characteristics and the difficulty in obtaining tissue from the peritoneum without laparoscopy. Endoscopic ultrasound - guided fine needle aspiration is emerging as the most effective and safe method for obtaining tissue from the structures surrounding the gut lumen. Our study aimed to elucidate the efficacy of endoscopic ultrasound-fine needle aspiration of the peritoneum in the diagnosis of tuberculous peritonitis. Three patients (2 male and 1 female; aged 38, 25, and 65 years, respectively) suspected of having tuberculous peritonitis were recruited into the study. Clinical evaluation including computed tomography imaging and analysis of ascitic fluid were performed. Endoscopic ultrasound-fine needle aspiration biopsy of the peritoneum was performed trans-gastrically with a 19-gauge ProCore needle in all patients. At least two different areas of the peritoneum suspected to be involved were sampled and paraffin-embedded cell blocks were prepared for each biopsy specimen. Biopsy specimens were positive for Mycobacterium tuberculosis by polimerase chain reaction in 2 patients and positive for multinucleated giant cells in all patients. Treatment for tuberculosis resulted in the resolution of symptoms and ascites. No procedure- related complications occured. Endoscopic ultrasound-fine needle aspiration is an efficacious and safe method to obtain tissue from the peritoneum to use in the diagnosis of tuberculous peritonitis.

Tuberculous peritonitis in a German patient with primary biliary cirrhosis: a case report

BackgroundThe number of cases of tuberculosis as a complication in people with immunodeficiency, people on immunosuppressive therapy and among the immigrant population is increasing in Germany. However, tuberculous peritonitis rarely occurs without these risks, particularly in Germans. The incidence of tuberculous peritonitis in Germany is very low; tuberculosis of the intestinal tract was found in approximately 0.8 % of tuberculosis cases in 2004. The diagnosis of tuberculous peritonitis is often delayed on account of non-specific clinical symptoms. The absence of specific biological markers, long incubation times for cultures and non-specific radiographic or ultrasonographic signs increase the morbidity associated with this treatable condition.Case presentationWe report a case of tuberculous peritonitis in a 73-year-old female German patient. Her medical history revealed primary biliary cirrhosis (PBC) since 1992. On admission, she complained of abdominal pain, vomiting, ascites and peripheral edema. The patient has been in a seriously reduced general condition and had fever up to 39.6°C. A few weeks earlier, the patient was in another hospital with the same complaint. Inflammatory parameters were elevated, but the procalcitonin level was normal. Blood culture was always negative, as was the tuberculin test. Ultrasonography of the abdomen showed massive ascites with multiple septa. The patient underwent a computed tomography (CT) scan of the abdomen which showed a thickened intestinal wall in the sigmoid colon and a pronounced enhancement of the peritoneum. Computed tomography scans of the lung showed only slight bilateral pleural effusion. Because of the anaesthetic and bleeding risk due to thrombocytopenia, laparoscopy was not immediately undertaken. The culture from ascites was positive for M.tuberculosis after three weeks.ConclusionIn primary biliary cirrhosis patients with non-specific clinical symptoms, such as vomiting, abdominal pain, ascites, weight loss, and fever, tuberculous peritonitis must be considered in the initial differential diagnosis, although these symptoms may be attributed to cirrhosis of the liver with spontaneous bacterial peritonitis. Ultrasonographic and CT scab findings are not specific for tuberculous peritonitis, but an awareness of the ultrasonographic features and the features of the CT scan may help in the diagnosis of tuberculous peritonitis and avoid clinical mismanagement.

Role of laparoscopy in the diagnosis of abdominal tuberculosis

Tuberculosis continues to be a common disease in Iran and one of its presentations is abdominal tuberculosis. Histopathological confirmation of abdominal tuberculosis is difficult because of suboptional, noninvasive access to the pathology. Laparoscopy provides minimally invasive access to the peritoneum. The aim is to evaluate the role and importance of laparoscopy in the diagnosis of tuberculous peritonitis (TP). A retrospective study on laparoscopy in Razi hospital of Rasht (in northern Iran) over a period of ten years showed that diagnostic laparoscopy was performed in 290 patients with abdominal pain, with or without ascites. Most cases revealed malignancy and we found 28 cases of abdominal tuberculosis. Macroscopic findings of TP were whitish granulations over both peritoneal layers, inflammatory adhesions on the visceral or parietal surface, thickening, hyperemia and retraction of the greater omentum and stalactic band which is characteristic of TP. Pathology confirmed TP in 28 cases and all patients had excellent response to medical therapy. Although other diagnostic methods of TP such as imaging, culture of ascitis and polymerase chain reaction (PCR) are used today, laparoscopy with tissue biopsy provided rapid and correct diagnosis of abdominal tuberculosis.

Tuberculous peritonitis developing during chemotherapy for pulmonary and intestinal tuberculosis: A case report

This report is of a case of tuberculous peritonitis that developed during antituberculous chemotherapy. A 54-year-old man had been diagnosed as all-drug susceptible pulmonary and intestinal tuberculosis, and treatment with isoniazid, ethambutol and rifampicin had been initiated. About 5 months later, while still undergoing therapy, a large amount of ascites developed. A diagnostic laparoscopy was performed but due to the adhesion between the greater omentum and the parietal peritoneum, intestinal perforation occurred. An emergency operation was performed and the diagnosis of tuberculous peritonitis was confirmed. There are few reports of abdominal tuberculosis developing during antituberculous chemotherapy. In this case a paradoxical response may have been involved in the pathogenesis.

TUBERCULOUS PERITONITIS IN DIFFERENT DIALYSIS PATIENTS IN SOUTHERN TAIWAN

Eleven cases of tuberculous peritonitis (TBP) in hemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD) patients at the Kaohsiung Veterans General Hospital in Kaohsiung, Taiwan between 1991 and 2000 were studied retrospectively (six cases in the HD group and five cases in the CAPD group) The diagnosis of TBP was established by either positive ascite tuberculosis (TB) culture or biopsy-proven chronic granulomatous inflammation. Fever and abdominal pain were the most common symptoms, while leukocytosis and unexplained hypercalcemia were the most common laboratory findings. Ascite analysis showed a lymphocyte predominance in all HD patients, but in only 40% of the CAPD patients. The mean duration of a diagnosis by ascite TB cultures was six weeks, while a diagnosis confirmed by laparascopic biopsy took one week. All four fatal cases were diagnosed by TB cultures. Laparoscopic biopsy provided a rapid diagnosis and resulted in low morbidity and mortality in our patients. Based on our review of all possible abstracts found in a Medline search from 1966 to 2002 using the keywords tuberculosis, peritonitis, uremia, and dialysis, this may be the first study of TBP in different dialysis patients.

The usefulness of PCR amplification of the IS6110 insertion element of M. tuberculosis complex in ascitic fluid of patients with peritoneal tuberculosis

Background: The diagnosis of tuberculous peritonitis (TP) may be difficult and elusive. The present study was designed to demonstrate the diagnostic usefulness of a nested polymerase chain reaction (PCR) assay, specific for the IS6110 insertion element of M. tuberculosis complex, in patients with ascites who were suspected of having TP in order to achieve a more timely diagnosis and treatment. Methods: Three HIV-negative patients suffering from fever and ascites were evaluated for suspected TP. Specimens were obtained from ascitic fluid, bone marrow, and peripheral blood and analyzed by both conventional methods and nested PCR for the presence of bacilli. Response to antituberculous treatment was considered as the final criterion for diagnosis of peritoneal tuberculosis. Results: All three patients had an excellent response to antituberculous therapy. Our PCR-based protocol detected M. tuberculosis complex DNA in the ascitic fluid of all patients, whereas conventional methods failed to establish the disease. Furthermore, in one patient, M. tuberculosis was also detected in both bone marrow and peripheral blood. Conclusions: PCR amplification of the IS6110 sequence of M. tuberculosis complex in ascitic fluid is a useful tool when peritoneal tuberculosis is suspected. However, its validity still needs to be established.

Tuberculous peritonitis in uremic patients.

To identify clinical features and treatment response of tuberculous peritonitis (TBP) in a uremic population, a retrospective case-control study was performed. Thirteen uremic patients with TBP (Group I: 62.7 +/- 6.8 years, male 54%) collected between January 1986 and January 2002 were compared with another two age- and sex-matched controls: 19 non-azotemic patients with TBP (Group II: 62.9 +/- 7.3 years, male 47%) and 30 uremic patients without TBP (Group III: 61.1 +/- 8.7 years, male 47%). Clinical information and data of ascites and blood examinations were evaluated. Significant differences between Groups I and II were found in comorbidity, hypertension, anorexia, percentages of neutrophil and lymphocyte from blood and ascites, and serum calcium (sCa), phosphorus and albumin-adjusted calcium (sAACa). However, no significant differences in duration of symptoms, coexistent pulmonary tuberculosis (p = 0.061), duration or complications of therapy and mortality (p = 0.13) were detected. Significant differences between Groups I and III were found in peripheral white cell counts and percentages of neutrophil and lymphocyte as well as in serum creatinine (sCr), albumin, sCa, sAACa and intact parathyroid hormone (iPTH). Non-specific symptoms make the diagnosis of TBP in a uremic population difficult. However, neutrophil predominance in blood and ascites, hypoalbuminemia, relatively lower sCr and hypercalcemia with suppressed serum iPTH were found to be characteristic. In TBP uremic patients, therapy complications were not common and there was a tendency for higher mortality, largely due to septic shock.

Computed tomography in the diagnosis of tuberculous peritonitis

Computed tomography in the diagnosis of tuberculous peritonitis

Role of Laparoscopy in the Diagnosis of Tuberculous Peritonitis in Children

Tuberculous peritonitis (TP) is a rare disease in children, and this diagnosis is difficult. Clinical signs and routine hematologic investigations are nonspecific, and a tuberculin skin test can be negative. Bacteriologic investigations on samples of ascitic fluid, like retrieval of acid-fast bacilli and mycobacterial cultures, are often negative. We report a case of TP in a child in which all investigations were negative. Laparoscopy was performed, which showed the specific lesions of TP, with multiple intestinal adhesions and dissemination of whitish micronodules on the peritoneum. This laparoscopic approach allowed us to perform biopsies, which confirmed the diagnosis on histopathology examination and cultures. Laparoscopy is a safe and feasible approach when one suspects TP in children, leading to confirmation of the diagnosis on peritoneal biopsies with low morbidity.