Tuberculous Peritonitis Research Articles

Mycobacterial peritonitis: difference between non-tuberculous mycobacteria and Mycobacterium tuberculosis

Unlike tuberculous peritonitis, peritonitis due to non-tuberculous mycobacteria (NTM) has unclear clinical manifestations. This study aimed to clarify the clinical manifestations and laboratory results of NTM peritonitis and compare it to tuberculous peritonitis. This retrospective study was conducted from 2000 to 2008 in a medical centre in Taiwan. Patients with mycobacteria isolated from ascites were identified and compared according to causative pathogens (Mycobacterium tuberculosis or NTM). Those with NTM peritonitis were further classified into the ‘probable’ and ‘possible’ groups based on diagnostic evidence. Twenty-five patients with NTM peritonitis and 65 with tuberculous peritonitis were reviewed. Mycobacterium avium complex was the most common NTM pathogen (52%). There was no obvious difference between the ‘probable’ and ‘possible’ NTM peritonitis groups regarding age and laboratory data. Patients with NTM peritonitis and those with tuberculous peritonitis had no differences in age or gender but varied in symptoms and serum laboratory data. NTM peritonitis was 100% associated with underlying co-morbidities and had lower proportions of lymphocytes and albumin level in ascites. Twelve (48%) NTM peritonitis and 21 (32%) tuberculous peritonitis patients died during the 6-month follow-up. Antimycobacterial treatment, but not mycobacterial species, was correlated with better 6-month survival. In Taiwan, NTM is responsible for 28% of mycobacterial peritonitis cases, which have a poor prognosis if untreated. There are some differences in clinical manifestations between NTM and tuberculous peritonitis. NTM peritonitis should be considered in patients with peritonitis but without causative microorganisms identified other than NTM.

Primary tuberculous peritonitis during infliximab therapy for Crohn's disease

A 64year old male patient suffering from Crohn’s disease received infliximab therapy for a period of 5months prior to presentation to our hospital. Due to the symptoms fever, ascites, and diffuse abdominal tenderness on palpation of unknown origin, a CT scan of the abdomen was performed and led to the suspected diagnosis of a peritoneal carcinomatosis. QuantiFERON™ test revealed a tuberculosis infection and molecular analyses of a peritoneal specimen obtained by laparoscopy clearly identified Mycobacterium tuberculosis DNA. Quadruple tuberculostatic therapy was initiated and the patient's condition continuously improved thereafter.

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.

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.

Primary Tuberculous Abscess of the Spleen in an Immununocompetent Patient Diagnosed by Biochemical Markers and Radiologic Findings

Tuberculous splenic abscess in an immunocompetent patient is extremely rare. We came across a case of middle aged immunocompetent female who presented with abdominal distension, weight loss, and low grade fever. Abdominopelvic computed tomography showed multiple low density lesions in the spleen with ascites. Interferon-gamma release assay was positive and adenosine deaminase level of ascites was significantly high. No primary focus of infection was detected. The patient was diagnosed as having primary multiple tuberculous splenic abscesses with tuberculous peritonitis causing ascites. Follow up computed tomography, after completion of six month course of anti-tubercular therapy, showed splenic abscess and ascites completely disappeared.KeywordsSpleen; Abscess; Tuberculosis; Immunocompetent; Adenosine deaminase; Interferon-gamma

Esophageal tuberculosis with tuberculous peritonitis: a case report

Esophageal tuberculosis with tuberculous peritonitis: a case report

Significance of expression of TGF-β1 in peritoneal carcinomatosis and tuberculous peritonitis

Significance of expression of TGF-β1 in peritoneal carcinomatosis and tuberculous peritonitis

Tuberculous peritonitis in patients from an underdeveloped region: A retrospective analysis of 40 cases

Tuberculous peritonitis in patients from an underdeveloped region: A retrospective analysis of 40 cases

Cocoon-Like Fibroadhesive Tuberculous Peritonitis in a Peritoneal Dialysis Patient

Tuberculous peritonitis is a devastating complication of peritoneal dialysis (PD). Presentations of tuberculous peritonitis range from the common wet ascitic form to the rare fibroadhesive form, which is clinically indistinguishable from encapsulating peritoneal sclerosis. We describe a 76-year-old man on continuous ambulatory PD for three months developing wet ascitic form of tuberculous peritonitis. Three weeks after institution of antituberculous therapy and removal of PD catheter, his abdominal pain recurred and an encapsulating peritoneal sclerosis-like intestinal obstruction was noted. A rare fibroadhesive form of tuberculous peritonitis associated with the paradoxical response to antituberculous therapy was considered by excluding noncompliance, drug resistance and adverse effects, and other concomitant infections. After surgical enterolysis and continuation of antituberculous treatment, he recovered uneventfully. Our case might be the first report regarding paradoxical deterioration to antituberculous treatment in dialysis patients.

Tuberculous Lymphadenopathy Mimicking Pancreatic Neoplasm

Abdominal tuberculosis (TB) is the sixth most common location of extrapulmonary TB involvement. Because its symptoms and signs are often nonspecific, laboratory and imaging findings mimic other diseases including carcinoma. Therefore, the diagnosis of abdominal TB is challenging. We herein report a case of 74-year-old woman who presented with abdominal pain, anorexia, and weight loss. She had been given a diagnosis of pancreatic head carcinoma. Laboratory data was unremarkable except for elevated erythrocyte sedimentation rate, CA125, and sIL-2R. CT scan revealed multiple enlarged peripancreatic lymph nodes and concentric thickening of the ileocecal wall. Colonoscopy demonstrated deformed ileocecal valve and erosions. Histological examination showed epithelioid granulomas. Laparoscopy revealed numerous white tubercles diffusely covering the parietal peritoneum. Histopathological images of peripancreatic lymph node revealed large multiple caseating granulomas surrounded by Langhans_giant cells and epithelioid cells. Polymerase chain reaction and culture of the specimens were positive for Mycobacterium tuberculosis. Tuberculous lymphadenopathy, colitis, and peritonitis were finally diagnosed. She responded well to the antitubercular treatment.

Successful laparoscopic diagnosis of tuberculous peritonitis that was mimicking peritoneal carcinomatosis: a case report

Successful laparoscopic diagnosis of tuberculous peritonitis that was mimicking peritoneal carcinomatosis: a case report

A case of intestinal obstruction occurring during anti-tuberculous therapy for tuberculous peritonitis

A case of intestinal obstruction occurring during anti-tuberculous therapy for tuberculous peritonitis

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

Fausse sérologie syphilitique positive isolée découverte en début de grossesse : pronostic obstétrical (7 cas)

With the introduction of effective antituberculous chemotherapy, the clinical outcome of tuberculous peritonitis depends much on the diagnostic accuracy of this disease entity. This review summarizes the current state-of-the-art thinking regarding the protean manifestation and diagnostic modalities of this major infectious disease.This review was compiled after an extensive search of the current and historical literature, comprising 1,070 cases of tuberculous peritonitis. A number of important areas were highlighted, with emphasis on the diagnostic value and clinical impact of peritoneal biopsy.We believe an aggressive diagnostic approach, particularly with peritoneal biopsy, is warranted for the diagnosis and timely treatment of tuberculous peritonitis.

Tuberculous peritonitis: Analysis of 211 cases in Taiwan

Background Tuberculosis infection caused by Mycobacterium tuberculosis or other Mycobacterium species is a major communicable disease worldwide. Aim We evaluated the epidemiology of tuberculous peritonitis to determine diagnostic features and factors related to late diagnosis. Methods We retrospectively reviewed 211 tuberculous peritonitis cases diagnosed between January 1999 and December 2009. Clinical features, laboratory data, and diagnostic methods were analysed. Results Subjects included 115 males (54.5%) and 96 females (45.5%) with median age 61.0 years (range 43–72) and 29.2 days mean duration from symptoms to diagnosis. Disease histories included end-stage renal disease (20.9%), pulmonary tuberculosis (36.0%) and liver cirrhosis (23.7%). Most common symptoms were abdominal distension (80.1%), abdominal pain (68.7%) and weight loss (45.5%). Most common signs were ascites (62.6%) and fever (55.5%). One-year survival rate was 89.9%; 21 patients died during follow-up. Mortality risk was higher in patients with more concomitant diseases, including liver cirrhosis, AIDS, chronic steroid use, alcoholism, GI bleeding, haemoptysis, period from symptom presentation to treatment, secondary bacterial peritonitis requiring emergent operation. Conclusions Increased duration between symptoms and definitive diagnosis increases mortality risk. Early diagnosis and prompt initiation of anti-tuberculosis therapy improve prognosis. Neutrophil-predominant ascites influences poor prognosis when correlated with secondary bacterial peritonitis.

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

In spite of the myriad imaging modalities available to themodernsurgeon,thediagnosisoftuberculosis(TB)maydefyeverything but his clinical imagination and, perhaps, hislaparoscopic vision. Herein lies the problem intertwinedwith the solution: while the naked eye diagnosis of TB isoftenobvious,itisnotinfrequentlyavexingone.Isitcancer,pancreatitis, lymphoma, or Crohn’s disease? The surgeonmay ask himself many questions in different situations.The authors of the article under consideration [1] havemade an important point that needs to be stressed withrespect to the diagnosis of TB: while imaging tests are usu-ally the first line (or even the definitive one) of assessment,even the best computed tomography(CT)scanneris not abletogiveareliablediagnosisinmanyinstances.Notonly isthetest unable to detect tubercles, it is also dependent on theradiologist who interprets the images. In fact, if a magnifiedlaparoscopic image of tubercle-like lesions can elicit dif-ferent diagnoses among surgeons, why wouldthe CTimagesof bowel thickening or adhesions be different? In terms ofdecision-making, one may argue that a CT scan often makesthe job harder, or at least may not make things any easier.Additionally,themostreliabletestthatisproof-positiveforthe diagnosis of TB is the culture, and most of us would agreethat it is not often positive. The newer nucleic acid amplifi-cationtestsseemreasonablyspecific,butitistheT-SPOTtest(which tests for the presence of interferons) that seems to beverysensitivetoTB[2]. Onecouldalsothink,‘‘wouldgettingback to the basic, older tests help?’’ The ascitic fluid mea-surements known to every medical entrance exam candidateinclude ADA (adenosine deaminase) and lactase dehydroge-nase (LDH). As the authors say, these do have value, but theyare not as specific or sensitive as we would like them to be.Biopsy, of course, seems to be an attractive option to thesurgeon dealing with this disease. On the slides we would seethe caseating granulomas, the epithelioid cells, and the giantcells, leading us to gleefully unleash the full brunt of anti-TBpoisons. Again, reality does not always follow this course.In the paper under the spotlight, the authors have saidmuch of the above in better and more refined language. It isunfortunate that they have had high mortality and com-plications following laparoscopy, likely a reflection of thepatient sample they were dealing with. Their patients seemto be sicker than most. In fact, one might even wonder iflaparoscopy was not too invasive a test for some of them!The presence of atypical cells or crush artifacts in smalllaparoscopic biopsy fragments are some reasons for incon-clusive reports.In summary, with every test having its pitfalls, the surgeonhas to find a solution that works, and one that is an acceptablebasisforjustifyingaclinicaldecision.Thiswouldneedproperclinicalevaluation,appropriateimagingandendoscopictests,ascitic fluid measures, and, finally, laparoscopic assessmentsupplemented by histopathology. Once all these are placed inclinical perspective, an answer should be reasonably plausi-ble.Ifitisstillnot,anempiricaltrialofanti-TBdrugsstillhasarole in the 21st century, even if this sounds archaic.References

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.

Membranous glomerulonephritis and tuberculous peritonitis: a rare association

Membranous glomerulonephritis is rarely associated with tuberculosis infection. We report a case of a 24-year-old female with tuberculous peritonitis associated with membranous glomerulonephritis causing subnephrotic range proteinuria. Histological examination confirmed both diagnoses. The patient showed improvement with anti-tubercular drugs over six months of follow-up.

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.