Corticosteroid treatment of peritoneal tuberculosis

Young Male Presenting with an Acute Diarrheal Illness with Unexplained Transudative Ascites: An Atypical Presentation of Appendicular Tuberculosis

Introduction

Appendicular tuberculosis is a rare form of extrapulmonary tuberculosis involving the gastrointestinal tract. Diagnosis of appendicular tuberculosis is difficult due to its atypical presentation. Histological confirmation remains the gold standard in diagnosis. Case Presentation. We report a 37-year-old Sri Lankan male presenting with a diarrheal illness with high fever for 8 days in the background of constitutional symptoms for 1-month duration. He was pale and had moderate amount of free fluid in the abdomen. Inflammatory markers were elevated, and CT abdomen revealed a thickened elongated appendix. Diagnostic paracentesis revealed a lymphocytic transudative ascites. A macroscopically minimally inflammed appendix removed at laparotomy and histology confirmed presence of tuberculous granulomata with caseation. He made an uneventful recovery by the anti-tuberculous therapy.

Conclusion

High degree of suspicion is needed in diagnosis of appendicular tuberculosis due to its nonspecific presentation, and we emphasize the need of histological assessment of the appendix resected for the case of clinical appendicitis, as it may prompt the diagnosis of a rare but treatable case of tuberculosis.

Diagnostic and Therapeutic Strategies for Peritoneal Tuberculosis: A Review

Peritoneal tuberculosis (PTB), although rarer than its pulmonary counterpart, is a serious health concern in regions of the world with high tuberculosis prevalence. Individuals with baseline immunocompromise condition, whether acquired or medically induced, are at greatest risk for experiencing PTB. While medical treatment of the condition is similar to that of the pulmonary disease, the generally immunocompromised state of those infected with PTB, along with a lack of highly sensitive and specific testing methods make early diagnosis difficult. This review discusses the risks factors, clinical features, diagnostic methods, and treatment options for PTB.

Non-antibiotic adjunctive therapy: A promising approach to fight tuberculosis

Tuberculosis (TB) is currently a clinical and public health problem. There is a concern about the emergence and development of multidrug-resistant (MDR-TB) and extensively drug-resistant (XDR-TB) species. Additionally, the lack of effective vaccines is another limitation to control the related infections. To overcome these problems various approaches have been pursued such as finding novel drug candidates with a new mechanism of action or repurposing conventional antibiotics. However, these strategies are still far from clinical application. Hence, the use of adjunctive therapy has been suggested for TB. In this paper, we review non-antibiotic adjunctive treatment options for TB. Natural products, vitamins, micronutrients, and trace elementals, as well as non-antibiotic drugs, are examples of agents which have been used as adjunctive therapies. The use of these adjunctive therapies has been shown to improve disease outcomes and reduce the adverse effects of antibiotic drugs. Employing these agents, either alone or in combination with antibiotics, might be considered as a promising approach to control TB infections and achieve better clinical outcomes. However, supportive evidence from randomized controlled trials is still scant and merits further investigations.

Use of steroids for abdominal tuberculosis: a systematic review and meta-analysis

BACKGROUND

The role of adjunctive steroids in abdominal tuberculosis is unclear.

OBJECTIVE

To evaluate effect of adjunctive use of steroids for abdominal tuberculosis in reducing/preventing complications.

METHODS

We searched electronic databases (Medline, Embase, CENTRAL, Scopus, Web of Science, CINAHL) from inception to 25th June 2018 using the terms "abdominal tuberculosis" OR "intestinal tuberculosis" OR "peritoneal tuberculosis" OR "tuberculous peritonitis" AND steroids OR methylprednisolone OR prednisolone. Bibliography of potential articles was also searched. We included studies comparing adjunctive steroids to antitubercular therapy (ATT) alone. We excluded non-English articles, case reports, reviews and unrelated papers. The primary outcome was a comprehensive clinical outcome including need for surgery or the presence of symptomatic stricture (abdominal pain or intestinal obstruction). Quality assessment of included studies was done using ROBINS-I tool. Random-effects model was used to calculate the summary effect for all the outcomes.

RESULTS

Of total 633 records, three studies on peritoneal tuberculosis were included in meta-analysis. These papers were of poor quality (one quasi-randomised study and two retrospective cohort studies). Meta-analyses showed adjunctive steroids, with ATT is more effective than ATT alone in tuberculous peritonitis patients for the prevention of composite end point (RR 0.15 [0.04, 0.62], p = 0.008), symptomatic stricture(RR 0.15 [0.04-0.62] p = 0.008) and intestinal obstruction (RR 0.18 [0.03-0.99] p = 0.05).

CONCLUSION

The data on use of steroids for abdominal tuberculosis are limited to peritoneal tuberculosis. Although steroids seem to have some benefit in patients of tubercular peritonitis, the poor quality of studies limits the generalisability of the findings.

SYSTEMATIC REVIEW REGISTRATION NUMBER

CRD42016047347.

Corticosteroids as an adjunct to tuberculosis therapy

INTRODUCTION

Inflammation, or the prolonged resolution of inflammation, contributes to death from tuberculosis. Interest in inflammatory mechanisms and the prospect of beneficial immune modulation as an adjunct to antibacterial therapy has revived and the concept of host directed therapies has been advanced. Such renewed attention has however, overlooked the experience of such therapy with corticosteroids. Areas covered: The authors conducted literature searches and evaluated randomized clinical trials, systematic reviews and current guidelines and summarize these findings. They found evidence of benefit in meningeal and pericardial tuberculosis in HIV-1 uninfected persons, but less so in those HIV-1 coinfected and evidence of harm in the form of opportunist malignancy in those not prescribed antiretroviral therapy. Adjunctive corticosteroids are however of benefit in the treatment and prevention of paradoxical HIV-tuberculosis immune reconstitution inflammatory syndrome. Expert commentary: Further high-quality clinical trials and experimental medicine studies are warranted and analysis of materials arising from such studies could illuminate ways to improve corticosteroid efficacy or identify novel pathways for more specific intervention.

Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis

The American Thoracic Society, Centers for Disease Control and Prevention, and Infectious Diseases Society of America jointly sponsored the development of this guideline for the treatment of drug-susceptible tuberculosis, which is also endorsed by the European Respiratory Society and the US National Tuberculosis Controllers Association. Representatives from the American Academy of Pediatrics, the Canadian Thoracic Society, the International Union Against Tuberculosis and Lung Disease, and the World Health Organization also participated in the development of the guideline. This guideline provides recommendations on the clinical and public health management of tuberculosis in children and adults in settings in which mycobacterial cultures, molecular and phenotypic drug susceptibility tests, and radiographic studies, among other diagnostic tools, are available on a routine basis. For all recommendations, literature reviews were performed, followed by discussion by an expert committee according to the Grading of Recommendations, Assessment, Development and Evaluation methodology. Given the public health implications of prompt diagnosis and effective management of tuberculosis, empiric multidrug treatment is initiated in almost all situations in which active tuberculosis is suspected. Additional characteristics such as presence of comorbidities, severity of disease, and response to treatment influence management decisions. Specific recommendations on the use of case management strategies (including directly observed therapy), regimen and dosing selection in adults and children (daily vs intermittent), treatment of tuberculosis in the presence of HIV infection (duration of tuberculosis treatment and timing of initiation of antiretroviral therapy), as well as treatment of extrapulmonary disease (central nervous system, pericardial among other sites) are provided. The development of more potent and better-tolerated drug regimens, optimization of drug exposure for the component drugs, optimal management of tuberculosis in special populations, identification of accurate biomarkers of treatment effect, and the assessment of new strategies for implementing regimens in the field remain key priority areas for research. See the full-text online version of the document for detailed discussion of the management of tuberculosis and recommendations for practice.

Our experience with glucocorticoid treatment of tuberculous peritonitis

AIM: To investigate the indications and methods for the application of glucocorticoid treatment in exudative tuberculous peritonitis (TBP) in order to achieve the best treatment effect.

METHODS: Thirty patients with exudative TBP hospitalized in the same period were chosen as subjects and given glucocorticoid 2 wk after anti-tuberculosis treatment. According to the result of glucocorticoid treatment, the patients were divided into either group A (excellent and effective; n = 18) or group B (invalid or deteriorated; n = 12). The basic conditions, clinical manifestations, complications, auxiliary examination, treatment effect and prognosis were compared for the two groups.

RESULTS: Patients in groups A and B had different average age (29.1 years ± 29.1 years vs 48.5 years ± 20.8 years, P < 0.05). Complications in groups A and B were as follows: adhesive type TBP (2/18 vs 9/12), intestinal tuberculosis (1/18 vs 2/12), tuberculous pleurisy (12/18 vs 2/12), and ovarian tuberculosis (1/18 vs 2/12) (P < 0.05 for all). In group A, 12 cases had high fever, and 5 cases had moderate fever; in group B, 5 cases had moderate fever, and 7 cases had low grade fever. PPD test was strongly positive in 10 cases and positive in 8 cases in group A, and positive in 5 cases and weakly positive in 7 cases in group B. In group A, ESR was greater than 100 mm/h in 10 cases, 50-100 mm/h in 4 cases, and 20-50 mm/h in 1 case; in group B, ESR was 50-60 mm/h in 2 cases and 20-50 mm/h in 10 cases. In group A, 8 cases had massive ascites, and 10 cases had moderate ascites; in group B, 3 cases had moderate ascites, and 9 cases had mild ascites. In group A, 14 cases had an excellent response, their urine volume increased 300-500 mL/d, and abdominal distention was greatly relieved; 4 cases had effective results, their urine volume increased 200-350 mL/d, and distension was alleviated. Only a small amount of ascites was detected by ultrasound after four weeks of glucocorticoid treatment and ascites disappeared after 6-8 wk. In contrast, no significant improvement was observed in all the 12 cases of group B. Ascites was not reduced and distension was not improved after the glucocorticoid treatment. Ascites disappeared after 5-8 wk. In a follow-up period of 6 mo, all patients had neither disease progression nor related complications and recovered well.

CONCLUSION: Glucocorticoid is mainly suitable for exudative TBP patients who had strong allergic reaction. After 2 wk of regular anti-tuberculosis treatment, the application of glucocorticoid following the principle of short period, small quantity, draught, and decrement is safe and effective.

Adjunctive steroid therapy for managing pulmonary tuberculosis

BACKGROUND

Tuberculosis causes approximately 8.6 million disease episodes and 1.3 million deaths worldwide per year. Although curable with standardized treatment, outcomes for some forms of tuberculosis are improved with adjunctive corticosteroid therapy. Whether corticosteroid therapy would be beneficial in treating people with pulmonary tuberculosis is unclear.

OBJECTIVES

To evaluate whether adjunctive corticosteroid therapy reduces mortality, accelerates clinical recovery or accelerates microbiological recovery in people with pulmonary tuberculosis.

SEARCH METHODS

We identified studies indexed from 1966 up to May 2014 by searching: Cochrane Infectious Diseases Group's trials register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and LILACS using comparative search terms. We handsearched reference lists of all identified studies and previous reviews and contacted relevant researchers, organizations and companies to identify grey literature.

SELECTION CRITERIA

Randomized controlled trials and quasi-randomized control trials of recognized antimicrobial combination regimens and corticosteroid therapy of any dose or duration compared with either no corticosteroid therapy or placebo in people with pulmonary tuberculosis were included.

DATA COLLECTION AND ANALYSIS

At least two investigators independently assessed trial quality and collected data using pre-specified data extraction forms. Findings were reported as narrative or within tables. If appropriate, Mantel-Haenszel meta-analyses models were used to calculate risk ratios.

MAIN RESULTS

We identified 18 trials, including 3816 participants, that met inclusion criteria. When compared to taking placebo or no steroid, corticosteroid use was not shown to to reduce all-cause mortality, or result in higher sputum conversion at 2 months or at 6 months (mortality: RR 0.77, 95%CI 0.51 to 1.15, 3815 participants, 18 studies, low quality evidence; sputum conversion at 2 months RR 1.03, 95%CI 0.97 to 1.09, 2750 participants, 12 studies; at 6 months; RR1.01, 95%CI 1.01, 95%CI 0.98 to 1.04, 2150 participants, 9 studies, both low quality evidence). However, corticosteroid use was found to increase weight gain (data not pooled, eight trials, 1203 participants, low quality evidence), decrease length of hospital stay (data not pooled, three trials, participants 379, very low quality of evidence) and increase clinical improvement within one month (RR 1.16, 95% CI 1.09 to 1.24; five trials, 497 participants, low quality evidence).

AUTHORS' CONCLUSIONS

It is unlikely that adjunctive corticosteroid treatment provides major benefits for people with pulmonary tuberculosis. Short term clinical benefits found did not appear to be maintained in the long term. However, evidence available to date is of low quality. In order to evaluate whether adjunctive corticosteroids reduce mortality, or accelerate clinical or microbiological recovery in people with pulmonary tuberculosis further large randomized control trials sufficiently powered to detect changes in such outcomes are needed.

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

AIM: To investigate the characteristics of tuberculous peritonitis in patients from an underdeveloped region.

METHODS: The clinical data for 40 patients with tuberculous peritonitis were analyzed to summarize the features of tuberculosis peritonitis in terms of its history, clinical manifestations, laboratory testing, auxiliary examination, diagnosis, and differential diagnosis.

RESULTS: In our series, tuberculous peritonitis was more common in patients between 20-40 years old (57.5%), and only 22.5% of patients had a previous history of tuberculosis or chronic diseases. Tuberculous peritonitis usually had a chronic onset (85%). Common manifestations were abdominal distention (85%), anorexia (67.5%), fever (52.5%), and abdominal pain (47.5%). The signs of ascites (67.5%) and abdominal tenderness (65%) were common. Serological tests had low specificity. Ascites was exudative. Ascites ADA > 33 U/L and monocyte predominance may contribute to the diagnosis of tuberculous peritonitis. The positive rates of ascites acid-fast bacillus smear and Mycobacterium tuberculosis culture were low (4.75% and 0%, respectively). The positive rate of PPD test and abnormal rate of chest X-ray were both 37.5%. The abnormal rate of abdominal CT and B-mode ultrasound scan were both 78%. The uterus and annexes were involved in 72.7% of female TBP patients. Five cases (12.5%) were misdiagnosed, of whom 3 were misdiagnosed as gynecologic tumors. Only 4 cases (10%) were confirmed by microbiology or pathology, and the remaining 36 cases (90%) relies on experimental anti-TB treatment to achieve the diagnosis.

CONCLUSION: In underdeveloped regions, the vast majority of tuberculous peritonitis cases are diagnosed by experimental anti-TB treatment due to the limited availability of laparoscopy or B ultrasound-guided biopsy.

Peritoneal tuberculosis in Qatar: a five-year hospital-based study from 2005 to 2009

There is limited information about peritoneal tuberculosis in Qatar. This retrospective study aimed to review our experience with peritoneal tuberculosis in patients admitted to Hamad general hospital over a period of 5 years, from 2005 to 2009, with emphasis on presentation, investigation, diagnosis and therapeutic outcome. Fifty-four patients with peritoneal tuberculosis identified during the study period were included. The mean age of them was 31.85 years and 96.3% (52/54) of them were non-Qataris with male predominance. The main symptoms and signs at the time of presentation were abdominal pain and ascites respectively. Underlying diseases were described in 24% (13/54) and history of contact with tuberculous cases was present in 31.5% (17/54) of patients. Tuberculin test was positive in 66.7% (36/54). The ascitic fluid smear showed acid fast bacilli in 2% (1/53), and culture was positive in 39.6% (21/53) of cases. Laparoscopically obtained peritoneal biopsy showed caseating granulomas in 93% (40/43) and mycobacteria were identified by acid fast staining and culture in 58.5% (24/41) and 98% (40/41) of the tested specimens respectively. Most of the patients (84%; 37/44) who had completed their therapy in Qatar improved with antituberculosis therapy, and only one patient died. In conclusion, the clinical features and the imaging findings of the disease were non-specific. A high index of suspicion is essential for early diagnosis. Culture of ascitic fluid delayed the diagnosis in clinically suspected cases, whereas laparoscopically guided peritoneal biopsy provided rapid and correct diagnosis. A Six-month course with antituberculous therapy was effective and improved the outcome.

An unusual cause of abdominal pain

A 26-year-old man presented to the Emergency Department with abdominal pain, diarrhoea, anorexia and haematemesis. The patient was previously diagnosed with latent tuberculosis (TB). On examination, his abdomen was diffusely tender, with localised guarding in the right iliac fossa. CT imaging of his abdomen and pelvis demonstrated a low volume of ascites, diffuse studding of the peritoneum, omental caking and several bulky low-density lymph nodes in the retroperitoneum. A laparoscopy was performed to obtain a peritoneal biopsy. Histology demonstrated fragments of peritoneum with necrotising granulomatous inflammatory infiltrate in keeping with an infectious process, favouring TB. He was commenced on rifampicin, isoniazid, pyrazinamide, ethambutol and pyridoxine under the direct observed therapy by the infectious diseases team. In view of his extensive peritoneal involvement, he was empirically started on high-dose prednisolone for symptomatic control and to reduce complications related to peritoneal adhesions.

Tuberculous appendicitis

Gastrointestinal tuberculosis is quite rare, representing only 3% of all extrapulmonary cases. Involvement of the appendix is rare, only occurring in about 1% of cases. It is usually secondary to tuberculosis elsewhere in the abdomen. A prompt diagnosis depends on a high index of suspicion as clinical signs may be nonspecific and microbiological confirmation is difficult. Histopathologic examination is often the only way to reach a diagnosis and to establish specific antibiotic therapy. In these cases, due to the absence of specific symptoms and signs, the diagnosis is delayed until after surgery.

Peritoneal tuberculosis

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

Appendicular tuberculosis: The resurgence of an old disease with difficult diagnosis

Gastrointestinal tuberculosis (TB) is quite rare, representing only 3% of all extra-pulmonary cases. Blind gut and ileum are the most common gastrointestinal localizations, while appendix involvement is infrequent. Appendix involvement is usually related to symptoms of acute appendicitis since the caseous necrosis may lead to adhesions and surgical complications such as perforation. For this reason patients with suspected appendicular TB usually undergo surgery even without a secure diagnosis. In these cases, due to the absence of specific symptoms and signs, the diagnosis is delayed after surgery, thus resulting in a high percentage of important, and sometimes lethal, complications. Histopathological examination is often the only way to reach a diagnosis and to establish specific antibiotic therapy, while an early diagnosis could avoid surgical treatment. We report a case of appendicular TB not only for its rarity but also to discuss the difficulty in its diagnosis.

Treatment of tuberculosis in children

The treatment of children with TB is influenced by a number of factors specific to both the bacterium and the child. We review the variables impacting the selection of individual medications; indications, pharmacology, dosing and side effects for first- and second-line agents; adjunctive therapy; and special cases, including treatment of TB in HIV-infected children and multidrug-resistant TB. Finally, evolving trends in TB therapy, such as the impact of HIV and multidrug-resistant TB on future therapeutics, emerging or re-emerging medication options, shorter-course regimens and immunomodulation, are discussed.

Tuberculous peritonitis in children: Report of nine patients and review of the literature

AIM: To present our experience with tuberculous peritonitis treated in our hospital from 2002-2007.

METHODS: We reviewed the medical records of 9 children with tuberculous peritonitis.

RESULTS: Nine patients (5 boys, 4 girls) of mean age 14.2 years were diagnosed with peritoneal tuberculosis. All patients presented with abdominal distention. Abdominal pain was seen in 55.5% and fever in 44.4% of the patients. Four cases had coexisting pleural effusion and two had pulmonary tuberculosis with parenchymal consolidation. Ultrasonography found ascites with septation in 7 patients. Two patients had only ascites without septation. Ascitic fluid analysis of 8 patients yielded serum-ascite albumin gradients of less than 1.1 gr/dL. Laparoscopy and laparotomy showed that whitish tuberculi were the most common appearance. Adhesions were also seen in three cases. The diagnosis of peritoneal tuberculosis was confirmed histo-pathologically in 7 patients and microbiologically in two. Two patients had been diagnosed by ascitic fluid diagnostic features and a positive response to antituberculous treatment. All patients completed the antituberculous therapy without any complications.

CONCLUSION: Tuberculous peritonitis has to be clinically suspected in all patients with slowly progressive abdominal distension, particularly when it is accompanied by fever and pain. Laparoscopy and peritoneal biopsy are still the most reliable, quick and safe methods for the diagnosis of tuberculous peritonitis.

Systematic review: tuberculous peritonitis--presenting features, diagnostic strategies and treatment

The peritoneum is one of the most common extrapulmonary sites of tuberculous infection. Peritoneal tuberculosis remains a significant problem in parts of the world where tuberculosis is prevalent. Increasing population migration, usage of more potent immunosuppressant therapy and the acquired immunodeficiency syndrome epidemic has contributed to a resurgence of this disease in regions where it had previously been largely controlled. Tuberculous peritonitis frequently complicates patients with underlying end-stage renal or liver disease that further adds to the diagnostic difficulty. The diagnosis of this disease, however, remains a challenge because of its insidious nature, the variability of its presentation and the limitations of available diagnostic tests. A high index of suspicion is needed whenever confronted with unexplained ascites, particularly in high-risk patients. Based on a systematic review of the literature, we recommend: tuberculous peritonitis should be considered in the differential diagnosis of all patients presenting with unexplained lymphocytic ascites and those with a serum-ascites albumin gradient (SAAG) of <11 g/L; culture growth of Mycobacterium of the ascitic fluid or peritoneal biopsy as the gold standard test; further studies to determine the role of polymerase chain reaction, ascitic adenosine deaminase and the BACTEC radiometric system for acceleration of mycobacterial identification as means of improving the diagnostic yield; increasing utilization of ultrasound and computerized tomographic scan for the diagnosis and as a guidance to obtain peritoneal biopsies; low threshold for diagnostic laparoscopy; treatment for 6 months with the first-line antituberculous drugs (isoniazid, rifampicin, ethambutol and pyrazinamide) in uncomplicated cases.

La tuberculose péritonéale : une entité toujours présente. À propos de quatre observations

INTRODUCTION

Tuberculous peritonitis, a major problem in developing country, occurs preferentially in immigrant population and in patients with acquired immune deficiency syndrome (AIDS). Although rare in France, it did not disappear and epidemiological, clinical and therapeutic approach deserve to be reminded.

EXEGESIS

We reported 4 patients (immigrants in two cases), occurred in caucasian and African persons (one with AIDS). Disease was characterized by fever, abdominal pain, anorexia, weight loss and ascites. Biological and radiological were unconclusive. Cell count analysis from ascitic fluid show a lymphocytic predominance with negative direct smear for Ziehl-Neelsen strain. Tuberculous peritonitis was established with combined visual and histological diagnosic laparoscopic examination.

CONCLUSION

These observations have the interest to underline that tuberculous peritonitis must be evoked in case of lymphocytic ascitis. We believe an aggressive diagnostic approach, particulary with peritoneal biopsy, is warranted for the diagnosis of tuberculous peritonitis. Validity of PCR amplification is ascitic fluid still needs to be established.

Gastrointestinal tuberculosis: 17 cases collected in 4 hospitals in the northeastern suburb of Paris

Gastrointestinal tuberculosis is a rare form of extrapulmonary tuberculosis and its diagnosis can be difficult.

AIMS

To analyze the diagnostic and therapeutic characteristics of gastrointestinal tuberculosis.

METHODS

Retrospective study from 17 cases collected in 4 hospitals in Seine Saint-Denis between 1987 and 2002.

RESULTS

Seventeen cases and 19 localizations were collected: small intestine (N = 7), ileocecum (N = 6), colon (N = 4) and gastroduodenum (N = 2). Two patients had two localizations. Mean age was 43.9 years. Subjects from immigrant populations (76.5%) were preferentially affected. Twenty-three percent of patients (13 tested) were infected by human immunodeficiency virus. Weight-loss and general weakness (88%), abdominal pain (88%), fever (59%), nausea/vomiting (53%) were the predominant symptoms. The delay in diagnosis was 82 days (range: 7-180) and time before specific treatment 31.6 days (range: 7-90). Histological evidence of caseating granuloma was found in six patients. Mycobacterium tuberculosis was detected in six. Digestive imaging was abnormal in 15 patients. Mesenteric lymph nodes were the most common associated site of tuberculosis (N = 8, 47%). Mean duration of treatment was 8.2 months (range: 6-12). Thirteen patients were cured, three died and one was lost to follow up.

CONCLUSION

Gastrointestinal tuberculosis is not an uncommon diagnosis in the north-eastern Parisian area, especially among immigrant populations and immunodeficient patients. The most frequent localizations are the small intestine and ileocecum. Diagnosis can be made by pathology and/or bacteriology on endoscopic and/or surgical biopsy samples.

Tuberculose péritonéale de l'enfant : à propos de deux cas

Peritoneal tuberculosis is an uncommon presentation of extra-pulmonary tuberculosis in children. It usually presents as ascites, abdominal pain, anorexia and weight loss.

CASES REPORT

We report two adolescent patients who presented with ascites, fever, weight loss and abdominal distension. In one case, the diagnosis was late, and confirmed by ascites culture. In the second case, a laparoscopy was performed and showed whitish nodules involving the entire abdominal cavity, compatible with peritoneal tuberculosis, later confirmed bacteriologically.

CONCLUSION

Peritoneal tuberculosis presents with nonspecific symptoms. Because laboratory investigations may not be helpful, diagnosis may be difficult. Peritoneal-fluid adenosine deaminase (ADA) determination and coelioscopy seem to be the best way to make a rapid diagnosis.

Tuberculous peritonitis--reports of 26 cases, detailing diagnostic and therapeutic problems

OBJECTIVE

To evaluate the clinical presentation, biochemical (ascites and serum) and laparoscopic findings, and to assess the efficacy of triple antituberculous therapy without rifampicin for 6 months in patients with tuberculous peritonitis.

METHODS

Twenty-six tuberculous peritonitis patients (11 male, 15 female) with a mean age of 34.8 +/- 3.4 years (range 14-77) were assessed with regard to diagnostic and therapeutic features.

RESULTS

The most common symptoms and signs were abdominal pain (92.3%) and ascites (96.2%), respectively. Tuberculin skin test (TST) was positive in all patients. An abnormal chest radiography suggestive of previous tuberculosis was present in five patients (19.2%), and two patients (7.7%) had extra-peritoneal (cerebral, pericardial) active tuberculous involvement. In 24 of the 25 patients who underwent laparoscopy with directed biopsy, whitish nodules suggested tuberculous peritonitis; 76% of the biopsy specimens revealed caseating, 20% non-caseating granulomatous inflammation, and 4% non-specific findings. The ascitic fluid of one patient (3.8%) was positive for acid-resistant bacilli, and culture was positive in two patients (7.7%). Twenty-four of the patients were treated for 6 months with isoniazid, streptomycin (total dose 40 g) and pyrazinamide (for the first 2 months and then substituted with ethambutol). Eighteen patients also received methyl prednisolone, initially 20 mg/day, for 1 month. The follow-up period was 19 +/- 1.7 months after the end of therapy (range 6-36). Ascites and abdominal pain abated earlier in patients on steroid therapy. All but two of the 24 patients responded to treatment.

CONCLUSION

Non-invasive tests such as acid-fast stain and culture of the ascitic fluid are usually insufficient, hence invasive laparoscopy and peritoneal biopsy are necessary for the diagnosis of tuberculous peritonitis if non-invasive tests such as ascites adenosine deaminase activity measurement are not easily available. Triple therapy without rifampicin for 6 months is sufficient to treat tuberculous peritonitis.