Extrapulmonary tuberculous infection manifested as peritoneal fluid eosinophilia in a continuous ambulatory peritoneal dialysis patient

Tuberculosis manifesting with significant peripheral eosinophilia: A case report and review of literature

Key Clinical Message

Peripheral eosinophilia is a rare but potential sign of TB infection. Physicians should assess patients for TB, especially if they display related symptoms or risk factors, and consider TB as a differential diagnosis, especially in idiopathic cases.

Abstract

Millions of new tuberculosis (TB) cases are reported annually. Peripheral eosinophilia is rare in tuberculosis. We describe a rare case of tuberculosis with a high peripheral eosinophil count. A 9-year-old male presented with fever, cough, and respiratory discomfort for a month. The patient's cough did not respond to treatment, along with weight loss and a loss of appetite. A physical examination revealed cervical lymphadenopathy and bilateral lung crepitations. A hematological investigation showed a high eosinophil count of 25,920 cells per cubic millimeter and medical imaging abnormalities consistent with TB. Some malignancies, allergies, and parasitic infections produce peripheral eosinophilia. However, medical literature rarely discusses TB-induced eosinophilia. Several studies attribute it to mycobacterium antigen hyperreactivity. Eosinophilic release of cytotoxic chemicals may cause tissue damage, and TB patients' eosinophil levels may fluctuate. This case report emphasizes the need to investigate TB in peripheral eosinophilia patients after ruling out other explanations. Our patient benefited from early detection and anti-TB medication. More studies are required to investigate the causes of TB eosinophilia and its consequences. A detailed medical history and physical examination are essential to diagnose and treat atypical presentations of TB.

Sterile Peritonitis in the Peritoneal Dialysis Patient

Peritonitis is a serious and common problem in the peritoneal dialysis (PD) population. Abdominal pain, fever, and cloudy PD fluid usually heralds the onset of infective peritonitis. However, in up to 20% of cases, no organism is identified. In these situations, diagnosis can be made only by excluding a microbiological cause and performing a cytological examination of the PD fluid to determine the cellular or noncellular constituents. This review examines the differential diagnosis of sterile peritonitis and uses cytological examination to facilitate the appropriate diagnosis.

Cytomorphological changes induced by intraperitoneal chemotherapy present important diagnostic pitfalls in peritoneal fluid cytology

OBJECTIVE

Intraperitoneal chemotherapy (IP ChT) is an emerging modality in the treatment of advanced gastric adenocarcinoma with peritoneal disease. Cytological evaluation of peritoneal fluid specimens from patients undergoing IP ChT is important in clinical management. However, direct intraperitoneal exposure to chemotherapeutic agents induces cytomorphological changes in benign constituents of peritoneal fluid, presenting particular challenges to accurate cytological interpretation. These morphological changes have not been well characterised in the literature. We systematically reviewed the cytomorphological features in immunocytochemically-confirmed positive and negative IP ChT peritoneal fluid samples to elucidate the degree of morphological overlap between malignant and reactive cells.

METHODS

We reviewed 39 peritoneal fluid samples of patients treated with IP ChT, and scored specific cytomorphological parameters of both benign and malignant cells with the aid of relevant immunocytochemical interrogation.

RESULTS

The present findings show a significant degree of morphological overlap between reactive and malignant cells. Abnormal, "exploding" mitotic figures, nuclear membrane irregularities, multi-nucleation and cytoplasmic vacuolation were commonly observed in negative fluid specimens. The most helpful feature that favoured malignant cells was the increased nuclear-to-cytoplasmic ratio. A background inflammatory milieu of eosinophils and/or neutrophils was seen in 45-58% of post IP ChT peritoneal fluid specimens. The presence of pseudoparakeratotic cells, a novel observation in post IP ChT fluid specimens is also described.

CONCLUSIONS

The extent of reactive cytomorphological anomalies arising from treatment with IP ChT poses unique diagnostic challenges and may prompt a malignant or 'atypical' diagnosis in benign reactive samples.

Intestinal Strongyloides causing peritoneal eosinophilia in peritoneal dialysis

A 59-year-old Laotian male with a past medical history of multiple myeloma on peritoneal dialysis (PD) presented with abdominal pain and peritoneal eosinophilia. He was treated empirically for bacterial peritonitis and discharged although his PD fluid did not isolate any pathogens. He soon developed a partial small bowel obstruction and his serum Strongyloides IgG was positive. After treatment with ivermectin, stool microscopic examination showed Strongyloides stercoralis larvae. This case illustrates that the differential diagnosis of peritoneal eosinophilia should include typical and atypical infections in addition to an allergic or hypersensitivity type reaction.

Mycobacterial infections in patients with chronic renal disease

In this article, the authors have provided a comprehensive review of TB and MOTT infections in patients on renal dialysis and receiving kidney transplants. Because most published series are small retrospective studies or case reports, there are several uncertainties still involved in the diagnosis and treatment of such patients. Unanswered questions include selection of optimal dosage and duration of therapeutic agents; the best tests for screening and diagnosis, especially in high prevalence areas; and the best management of MOTT infections because of unavailability of highly effective therapy.