Clinical features and outcomes of abdominal tuberculosis in southeastern Korea: 12 years of experience

Diagnosis of abdominal tuberculosis: Detection of mycobacterial CFP-10 and HspX proteins by gold nanoparticle-PCR amplified immunoassay

Attempts were made to improve the efficacy of PCR amplified immunoassay (I-PCR) for diagnosing abdominal TB cases by utilizing the gold nanoparticle (AuNP)-based I-PCR, where AuNPs were functionalized with detection antibodies/oligonucleotides that exhibited 84.3% sensitivity and 95.1% specificity. This assay would improve the ongoing algorithms used in abdominal TB diagnosis.

Patterns and Outcomes in Pediatric Abdominal Tuberculosis: A Single Centre Cohort Study

INTRODUCTION

Abdominal tuberculosis presents in a variety of ways. Different testing modalities must be applied in addition to having a high clinical suspicion to diagnose and initiate therapy. Medications have a good response; however, morbidity has been seen following surgical management of complicated presentations like intestinal obstruction and perforation. There is a paucity of studies in the pediatric age group which evaluate response to the different treatment regimen and identify factors associated with poorer outcomes in children with abdominal tuberculosis.

METHODS

Patient records of 75 children with abdominal tuberculosis at a single center were evaluated using a questionnaire, covering a 14-year period from 2007 to 2021. Demographic features, presenting signs and symptoms, investigations and treatment details were studied. In- person or telephonic follow-up was conducted to identify treatment outcomes.

RESULTS

Incidence of abdominal TB was 7%, of all TB children with a mean age of 10.1 years. Mesenteric lymph nodes were involved in 67% and small intestine in 33% cases. Surgery was required in 22 children. 85% children completed treatment. Small intestine involvement had higher probability of undergoing surgery. Of the 70 children with complete follow up, 64 were well and 6 children succumbed to the disease. Older age, small intestine involvement and surgery were independently associated with higher mortality.

CONCLUSION

Intestinal involvement is associated with greater need for surgical intervention and greater mortality. Adolescents have poorer outcomes. Further studies are required focusing on these individual subgroups to understand the patterns of presentation, causes for mortality and prevention.

LEVEL OF EVIDENCE

Level 5.

Multi-Drug-Resistant Tuberculosis Peritonitis: A Case Report

The increasing incidence of tuberculosis raises concerns globally, impacting both developing and developed nations. Abdominal tuberculosis stands out as the most prevalent form of extrapulmonary tuberculosis. This case report details the diagnostic journey of a young male with abdominal TB complicated by concurrent HIV infection. The patient presented with night sweats and substantial weight loss, concurrently receiving a naive human immunodeficiency virus (HIV) diagnosis with an undetectable CD4 count. Imaging revealed abdominal lymphadenopathy concealing the pancreatic head while bronchoscopy unveiled TB in the lung. The patient faced septic shock and bilateral pulmonary embolism, possibly due to immune reconstitution inflammatory syndrome (IRIS). The patient then developed ascites, and a diagnosis of TB peritonitis was made based on low serum ascites albumin gradient (SAAG) and a positive acid-fast bacillus (AFB) result in the para-aortic lymph node. Treatment complexity arose from drug resistance to isoniazid and ethambutol.

An Updated Systematic Review and Meta-Analysis for the Diagnostic Test Accuracy of Ascitic Fluid Adenosine Deaminase in Tuberculous Peritonitis

BACKGROUND

Tuberculous peritonitis is difficult to diagnose due to its non-specific clinical manifestations and lack of proper diagnostic modalities. Current meta-analysis was performed to find the overall diagnostic accuracy of adenosine deaminase (ADA) in diagnosing tuberculous peritonitis.

MATERIALS AND METHODS

PubMed, Google Scholar, and Cochrane library were searched to retrieve the published studies which assessed the role of ascitic fluid ADA in diagnosing tuberculous peritonitis from Jan 1980 to June 2022. This meta-analysis included 20 studies and 2,291 participants after fulfilling the inclusion criteria.

RESULTS

The pooled sensitivity was 0.90 (95% confidence interval [CI]: 0.85 - 0.94) and pooled specificity was 0.94 (95% CI: 0.92 - 0.95). The positive likelihood ratio was 15.20 (95% CI: 11.70 - 19.80), negative likelihood ratio was 0.10 (95% CI: 0.07 - 0.16) and diagnostic odds ratio was 149 (95% CI: 86 - 255). The area under the summary receiver operating characteristic curve was 0.97. Cut- off value and sample size were found to be the sources of heterogeneity in the mete-regression analysis.

CONCLUSION

Ascitic fluid ADA is a useful test for the diagnosis of tuberculous peritonitis with good sensitivity and specificity however, with very low certainty of evidence evaluated by Grading of Recommendations, Assessment, Development and Evaluation approach. Further well- designed studies are needed to validate the diagnostic accuracy of ascitic fluid ADA for tuberculous peritonitis.

Anti-tubercular therapy in the treatment of tubercular uveitis: A systematic review and meta-analysis

We quantitatively evaluated the efficacy of antitubercular therapy (ATT) in tubercular uveitis (TBU) patients. Main outcome measures include inflammation recurrence, inflammation reduction, complete resolution of inflammation, improved visual acuity (VA), ability to taper corticosteroids to < 10 mg/day without inflammatory progression, and use of adjunctive immunosuppressants while on ATT. This review is prospectively registered in PROSPERO (CRD42020206845). Forty-nine studies reporting data for 4,017 TBU patients were included. In comparative studies, the odds ratio (OR) of inflammatory recurrence was 0.33 (95%CI:0.19-0.60) for TBU patients treated with ATT±corticosteroid versus no ATT. For TBU patients treated with ATT±corticosteroid, the pooled absolute incidences of inflammatory recurrence, inflammatory reduction, complete resolution of inflammation, and visual acuity improvement were 13% (n=310/2,216; 95%CI:9-18), 81% (n=217/276; 95%CI: 62-95), 83% (n=1,167/1,812; 95%CI: 77-89), and 65% (n=347/542; 95%CI:51-78), respectively. Corticosteroids were tapered to <10 mg/day without inflammatory progression in 91% (n=326/395; 95%CI:78-99) of patients, 9% (n=121/1,376; 95%CI:6-13) of whom were administered concomitant immunosuppressive agents alongside ATT. We conclude that treatment of TBU with ATT±corticosteroid is associated with a high level of control or improvement of inflammation. More prospective studies with detailed reporting of ATT regimens, patient subgroups, and outcomes are required to better evaluate ATT effectiveness.

The gut microbiome: A line of defense against tuberculosis development

The tuberculosis (TB) burden remains a significant global public health concern, especially in less developed countries. While pulmonary tuberculosis (PTB) is the most common form of the disease, extrapulmonary tuberculosis, particularly intestinal TB (ITB), which is mostly secondary to PTB, is also a significant issue. With the development of sequencing technologies, recent studies have investigated the potential role of the gut microbiome in TB development. In this review, we summarized studies investigating the gut microbiome in both PTB and ITB patients (secondary to PTB) compared with healthy controls. Both PTB and ITB patients show reduced gut microbiome diversity characterized by reduced Firmicutes and elevated opportunistic pathogens colonization; Bacteroides and Prevotella were reported with opposite alteration in PTB and ITB patients. The alteration reported in TB patients may lead to a disequilibrium in metabolites such as short-chain fatty acid (SCFA) production, which may recast the lung microbiome and immunity via the "gut-lung axis". These findings may also shed light on the colonization of Mycobacterium tuberculosis in the gastrointestinal tract and the development of ITB in PTB patients. The findings highlight the crucial role of the gut microbiome in TB, particularly in ITB development, and suggest that probiotics and postbiotics might be useful supplements in shaping a balanced gut microbiome during TB treatment.

Clinical presentation of peritoneal tuberculosis

Peritoneal tuberculosis arises from hematogenous spread of pulmonary foci or from direct spread from an adjacent structure. Diagnosis of peritoneal tuberculosis can be challenging due to nonspecific symptoms, insidious onset, and variable imaging findings. Herein, we report a patient presenting with ascites who was eventually diagnosed with peritoneal tuberculosis.

Diagnosis of abdominal tuberculosis by multi-targeted (mpt64 and IS6110) loop-mediated isothermal amplification assay

BACKGROUND AND AIM

Diagnosis of abdominal TB is an exigent task due to variable anatomical sites and non-specific clinical manifestations that closely resemble other diseases. Most of the available diagnostic modalities yield low sensitivities and need expertise to handle the specialized equipment. Hence, there is an urgent need to develop a rapid and reliable diagnostic test, so as to reduce the unnecessary morbidity. Therefore, we designed a multi-targeted loop-mediated isothermal amplification (MT-LAMP) for diagnosing abdominal TB.

METHODS

We evaluated an MT-LAMP (using mpt64 and IS6110) to diagnose abdominal TB within ascitic fluids and intestinal/peritoneal biopsies and compared these results with multiplex-PCR (M-PCR) using the same targets. MT-LAMP products were analyzed by gel electrophoresis and visual detection methods, that is, hydroxy naphthol blue and SYBR Green I reaction.

RESULTS

Sensitivities of 80.9% and 84.6% were obtained in suspected (n = 42) and total abdominal TB (n = 52) cases, respectively by gel-based MT-LAMP, with 97.3% (n = 37) specificity in non-TB controls. Notably, sensitivities attained by gel-based/SYBR Green I MT-LAMP in both clinically suspected and total abdominal TB cases were significantly higher (P < 0.05) than M-PCR. Furthermore, sensitivity obtained with SYBR Green I was equivalent to that of gel-based MT-LAMP, while somewhat lesser specificity (94.6%) was attained with SYBR Green I, compared with gel-based MT-LAMP.

CONCLUSION

Both gel-based and SYBR Green MT-LAMP exhibited equivalent sensitivities to diagnose abdominal TB. Because SYBR Green LAMP is easier to perform than a gel-based assay, we are currently focused on improving the specificity of this assay so as to develop a diagnostic kit.

Rectal cancer combined with abdominal tuberculosis: A case report

BACKGROUND

It is very rare to suffer from colorectal adenocarcinoma and abdominal tuberculosis simultaneously. Even in a country such as China, where tuberculosis is still endemic, its diagnosis and treatment are challenging. This article describes in detail a case of rectal cancer complicated by abdominal tuberculosis and its pathological features.

CASE SUMMARY

We outline the case of a 71-year-old female who was admitted with intermittent blood in the stool over the past year. The patient was diagnosed with low rectal cancer and received neoadjuvant therapy. The patient then returned to the hospital for surgery, but diffusely distributed nodules were found during laparoscopic exploration. The diagnosis of rectal cancer with extensive metastasis was considered during the operation. There was no opportunity for radical surgery. Thus, nodules were taken for pathological examination, and the abdomen was closed. The histopathological diagnosis was tuberculous granuloma, and the patient was treated with standardized anti-tuberculosis drugs in a specialized hospital. Later, the patient again came to our hospital and underwent abdominoperineal resection. She was discharged 10 d after the operation in good clinical condition.

CONCLUSION

We aim to emphasize the importance of preoperative and postoperative pathological examination in diagnosis and treatment.

Peritoneal and Pulmonary Tuberculosis in a Postpartum Female with Elevated Cancer Antigen 125 and Ascites

BACKGROUND

Peritoneal tuberculosis is a rare form of extrapulmonary tuberculosis and presents a challenging diagnosis because of its nonspecific clinical manifestations. Peritoneal TB mimics other pathologies, including abdominal carcinomatosis, especially when the patient presents with ascites and an elevated cancer antigen (CA)-125 levels. Case Presentation. A postpartum 20-year-old Hispanic female recently discharged after transverse cesarean surgery, presented to the ER with fever, chills, edema, abdominal distension, nausea, and vomiting. The patient was febrile, tachycardic, and hypotensive. Chest X-ray demonstrated alveolar and interstitial consolidations; chest CT revealed tree-in-bud opacities in the right lower lobe, suggestive of atypical (TB)/fungal infection. CT of the abdomen and pelvis demonstrated ascites, omental thickening, peritoneal thickening, and mesenteric adenopathy, suggestive of carcinomatosis. She was admitted with a presumed diagnosis of sepsis secondary to pneumonia and started empirically on broad-spectrum antibiotics without clinical improvement. A battery of oncology markers was ordered and revealed a mildly elevated cancer antigen (CA)-125. Diagnostic paracentesis showed lymphocytic predominance with positive mycobacteria PCR, elevated adenosine deaminase (ADA), and no malignant cells. Subsequently, the sputum acid-fast bacilli (AFB) stain returned positive for tuberculosis, confirming the diagnosis of pulmonary tuberculosis. A peritoneal biopsy was obtained and demonstrated caseating granulomas consistent with peritoneal tuberculosis. The patient was started on standard antituberculosis therapy with clinical improvement.

CONCLUSIONS

This case highlights the need for a high-level of suspicion for peritoneal tuberculosis in a patient with pulmonary tuberculosis who presents with intra-abdominal ascites, omental thickening, peritoneal thickening, and mesenteric lymphadenopathy, despite the presence of an elevated CA-125 level.

The Case of the Young Male with a Longstanding History of Dyspeptic Symptoms: Peritoneal Tuberculosis

Portal vein thrombosis associated with peritoneal tuberculosis is an uncommon manifestation of extrapulmonary tuberculosis. We report one such case of a 33-year-old male with a one-year history of dyspepsia, having been on proton pump inhibitors all this time with temporary relief. In view of ongoing symptoms, an endoscopy was done, which at first showed duodenal ulcer. On repeat endoscopy after an interval, there was evidence of mucosa-associated lymphoid tissue (MALT) lymphoma, which prompted a host of investigations in the patient. A positron emission tomography (PET) scan revealed extensive omento-peritoneal involvement along with a hypodense lesion in the liver with interval development of portal vein thrombosis on a CT scan of the abdomen. The biopsy of the hepatic lesion showed granulomatous inflammation. Faced with a diagnostic dilemma, finally, a laparoscopic biopsy was done, which confirmed the diagnosis of peritoneal TB with portal vein thrombosis.

This case highlights the importance of keeping a high index of suspicion to include tuberculosis as a differential when presented with a case such as this and to conduct appropriate investigations to establish the correct diagnosis.

Clinical, laboratory and evolutionary features of abdominal tuberculosis in comparison with other forms of extrapulmonary tuberculosis

BACKGROUND/OBJECTIVES

Tuberculosis is a multisystem disease that might affect any organ. Abdominal tuberculosis (ABT) represents 5-17% from all extrapulmonary tuberculosis (EPT) sites. We aimed to study the clinical, laboratory and evolutionary features of ABT cases and to identify predictive factors associated with ABT.

METHODS

We conducted a retrospective study including all patients hospitalized in the infectious diseases department for EPT between 1991 and 2019. We studied the characteristics of ABT cases, and we compared them with other EPT cases.

RESULTS

We identified 519 patients with EPT, among whom 86 (16.6%) patients had ABT. There were 58 females (67.4%). Peritoneal tuberculosis was the most common clinical form of ABT (68.6%), followed by intestinal tuberculosis (18.6%). Patients aged 60 years and above were significantly less affected with ABT (odds ratio (OR) = 0.2; p = 0.001). The revealing systemic symptoms including fever (OR = 2.04; p = 0.006), weight loss (OR = 2.5; p < 0.001) and anorexia (OR = 1.7; p = 0.021) were significantly more frequent among ABT patients. Inflammatory markers including C-reactive protein levels (37 [10-89] mg/l vs 10 [4-57] mg/l; p < 0.001) and erythrocyte sedimentation rates (43 [15-95] mm/h vs 27 [15-60] mm/h; p = 0.044) were significantly higher among ABT cases. Multivariate logistic regression analysis showed that anorexia (adjusted OR (AOR) = 1.9; p = 0.015) and pulmonary involvement (AOR = 3.3; p = 0.002) were independent predictors of higher rate of ABT. Concomitant involvement of neuro-meningeal (AOR = 0.18; p = 0.001) and osteo-articular (AOR = 0.2; p = 0.01) sites, 40-59 (AOR = 0.2; p < 0.001) and ≥60 (AOR = 0.2; p < 0.001) age groups as well as hemoglobin rate (AOR = 0.7; p < 0.001) were independently associated with lower rate of ABT.

CONCLUSIONS

Anorexia and pulmonary involvement were independent predictors of higher rate of ABT. Concomitant involvement of neuro-meningeal and osteo-articular sites, 40-59 and ≥60 age groups and hemoglobin rate were independently associated with lower rate of ABT.

Comparative Evaluation of Clinical, Cytological and Microbiological Profile in Abdominal vs. Cervical Lymph Nodal Tuberculosis with Special Emphasis on Utility of Auramine-O Staining

Context:

Extrapulmonary tuberculosis (EPTB) especially abdominal lymph nodal tuberculosis (LNTB) poses a unique diagnostic challenge. The clinical, cytological, and microbiological profiles, especially with respect to the use and role of Auramine –O (AO) stain, are not as well characterized in abdominal LNTB as cervical LNTB and were evaluated in the present comparative study.

Subjects and Methods:

This study was conducted in the Department of Pathology of a tertiary care hospital in Shillong, Meghalaya in 540 clinical suspected cases of tuberculosis who underwent FNAC. The smears were submitted for Leishman's stain for cytological analysis, along with ZN and Auramine O stain for demonstration of the organism, analyzed, and scored and the results were compared with culture wherever available. The results from abdominal and cervical lymph nodal tuberculosis were compared using Microsoft Excel and SPSS software.

Results:

Out of 540 cases, most were tuberculosis (266) followed by reactive lymphadenitis (162), malignancy, and acute necrotizing lesion. On comparing, abdominal lymph nodes (n = 163) were more likely to reveal cheesy/purulent material macroscopically, necrotizing lymphadenitis along with ZN stain and Auramine positivity (P < 0.05) while cervical lymph nodes (n = 66) revealed a higher proportion of granulomatous lymphadenitis and culture positivity (P < 0.05). The sensitivity, NPV, and diagnostic accuracy of AO stain (85.9%, 48.0%, and 62.3%) were higher as compared to ZN stain (47.4%, 39.3%, and 51.9%) with culture as the gold standard. The combined sensitivity of Ziehl Neelsen stain and Auramine stain was 92.05%.

Conclusion:

Cytological and microbiologic features of abdominal LNTB differ from cervical LNTB. Moreover, AO stain increases the smear positivity, is almost twice as sensitive as ZN stain and should be used as an adjunct in cytological material wherever available.

Recent updates in diagnosis of abdominal tuberculosis with emphasis on nucleic acid amplification tests

INTRODUCTION

Abdominal tuberculosis (TB) is a common epitome of extrapulmonary TB (EPTB), wherein peritoneal and intestinal TB are the most prevalent forms. Diagnosis of abdominal TB is a daunting challenge owing to variable anatomical locations, paucibacillary nature of specimens and atypical clinical presentations that mimic other abdominal diseases, such as Crohn's disease and malignancies. In this review, we made a comprehensive study on the diagnosis of abdominal TB.

AREA COVERED

Various modalities employed for abdominal TB diagnosis include clinical features, imaging, bacteriological tests (smear/culture), histopathological/cytological observations, interferon-gamma release assays and nucleic acid amplification tests (NAATs). Among NAATs, loop-mediated isothermal amplification assay, PCR, multiplex-PCR, nested PCR, real-time PCR and GeneXpert® MTB/RIF were discussed. Identification of circulating Mycobacterium tuberculosis cell-free DNA by real-time PCR within ascitic fluids is another useful approach.

EXPERT OPINION

Several novel molecular/immunological methods, such as GeneXpert Ultra, aptamer-linked immobilized sorbent assay, immuno-PCR (I-PCR) and nanoparticle-based I-PCR have recently been developed for detecting pulmonary TB and several EPTB types, which may also be explored for abdominal TB diagnosis. Precise and prompt diagnosis of abdominal TB may initiate an early therapy so as to reduce the complications, i.e. abdominal pain, ascites, abdominal distension, intestinal obstruction/perforation, etc., and avoid surgical involvement.Plain Language SummaryAbdominal tuberculosis (TB) is a manifestation of extrapulmonary TB (EPTB), where peritoneal and intestinal TB are two major forms. Diagnosis of abdominal TB is difficult owing to low bacterial load present in clinical samples and non-specific clinical presentations as it mimics other diseases such as inflammatory bowel diseases, abdominal malignancies, etc. Bacteriological tests (smear/culture) almost fail owing to poor sensitivities and it is not always possible to get representative tissue samples for histopathological and cytological observations. In recent years, molecular tests i.e. nucleic acid amplification tests (NAATs), such as PCR/multiplex-PCR (M-PCR), nested PCR and GeneXpert are widely employed. Markedly, PCR/M-PCR and nested PCR exhibited reasonable good sensitivities/specificities, while GeneXpert revealed low sensitivity in most of the studies but high specificity, thus it could assist in differential diagnosis of intestinal TB and Crohn's disease. Further, novel molecular/immunological tests employed for pulmonary TB and other EPTB types were described and those tests can also be utilized to diagnose abdominal TB. Reliable and rapid diagnosis of abdominal TB would initiate an early start of anti-tubercular therapy and reduce the severe complications.

Small Bowel Obstruction As a Consequence of Peritoneal Tuberculosis

Peritoneal tuberculosis (PTB) is a rare subset of extrapulmonary tuberculosis which account for only 0.5-1% of all cases. PTB diagnosis can be challenging due to nonspecific clinical manifestations. We present a known case of pulmonary tuberculosis that admitted to the surgery ward due to the major complaint of abdominal pain since ten days before admission. In imaging studies, positive findings favoring mechanical obstruction were detected. There were also several hypodense lesions in the liver suggestive of visceral tuberculosis. An adhesion was noted during exploratory laparotomy prior to the ileocecal valve responsible for intestinal obstruction, which was released. Pathology reports of excised tissues were consonant with the PTB diagnosis. PTB diagnosis can be challenging because of its presentation. This can delay the treatment of patients and thus increase morbidity and mortality. As a result, physicians should always be aware of the PTB diagnosis in patients with nonspecific abdominal involvement.

Ileocaecal Tuberculosis Presenting with Massive Hematochezia: A Rare Clinical Manifestation

Abdominal pain, diarrhea, weight loss, anorexia, and fever are common symptoms of intestinal tuberculosis, while bleeding from the lumen, intestinal obstruction, perforation, and fistula formation are uncommon presentations in ileocaecal tuberculosis. Here, we present a case of a 33-year-old male with intestinal tuberculosis who initially presented with massive bleeding per rectum.

Incidence and Mortality of Extrapulmonary Tuberculosis in Ukraine: Analysis of National Surveillance Data

BACKGROUND

Improved understanding of the epidemiology and mortality risk factors of extrapulmonary tuberculosis (EPTB) may facilitate successful diagnosis and management.

METHODS

We analyzed national surveillance data from Ukraine to characterize EPTB subtypes (i.e., localized in different anatomic sites). We calculated annual reported incidence, stratified by age, sex, and HIV status. Using Cox regression, we estimated mortality risk factors.

RESULTS

Between January 2015-November 2018, 14,062 adults/adolescents (≥15 years old) and 417 children (<15 years old) had extrapulmonary TB with or without concomitant pulmonary TB. The most commonly reported EPTB subtypes were pleural, peripheral lymph node, and osteoarticular. Most EPTB subtype notifications peaked at age 30-39 years and were higher in males. In adults/adolescents, most peripheral TB lymphadenitis, central nervous system (CNS) TB, and abdominal TB occurred in those with untreated HIV. CNS TB notifications in people without HIV peaked before age five years. Adults/adolescents with CNS TB (adjusted hazard ratio (aHR) 3.22, 95% CI: 2.89-3.60) and abdominal TB (aHR 1.83, 95% CI: 1.59-2.11) were more likely to die than those with pulmonary TB. Children with CNS TB were more likely to die (aHR 88.25, 95% CI: 43.49-179.10) than those with non-CNS TB. Among adults/adolescents, older age and HIV were associated with death. Rifampicin resistance was associated with mortality in pleural, peripheral lymph node, and CNS TB.

CONCLUSION

We have identified the most common EPTB subtypes by age and sex; patterns of EPTB disease by HIV status; and mortality risk factors. These findings can inform diagnosis and care for people with EPTB.

Clinical features of and diagnostic approaches for abdominal tuberculosis: 5-year experience from a non-tuberculosis-designated hospital in China

BACKGROUND AND PURPOSE

Abdominal tuberculosis (TB) is a common form of extrapulmonary TB but is still a diagnostic dilemma in clinical practice. We are aimed to highlight the clinical features of and diagnostic approaches for abdominal TB.

METHODS

Seventy cases of diagnosed abdominal TB were retrospectively collected at Zhongshan Hospital, Fudan University in Shanghai, China, between 1 August 2015 and 30 June 2020. They were classified as peritoneal TB, lymph node TB, gastrointestinal TB, visceral TB, or mixed TB.

RESULTS

Eighteen patients were diagnosed with peritoneal TB, 9 with lymph node TB, 5 with gastrointestinal TB, 2 with visceral TB, and 36 with mixed TB. Twenty-four patients had only abdominal TB, while 7 had abdominal TB combined with pulmonary TB (PTB), 19 had abdominal TB combined with extrapulmonary TB (EPTB) in one or more sites, and 20 had abdominal TB combined with both PTB and EPTB in other sites. The median diagnosis time was 60 days. Ascites(58.6%), abdominal distension(48.6%), weight loss(44.3%) and fever(42.9%) were the most common symptoms. The overall microbiological and histological confirmation rates were 70.0% and 38.6% respectively. The non-ascites samples yielded a higher microbiological confirmation rate (63.6%) than the total samples (40.8%). Diagnosis was confirmed histologically in 18 patients (69.2%). Forty-five cases (64.3%) were clinically diagnosed. Invasive procedures such as surgery (6/7), percutaneous biopsy (7/7) and endoscopy in lymph node TB (4/5) had high confirmation rates.

CONCLUSIONS

The diagnosis of abdominal TB should be reached by a combination of clinical, laboratorial, radiographic, microbiological and pathological findings.

Angioplasty With Stent Implantation for Portal Venous Stenosis Caused by Abdominal Tuberculosis: A Case Report and Literature Review

Abdominal tuberculosis is one of common forms of extra-pulmonary tuberculosis. However, portal vein involvement leading to portal venous stenosis and portal hypertension is a rare complication in abdominal tuberculosis. Because of the non-specific presentations and insensitive response to anti-tuberculosis therapy of the lesions involving portal vein, it continues to be both a diagnostic and treatment challenge. We have reported a 22-year-old woman presented with massive ascites and pleural effusion, which was proved to be TB infection by pleural biopsy. After standard anti-tuberculosis therapy, her systemic symptoms completely resolved while ascites worsened with serum-ascites albumin gradient >11 g/L. Contrast-enhanced computed tomography and portal venography showed severe main portal vein stenosis from compression by multiple calcified hilar lymph nodes. Finally, the patient was diagnosed with portal venous stenosis due to lymphadenopathy after abdominal tuberculosis infection. Portal venous angioplasty by balloon dilation with stent implantation was performed and continued anti-tuberculosis therapy were administrated after discharge. The ascites resolved promptly with no recurrence occurred during the six-month follow-up. Refractory ascites due to portal venous stenosis is an uncommon vascular complication of abdominal tuberculosis. Portal venous angioplasty with stent placement could be a safe and effective treatment for irreversible vascular lesions after anti-tuberculosis therapy.

Gastrointestinal tuberculosis: A systematic review of epidemiology, presentation, diagnosis and treatment

Tuberculosis (TB) once considered a disease of the developing world is infrequent in the developing world too. Its worldwide prevalence with a huge impact on the healthcare system both in economic and health terms has prompted the World Health Organization to make it a top priority infectious disease. Tuberculous infection of the pulmonary system is the most common form of this disease, however, extrapulmonary TB is being increasingly recognized and more often seen in immunocompromised situations. Gastrointestinal TB is a leading extrapulmonary TB manifestation that can defy diagnosis. Overlap of symptoms with other gastrointestinal diseases and limited accuracy of diagnostic tests demands more awareness of this disease. Untreated gastrointestinal TB can cause significant morbidity leading to prolonged hospitalization and surgery. Prompt diagnosis with early initiation of therapy can avoid this. This timely review discusses the epidemiology, risk factors, pathogenesis, clinical presentation, current diagnostic tools and therapy.

The puzzle of the evolutionary natural history of tuberculosis

Several pieces of the puzzle of the natural history of tuberculosis are assembled in this review to illustrate the potential reservoirs and sources of the Mycobacterium tuberculosis complex (MTBC) mycobacteria, their transmission to animals and humans, and their fate in populations, in a co-evolutionary perspective. Millennia-old companions of mammalian and human populations, MTBC are detected in the soil, in which they infect and survive within vegetative amoebae and cysts, except for Mycobacterium canettii. Never detected in the sphere of plants, they are transmissible by transcutaneous, digestive and respiratory routes and cause an infection of the lymphatic system with secondary dissemination in most tissues, in which they determine a specific and non-pathognomonic granulomatous inflammatory reaction; in which MTBC survives in dormant form irrespective of MTBC species and mammalian species; indicating that the current epidemiology in mammalian populations is essentially governed by the probabilities of contact between mammalian species and MTBC species. Individual variabilities in clinical expression of tuberculosis are related to MTBC species, strain and inoculum; host genetic factors; acquired modulations of the inflammatory response; and probably human microbiota. This review of the literature suggests an evolutionary natural history of telluric environmental mycobacteria, satellites of unicellular eukaryotes, transmissible to mammals via the digestive and then respiratory tracts, in which they determine a fatal contagious infection that is primarily lymphatic and a quiescence-mimicking encysted form. This review opens perspectives for microbiological and translational medical research.

Surgical management of abdominal tuberculosis: A prospective single-center study

Objective

Tuberculosis (TB) can affect any part of the gastrointestinal tract. It is estimated that in 2018, 10 million people were affected with TB worldwide and there were 1.2 million TB deaths among human immunodeficiency virus-negative people. India has the highest TB burden in the world (27%), a significant proportion of which are of intestinal TB. The aims of this study were to assess clinical features and investigations for the diagnosis of abdominal TB and to analyze its various surgical manifestations and its management.

Materials and Methods

From October 1, 2014, to October 30, 2016, a total of 50 patients meeting the inclusion criteria for the study, age between 15 and 65 years and diagnosis of symptomatic intestinal TB requiring surgery, were enrolled in the study. We used descriptive statistics to analyze the data.

Results

Abdominal TB was most commonly seen in young adults. Intestinal obstruction was the most frequent presentation. The most common site of involvement in the present study was the ileum. Ultrasonography (USG) and X-ray were an integral part of the diagnosis, with computed tomography (CT) scan being rarely required. Although both anemia and erythrocyte sedimentation rate (ESR) are nonspecific, they may help in supporting the clinical and pathological findings. Most operations were elective, with intestinal obstruction being the most common indication and resection and end-to-end anastomosis performed most often. Histopathological examination was performed in all patients and showed caseating granuloma in 90% of cases, while 10% of cases had chronic noncaseating granulomas with ill-defined aggregates of epithelioid histiocytes.

Conclusion

Abdominal TB causes a significant problem in diagnosis due to nonspecific symptomatology and lack of specific laboratory tests. USG and X-ray were an integral part of the diagnosis. CT scan is rarely required. Although anemia and ESR are both nonspecific features, they may help in supporting the clinical and pathological findings. The most common site of involvement in the present study was the ileum. Intestinal obstruction was the most common indication for operation, with resection and end-to-end anastomosis being the most common operation. The mainstay of treatment is medical therapy and timely surgical intervention is required in a sizable number of patients.

Peritoneal tuberculosis: A case report on a rare cause of tumor marker elevation

Peritoneal tuberculosis (TB) is a rare extrapulmonary manifestation of TB with non-specific clinical characteristics which can produce test results mimicking malignancy and granulomatous peritonitis. This case describes a Filipino 59-year-old, nulliparous woman who was admitted with abdominal pain, ascites, and an elevated CA-125 level. Radiographically, peritoneal nodules were visualized and initial suspicion was high for malignancy. Following a bilateral salpingo-oophorectomy and peritoneal biopsy, histology was negative for malignancy but revealed non-caseating granulomas. She was discharged then readmitted with progressive abdominal pain, and a repeat laparoscopic biopsy yielded specimens with growth of acid-fast bacilli (AFB). A delay in diagnosis and treatment of tuberculous peritonitis increases mortality rates, making early diagnosis with laparoscopic biopsy of paramount importance in prompt diagnosis and initiation of therapy. This patient was initiated on standard anti-TB therapy and experienced no complications.

Non-Tuberculous Mycobacteria: Molecular and Physiological Bases of Virulence and Adaptation to Ecological Niches

Non-tuberculous mycobacteria (NTM) are paradigmatic colonizers of the total environment, circulating at the interfaces of the atmosphere, lithosphere, hydrosphere, biosphere, and anthroposphere. Their striking adaptive ecology on the interconnection of multiple spheres results from the combination of several biological features related to their exclusive hydrophobic and lipid-rich impermeable cell wall, transcriptional regulation signatures, biofilm phenotype, and symbiosis with protozoa. This unique blend of traits is reviewed in this work, with highlights to the prodigious plasticity and persistence hallmarks of NTM in a wide diversity of environments, from extreme natural milieus to microniches in the human body. Knowledge on the taxonomy, evolution, and functional diversity of NTM is updated, as well as the molecular and physiological bases for environmental adaptation, tolerance to xenobiotics, and infection biology in the human and non-human host. The complex interplay between individual, species-specific and ecological niche traits contributing to NTM resilience across ecosystems are also explored. This work hinges current understandings of NTM, approaching their biology and heterogeneity from several angles and reinforcing the complexity of these microorganisms often associated with a multiplicity of diseases, including pulmonary, soft-tissue, or milliary. In addition to emphasizing the cornerstones of knowledge involving these bacteria, we identify research gaps that need to be addressed, stressing out the need for decision-makers to recognize NTM infection as a public health issue that has to be tackled, especially when considering an increasingly susceptible elderly and immunocompromised population in developed countries, as well as in low- or middle-income countries, where NTM infections are still highly misdiagnosed and neglected.

Extrapulmonary Tuberculosis: Pathophysiology and Imaging Findings

Extrapulmonary tuberculosis (TB) represents approximately 15% of all TB infections. It is difficult to diagnose on the basis of imaging characteristics and clinical symptoms, and biopsy is required in many cases. Radiologists must be aware of the imaging findings of extrapulmonary TB to identify the condition in high-risk patients, even in the absence of active pulmonary infection. In extrapulmonary TB, the lymphatic system is most frequently affected. The presence of necrotic lymph nodes and other organ-specific imaging features increases the diagnostic probability of extrapulmonary TB. Disseminated infection and central nervous system involvement are the most frequent manifestations in immunosuppressed patients. Renal disease can occur in immunocompetent patients with very long latency periods between the primary pulmonary infection and genitourinary involvement. In several cases, gastrointestinal, solid-organ, and peritoneal TB show nonspecific imaging findings. Tuberculous spondylitis is the most frequent musculoskeletal manifestation. It is usually diagnosed late and affects multiple vertebral segments with extensive paraspinal abscess. Articular disease is the second most frequent musculoskeletal manifestation, and synovitis is its predominant imaging finding.^©RSNA, 2019.

Evaluation of Twenty-One Cases of Abdominal Tuberculosis: A Single-Center Experience

Background: Abdominal tuberculosis (TB) remains an issue as it masquerades as many malignant or benign abdominal conditions. Objective: To analyze the clinical and laboratory features of abdominal TB retrospectively and discuss its management. Methods: The data of patients with a histopathologic diagnosis of abdominal TB seen from January 1, 2008, to February 1, 2019 were collected in The First Affiliated Hospital of Nanjing Medical University. Nodal, visceral, peritoneal, and mixed TB cases were included while excluding other forms of extra-pulmonary TB (EPTB). Results: A total of 21 patients presented having a median age of 49 years (interquartile range 33-57 years) with 12 females and 9 males. Ten presented with abdominal pain, whereas four had abdominal pain and distention. Weight loss was present in five and type 2 diabetes mellitus (DM) in three. Every patient received contrast-enhanced computed tomography (CE-CT) with positive results in all the cases. Seven patients received endoscopic ultrasound-guided fine-needle aspiration cytology examination (EUS-FNAC) and five had results positive for TB. Pre-operative diagnosis of abdominal TB was possible in seven; however, the majority (n = 14) underwent exploratory laparotomy, and all obtained a definitive diagnosis of TB. No deaths occurred. Conclusions: Both CE-CT and EUS-FNAC can aid in the timely diagnosis. Laparotomy is an invasive but efficient tool for the final diagnosis of abdominal TB.

Intra-abdominal tuberculosis masquerading as ovarian carcinoma

Intra-abdominal tuberculosis (TB) is rare in Australia, but it can be found in those who emigrate from endemic areas. We report a rare case of a 28-year-old lady from the Philippines who presented with abdominal pain, ascites and an elevated cancer antigen (CA) 125 with an initial concern of ovarian malignancy. She underwent a diagnostic laparoscopy which revealed typical features of intra-abdominal TB and histological features of granulomatous inflammation. The symptoms and signs of intra-abdominal TB are non-specific and can mimic many other conditions. The gold-standard mode of diagnosis in intra-abdominal TB is laparoscopy with tissue biopsy. Ovarian malignancy is relatively rare in pre-menopausal women; hence an elevated CA 125 warrants a broader differential diagnosis. It is important to have intra-abdominal TB as a differential even in the non-endemic settings to avoid delay in diagnosis and appropriate management.

Diagnosis of abdominal tuberculosis: lessons learned over 30 years: pectoral assay

Diagnosing abdominal tuberculosis remains a great challenge even for experienced clinicians. It is a great mimicker that has unusual presentations. A high index of suspicion is essential for reaching its diagnosis. Clinical and radiological findings of abdominal tuberculosis are non-specific. Herein, we report the lessons we have learned over the last 30 years stemming from our own mistakes in diagnosing abdominal tuberculosis supported by illustrative challenging clinical cases. Furthermore, we report our diagnostic algorithm for abdominal tuberculosis. This diagnostic algorithm will help in reaching the proper diagnosis by histopathology or microbiology. Our diagnostic workup depends on categorizing the clinical and radiological findings of abdominal tuberculosis into five different categories including (1) gastrointestinal, (2) solid organ lesions, (3) lymphadenopathy, (4) wet peritonitis, and (5) dry/fixed peritonitis. The diagnosis in gastrointestinal tuberculosis and dry peritonitis can be reached by endoscopy. The diagnosis in solid organ lesions can be reached by ultrasound-guided aspiration. The diagnosis in wet peritonitis and lymphadenopathy can be reached by ultrasound-guided aspiration followed by laparoscopy if needed. Diagnostic laparotomy should be kept as the last option for achieving a histological diagnosis. Capsule endoscopy and enteroscopy were not included in the diagnostic algorithm because of the limited data of using these modalities in abdominal tuberculosis. They need special expertise, and rarely used in low- and middle-income countries. Furthermore, capsule endoscopy may cause complete intestinal obstruction in small bowel strictures. A definite diagnosis can be reached in only 80% of the patients. Therapeutic diagnosis should be tried in the remaining 20%.

Isolated gastric varices secondary to abdominal tuberculosis mimicking lymphoma: a case report

Background

Abdominal tuberculosis (TB) rarely presents with abdominal masses and rarely causes isolated gastric varices.

Case presentation

We report a case of isolated gastric varices secondary to abdominal TB mimicking lymphoma. A 42-year-old woman without any history of liver disease presented with melena and mild abdominal pain. Upon admission to the hospital, laboratory investigations revealed a hemoglobin level of 76 g/L. Gastroduodenoscopic examination showed isolated gastric fundal varices with red color signs. Abdominal contrast-enhanced computed tomography (CECT) revealed non-enhanced masses of soft-tissue density in the lesser omental and the retropancreatic areas, multiple para-aortic lymph nodes, and multiple small hypodense splenic lesions. Positron emission tomography-CT showed hypermetabolic [F-18]2-fluoro-2-deoxyglucose activity involving multiple regional lymph nodes and the bone marrow, suggestive of lymphoma. Bone marrow biopsy revealed no abnormality. Histopathological examination of a CT-guided biopsy specimen showed granulomatous inflammation with necrosis and microorganisms that stained positive with acid-fast stains. Abdominal CECT showed a decrease in the size of the lesser omental and peripancreatic masses, as well as the para-aortic lymph nodes after 4-month anti-TB therapy.

Conclusions

TB should be considered among the differential diagnoses in patients with abdominal masses, isolated gastric varices, and regional lymphadenopathy. Prompt and definitive diagnosis of abdominal TB requires a coordinated approach involving laboratory tests, radiological examination, and invasive procedures for optimal decision making and management.