Tuberculous peritonitis in an endemic area

Serosal membrane tuberculosis in Iran: A comprehensive review of evidences

Tuberculosis (TB) is among the most common cause of serositis. There are many uncertainties in diagnostic and therapeutic approach to serous membranes tuberculosis. Our aim in the present review is to discuss the regional facilities for timely diagnosis, rapid decision-making and appropriate treatment regarding to serous membranes tuberculosis; with emphasis on situation in Iran. A comprehensive literature searches about the status of serous membranes tuberculosis in Iran were performed in English databases including Google Scholar, Science Direct, Scopus, Pub Med, and Web of Sciences, Persian SID databases, between 2000 and 2021. The main findings of the present review are as follow: a) pleural tuberculosis is more common than pericardial or peritoneal tuberculosis. b) Clinical manifestations are non-specific and so non-diagnostic. c) Smear and culture, PCR and characteristic granulomatous reaction have been used for definitive TB diagnosis by physicians. d) With Adenosine Deaminase Assays and Interferon-Gamma Release Assays in mononuclear dominant fluid, a possible diagnosis of TB is proposed by experienced physicians in Iran. e) In area of endemic for tuberculosis including Iran, a possible diagnosis of TB is enough to begin empirical treatment. f) In patients with uncomplicated tuberculosis serositis, treatment is similar to pulmonary tuberculosis. First line drugs are prescribed unless evidence of MDR-TB is detected. g) The prevalence of drug resistant tuberculosis (MDR-TB) in Iran is between 1% and 6%, and are treated by empirical standardized treatment. h) It is not known whether adjuvant corticosteroids are effective in preventing long term complication. i) Surgery may be recommended for MDR-TB. Tamponade or constrictive pericarditis and intestinal obstruction. In conclusion, it is recommended to consider serosal tuberculosis in patients who have unknown mononuclear dominant effusion and prolonged constitutional symptoms. Experimental treatment with first line anti-TB drugs can be started based on possible diagnostic findings.

[Tuberculous abdominal cocoon as a rare variant of peritonitis]

OBJECTIVE

To study and systematize clinical symptoms of tuberculous perivisceritis, to clarify diagnostic value of laboratory and instrumental survey in these patients and to identify the features of surgical treatment.

MATERIAL AND METHODS

There were 8 patients with tuberculous perivisceritis. Examination included computed tomography of the abdominal cavity and chest, ultrasound, laparoscopy. All patients underwent surgical treatment with histological, cytological, microbiological and molecular genetic analysis of peritoneal exudate and biopsy of peritoneal specimens.

RESULTS

Clinical picture of tuberculous perivisceritis is variable and non-specific. Periods of exacerbation are replaced by periods of prolonged remission. The complex of radiological survey used in verification of perivisceritis does not allow accurate determining the nature of disease. However, peritoneal tuberculosis may be suspected as a rule considering signs of thickening of the peritoneum. Objective confirmation of perivisceritis is possible only during surgical intervention. In this case, etiological factor can be established only after a thorough histological examination of resected fibrous capsule.

CONCLUSION

Clinical picture of tuberculous perivisceritis does not have specific symptoms. The disease is characterized by prolonged and undulating course. Acute peritonitis and acute intestinal obstruction may be suspected during exacerbation of the pathological process. Laparotomy followed by complete excision of fibrous capsule and adhesiolysis is preferred.

Extremely Elevated Erythrocyte Sedimentation Rates: Associations With Patients' Diagnoses, Demographic Characteristics, and Comorbidities

OBJECTIVE

To study associations between extreme erythrocyte sedimentation rate (ESR) elevations (≥100 mm/h) and diseases, age, sex, race, Charlson Comorbidity Index (CCI), and C-reactive protein (CRP) level.

PATIENTS AND METHODS

This was a retrospective cohort study of 4807 patients with extreme ESR values examined at Mayo Clinic, Rochester, Minnesota, from January 1, 2002, through December 31, 2011. Independent variables included diseases (infection, autoimmune, malignancy, renal disease, or miscellaneous), subcategories of diseases, patient demographic characteristics (age, sex, and race), CRP level, and CCI. The Wilcoxon rank sum test was used to assess comparisons of ESR between patients with and without disease as well as relationships between extreme ESR values and demographic characteristics of patients within disease categories. Associations between ESR and CRP level were determined using the Pearson correlation coefficient.

RESULTS

The leading diagnosis associated with extreme ESR elevations (n [%]) was infection (1932 [40]), followed by autoimmune (1839 [38]) and malignancy (1736 [36]) (P<.01). Extreme elevations in ESR varied by sex, with higher ESRs in men (mean, 117±13.3 mm/h) than in women (mean, 115.9±12.5 mm/h) (P=.008). Extreme ESR elevations correlated inversely with the CCI (P=.008) and did not correlate with the CRP level. There were no correlations between extreme elevations in ESR and age or race.

CONCLUSION

We found that almost all patients have an identifiable etiology for extreme ESR elevations and that infection is the most common disease association. Unlike previous research, we identified higher ESRs in men than in women and no associations with age, race, and comorbid illness. These findings may enhance the diagnostic evaluation of patients with extreme ESR elevations.

[Analysis of a series of 44 cases of peritoneal tuberculosis diagnosed in the pathology laboratory of the Tokoin teaching hospital of Lomé (1993-2014)]

It is a descriptive and cross-sectional study on all issues relating to peritoneal tuberculosis histological diagnosed in the pathology department (LAP) of the Lomé Tokoin CHU from January 1993 to December 2014 (20 years). A total of 44 cases of peritoneal tuberculosis were included. They were 18 women and 26 men, with a mean age of 37.6±0.2 years. The circumstances of discovery were dominated by ascites (84.1%), fever (75%), weight loss (63.6%) and abdominal pain (59.1%). The peritoneal involvement was isolated in 31.8% of cases, and associated with pleuropulmonary tuberculosis in 54.5% of cases. Co-infection with HIV was present in 63.9% of cases. Twenty-five patients (69.4%) with information about their social conditions had low socioeconomic level: unemployed (10 cases; 40%), workers (10 cases; 40%) and retired (5 cases; 20%). An increase in cell count was observed in 94.6% of cases. Histology revealed the epithelial giant cell granuloma associated with caseous necrosis in 38 cases (86.4%) and cheesy isolated in 6 patients. Peritoneal tuberculosis is not exceptional in our country. The diagnosis should be considered in febrile ascites, and will be confirmed by laparoscopy with histological samples for a histological diagnosis.

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.

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.

Ascites and spontaneous bacterial peritonitis: an Asian perspective

Ascites is the most common complication of liver cirrhosis, and it develops as a consequence of portal hypertension and splanchnic vasodilatation. Depending on severity, management of ascites consists of diverse strategy, including dietary sodium restriction, diuretic therapy, repeated large-volume paracentesis with albumin infusion, transjugular intrahepatic portosystemic shunt, and liver transplantation. Recently, advances in medical therapy have been made with satavaptan, a V2 receptor antagonist, vasoconstrictors, such as clonidine, midodrine, or terlipressin, and other categories of drugs, including docarpamine and Chinese herbs. These drugs may serve as useful adjuncts to conventional diuretics in the management of ascites. Besides ascites itself, serious complications, such as spontaneous bacterial peritonitis (SBP) and hepatorenal syndrome, frequently ensue in decompensated cirrhosis. SBP develops from the translocation of bacteria from the intestine, and successful management with early diagnosis and treatment with proper prevention in patients of high risk is necessary. In summary, ascites is a starting point for more serious complications in liver cirrhosis. Although liver transplantation is the fundamental treatment, it is not always feasible, and consequently various means of treatment should be used. Further study, particularly in Asia where hepatitis B virus-related cirrhosis is predominant, is warranted to improve the clinical outcome.

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.

Clinical review of tuberculous peritonitis in 39 patients in Diyarbakir, Turkey

Abdominal tuberculosis (TB) is a rare manifestation, which can be overlooked on long-lasting and non-specific findings unless a high index of suspicion is maintained. The purpose of the present study was to investigate the diagnostic features of 39 patients hospitalized with tuberculous peritonitis (TBP) in Dicle University Hospital, Turkey between January 1994 and August 2003. Twenty-two patients were male; patient age ranged between 1 and 59 years (mean: 16.2 +/- 14.4 years). There were 21 patients (54%) under 15 years of age. Thirteen children had a history of familial TB and seven adults had prior history of TB. Six (29%) of 21 pediatric cases had bacille Calmette-Guerin (BCG) scars and results of 5-tuberculin units (TU) tuberculin test were positive in seven children (18%). Of all cases, the most common presenting findings were abdominal pain (95%), ascites (92%) and abdominal distention (82%). Five of the patients had accompanying pulmonary TB, and six patients (15%) had intestinal TB who were admitted to emergency service with acute abdomen, of whom three (8%) had perforation and three (8%) had ileus. Histopathologically 20 cases (51%) were proven on abdominal ultrasonography, and computed tomography revealed most commonly ascites and thickening of peritoneum. No microbiologic evidence was obtained except three positive culture results for Mycobacterium tuberculosis. As a result, TBP should be considered for diagnosis, in patients with non-specific symptoms of abdominal pain, wasting, fever, loss of appetite, abdominal distension and even symptoms of acute abdomen, because early diagnosis and effective treatment will decrease morbidity and mortality.

Tuberculous peritonitis of the wet ascitic type: clinical features and diagnostic value of image-guided peritoneal biopsy

BACKGROUND

Abdominal tuberculosis is still a medical problem in developing countries.

AIMS

To analyse the clinical, laboratory, ultrasonography and computed tomography findings and to discuss the diagnostic approach of 19 patients with peritoneal tuberculosis.

PATIENTS

Nineteen patients diagnosed in our department, with peritoneal tuberculosis (8 female, 11 male; mean age: 47.89 +/- 4.3 years) between 1996 and 2002, were studied retrospectively.

METHODS

All clinical, laboratory, radiological findings, and diagnostic methods were reviewed.

RESULTS

The most common symptoms and signs of the disease in these patients were abdominal pain, ascites, weight loss and night sweats. On conducting skin test, eight patients (42%) were found to be positive, while all the patients had elevated serum cancer antigen 125 levels, but acid-resistant bacilli could not be demonstrated on the direct preparation. In three patients (15.78%), the ascitic fluid culture was positive. The most common ultrasonographic and computed tomographic findings were ascites, septation in the ascites, peritoneal thickening, mesenteric and omental involvement. An abnormal chest X-ray, suggestive of previous tuberculosis was present in three patients. Diagnosis was made by image-guided percutaneous peritoneal biopsy in 18/19, and by histological examination of biopsy specimens obtained via laparoscopy in 1/19. Laparoscopy was only performed in 1 of the 19 patients due to lack of sufficient material for histological diagnosis by percutaneous biopsy. Of the biopsy specimens, 84% revealed caseating granulomas, while 16% were non-caseating. Acid-fast bacilli were seen on the Ziehl-Neelsen stain in 18 patients.

CONCLUSIONS

Peritoneal tuberculosis should be considered in the differential diagnosis of exudative ascites. Image-guided percutaneous peritoneal biopsy seems to be a sufficient, safe and inexpensive method for diagnosis of peritoneal tuberculosis.