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Tuberculous Peritonitis

Peritoneal Tuberculosis

Tuberculous peritonitis is one of the possible forms of abdominal tuberculosis. It is an uncommon variant of tuberculosis with an estimated incidence of 0.1-0.7% among all reported cases.


Presentation

Tuberculous peritonitis (TP) is a rare, extrapulmonary manifestation of tuberculosis [1] [2]. TP mainly occurs via the hematogenous spread of Mycobacterium tuberculosis microorganisms from the affected lungs. It may also spread from infected abdominal or pelvic structures, however, this is a rare occasion [3]. Cases of tuberculosis (TB), including TP, have recently risen. Risk factors for developing TP include human immunodeficiency virus (HIV) infection, diabetes, peritoneal dialysis, and malignancy [2].

Diagnosis of TP is not straightforward, as the clinical picture differs between patients, and often the symptomatology is vague [2]. TP symptoms may be especially overlooked in pregnancy [4]. Furthermore, comorbidities such as liver cirrhosis could mask existing symptoms and thus lengthen the delay in diagnosis [5].

Commonly reported symptoms and signs are fever, ascites, abdominal pain, constipation, and diarrhea [6]. Manifestations such as weight loss and night sweats have been reported to varying degrees [2]. Ascites, which is almost always present, may be obvious or subtle [7]. The latter occurs in the minority of patients and may be palpated as a doughy abdomen or perceived by imaging or during surgery [7] [8]. The color of the ascitic fluid is pale yellow, but rarely may be bloody.

Unrecognized and untreated TP leads to death in over 50% of cases [9].

Fever
  • The presence of fever, elevated serum CA 125 level, normal serum CA 19-9, and CEA associated with lymphocyte predominant benign ascites may establish the diagnosis of TBP.[ncbi.nlm.nih.gov]
  • The patient presented with persistent fever and intermittent cough for 1 month, but had no gastrointestinal symptoms.[ncbi.nlm.nih.gov]
  • A 49-year-old female patient on continuous ambulatory peritoneal dialysis presented with fever, abdominal pain and loss of appetite.[ncbi.nlm.nih.gov]
  • On admission, he was complaining of abdominal fullness and fever. Ultrasound tomography and computed tomography (CT) scan of the abdomen showed massive ascites with multiple septa.[ncbi.nlm.nih.gov]
  • The patient's fever and abdominal distension gradually subsided after anti-tuberculosis treatment.[ncbi.nlm.nih.gov]
Weight Loss
  • Peritoneal tuberculosis should be considered in younger patients and adults with fever, abdominal pain and weight loss in endemic areas.[ncbi.nlm.nih.gov]
  • A young American Indian male with alcoholic cirrhosis and ascites presented with low grade fever and weight loss. A diagnosis of tuberculous peritonitis was made by laparoscopic guided peritoneal biopsy.[ncbi.nlm.nih.gov]
  • A case of a middle aged woman with weight loss, ascites, and a pleural effusion is presented where a clinical diagnosis of ovarian cancer was made.[ncbi.nlm.nih.gov]
  • A 13-year-old girl with weight loss and ascites was admitted with suspicion of a malignant disease. Abdominal magnetic resonance imaging indicated extensive peritonitis and showed no evidence of a solid tumor.[ncbi.nlm.nih.gov]
  • Herein, we describe a case of a primary small intestinal natural killer/T cell lymphoma in a 52-year-old man who presented with abdominal fullness and weight loss.[ncbi.nlm.nih.gov]
Chills
  • Signs and symptoms of PAD include abdominal tenderness; distended abdomen; nausea and vomiting; cloudy dialysis fluid; fever; chills.[diagnose-me.com]
  • Pain, fever, chills, weight loss and abdominal pain are common complaints [ 6 ]. In pregnant women, diagnosis of tuberculosis may be delayed by the non-specific nature of early symptoms and because they are often attributed to pregnancy [ 6 ].[jmedicalcasereports.biomedcentral.com]
  • She denied fevers, chills, night sweats, or cough. She denied sick contacts or recent travel outside the United States. She denied taking medications or using alcohol.[shmabstracts.com]
Fever of Unknown Origin
  • An 18-year-old man was admitted to our hospital for further examination of fever of unknown origin and ascites. Ga-67 scintigraphy revealed diffuse increased uptake throughout the abdomen.[ncbi.nlm.nih.gov]
  • In patients with massive ascites and fever of unknown origin, tuberculous peritonitis must be considered. Gallium-67 scintigraphy has been shown to be useful when there is a high index of suspicion of tuberculous peritonitis.[ncbi.nlm.nih.gov]
Abdominal Distension
  • The patient's fever and abdominal distension gradually subsided after anti-tuberculosis treatment.[ncbi.nlm.nih.gov]
  • Tuberculous peritonitis has to be clinically suspected in all patients with slowly progressive abdominal distension, particularly when it is accompanied by fever and pain.[ncbi.nlm.nih.gov]
  • Most common symptoms were abdominal distension (80.1%), abdominal pain (68.7%) and weight loss (45.5%). Most common signs were ascites (62.6%) and fever (55.5%). One-year survival rate was 89.9%; 21 patients died during follow-up.[ncbi.nlm.nih.gov]
  • 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[ncbi.nlm.nih.gov]
  • The patient's fever and abdominal distension gradually decreased after antituberculosis treatment.[casereports.bmj.com]
Abdominal Tenderness
  • Due to the symptoms fever, ascites, and diffuse abdominal tenderness on palpation of unknown origin, a CT scan of the abdomen was performed and led to the suspected diagnosis of a peritoneal carcinomatosis.[ncbi.nlm.nih.gov]
  • Ascites, fever, wasting, pallor, and abdominal tenderness were common findings. Ultrasonography demonstrated ascites in all patients who underwent this procedure; 21% also had adhesions.[ajtmh.org]
  • Signs and symptoms of PAD include abdominal tenderness; distended abdomen; nausea and vomiting; cloudy dialysis fluid; fever; chills.[diagnose-me.com]
  • tenderness and abdominal guarding , which are exacerbated by moving the peritoneum , e.g., coughing (forced cough may be used as a test), flexing one's hips, or eliciting the Blumberg sign (a.k.a. rebound tenderness , meaning that pressing a hand on[en.wikipedia.org]
  • Thorough clinical examination, with stress on the presence of pallor, jaundice, fever, manifestations of hepatocellular failure, ascites and its amount, abdominal tenderness, palpable abdominal masses, and localized or generalized lymphadenopathy.[azmj.eg.net]
Abdominal Fullness
  • Herein, we describe a case of a primary small intestinal natural killer/T cell lymphoma in a 52-year-old man who presented with abdominal fullness and weight loss.[ncbi.nlm.nih.gov]
  • On admission, he was complaining of abdominal fullness and fever. Ultrasound tomography and computed tomography (CT) scan of the abdomen showed massive ascites with multiple septa.[ncbi.nlm.nih.gov]
  • A 32-year-old man was admitted to our hospital complaining of abdominal fullness, anorexia, and a 15 kg weight loss. His abdomen was distended. There was neither any previous history nor recent contact with tuberculosis.[ncbi.nlm.nih.gov]
  • A 32-year-old man was admitted to our hospital complaining of abdominal fullness, anorexia, and a 15kg weight loss. His abdomen was distended. There was neither any previous history nor recent contact with tuberculosis.[link.springer.com]
Peritoneal Disease
  • Therefore, it is commonly misdiagnosed as another type of peritoneal disease, especially so in elderly patients with malignant disease.[ncbi.nlm.nih.gov]
  • Ultrasonography, computed tomography, magnetic resonance imaging, and serum CA-125 levels can be helpful but may not elucidate cases of diffuse peritoneal diseases mimicking carcinomatosis.[ncbi.nlm.nih.gov]
  • The abdomen is the most common site of extrapulmonary tuberculosis, with peritoneal disease being the commonest form within the abdomen.[radiopaedia.org]
Loss of Appetite
  • A 49-year-old female patient on continuous ambulatory peritoneal dialysis presented with fever, abdominal pain and loss of appetite.[ncbi.nlm.nih.gov]
  • Abdominal swelling (91.3%), loss of appetite (87%) and weight loss (82.6%) were the other commonest symptoms. The major physical findings were ascites (78.3%) and fever (60.9%). The serum ascites albumin gradient was 1.1 g/dL in all.[ncbi.nlm.nih.gov]
  • 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[ncbi.nlm.nih.gov]
Tachycardia
  • Signs and symptoms • Vague and consist of nothing more than lassitude, anorexia and failure to thrive • Pyrexia (often low-grade), tachycardia, leucocytosis and localised tenderness common • Later on, a palpable mass may develop • When palpable an intraperitoneal[slideshare.net]
  • Other symptoms [ edit ] Diffuse abdominal rigidity (" abdominal guarding ") is often present, especially in generalized peritonitis Fever Sinus tachycardia Development of ileus paralyticus (i.e., intestinal paralysis), which also causes nausea , vomiting[en.wikipedia.org]
Secondary Amenorrhea
  • In this article, we discuss a rare case of a 40-year-old Nigerian female presenting with abdominal pain, distension and secondary amenorrhea, and show that a high clinical suspicion combined with minimally invasive procedures can help physicians make[ncbi.nlm.nih.gov]

Workup

Most laboratory tests involve the analysis of the ascitic fluid. The culture of the ascitic fluid or bioptic material attained by means of paracentesis or peritoneal biopsy is the gold standard. Biopsy specimens are obtained efficiently through ultrasound or computerized tomography (CT) guidance. A newer, more rapid technique is the BACTEC radiometric system. Unlike conventional culture methods, results are available for approximately 2 weeks [9]. Other tests include assessing the protein content of the ascitic fluid, as well as polymerase chain reaction (PCR). Diagnostic minilaparotomy and laparoscopy are also important in the identification of tuberculous peritonitis.

In certain patients, active pulmonary TB may be visible on chest X-ray, but most radiographs show no specific findings. Ultrasound and CT of the abdomen are more valuable than chest X-ray. Using these modalities, it is possible to visualize omental and peritoneal abnormalities such as peritoneal thickening and an increase in the number of mesenteric lymph nodes [10]. Furthermore, the combined use of these imaging techniques increases their diagnostic precision [11].

Patients who have risk factors for TP, present with ascites that contains a predominance of lymphocytes, and have no apparent etiology should be managed with a high level of suspicion of tuberculosis with peritoneal involvement. The serum-ascites albumin gradient (SAAG) is often less than 11g/L. More advanced diagnostic methods are being developed, such as the ascitic adenosine deaminase test.

Treatment

  • An 82-year-old woman who had been on hemodialysis therapy for 6 years was admitted to our hospital for evaluation and treatment of hypercalcemia.[ncbi.nlm.nih.gov]
  • These findings suggest that Ga-67 scintigraphy is useful for diagnosis and observation during treatment of tuberculous peritonitis.[ncbi.nlm.nih.gov]
  • The serum CA-125 level also decreased significantly to 10.2 U/ml after treatment. cancer antigen-125 levels may serve as a potential follow-up marker of disease activity and treatment response in tuberculous peritonitis.[ncbi.nlm.nih.gov]
  • The CA 125 level was used to follow response to treatment and was undetectable after 12 weeks of antituberculous treatment. This tumor marker may be used to follow disease activity in non-neoplastic ascitic states.[ncbi.nlm.nih.gov]
  • Additionally, CA 125 is a useful marker for monitoring response to tuberculous peritonitis treatment.[ncbi.nlm.nih.gov]

Prognosis

  • Early diagnosis and prompt initiation of anti-tuberculosis therapy improve prognosis. Neutrophil-predominant ascites influences poor prognosis when correlated with secondary bacterial peritonitis.[ncbi.nlm.nih.gov]
  • Considering the poor prognosis of this infection when untreated, tuberculous peritonitis should be systematically suspected in such patients.[ncbi.nlm.nih.gov]
  • Ovarian cancer has the poorest prognosis of the gynecological cancers. Early diagnosis and treatment are important, but early-stage ovarian carcinoma has nonspecific symptoms.[ncbi.nlm.nih.gov]
  • The only book published devoted entirely to spontaneous bacterial peritonitis (SBP), this unique volume details the discovery, pathophysiology, diagnosis, prevalence, prognosis, treatment, and prevention of SBP, analyzing the various syndromes that constitute[books.google.com]
  • . • Prognosis of this variety of tuberculous peritonitis is relatively poor 31.[slideshare.net]

Etiology

  • In cases of ascites of unknown etiology, tuberculosis peritonitis (TBP) is a possible cause but a diagnostic challenge.[ncbi.nlm.nih.gov]
  • A major diagnostic challenge to the evaluation of an incomplete intestinal obstruction is to distinguish between infectious and malignant etiologies.[ncbi.nlm.nih.gov]
  • In geriatric patients with exudative ascites, malignant ascites is a common etiology. Tuberculous peritonitis is rarely seen and usually overlooked. We describe a 67-year-old man who suffered from exudative ascites for 1 month before admission.[ncbi.nlm.nih.gov]
  • ), peritoneum; tuberculous (manifestation), peritoneum; tuberculous peritonitis (etiology), peritoneum; tuberculous peritonitis (manifestation), peritonitis; tuberculous (etiology), peritonitis; tuberculous (manifestation), tuberculosis; peritoneum (etiology[fpnotebook.com]
  • ) , peritoneum; tuberculous (manifestation) , peritoneum; tuberculous peritonitis (etiology) , peritoneum; tuberculous peritonitis (manifestation) , peritonitis; tuberculous (etiology) , peritonitis; tuberculous (manifestation) , tuberculosis; peritoneum[fpnotebook.com]

Epidemiology

  • We evaluated the epidemiology of tuberculous peritonitis to determine diagnostic features and factors related to late diagnosis. We retrospectively reviewed 211 tuberculous peritonitis cases diagnosed between January 1999 and December 2009.[ncbi.nlm.nih.gov]
  • There are many important changes incorporated into this edition, including the dramatic effect of AIDS on the incidence and clinical mani festations of mycobacterial infection, new developments in epidemiology and bacteriology, and thoroughly updated[books.google.com]
  • . , «JOURNAL OF ANTIMICROBIAL CHEMOTHERAPY», 2013, 68, pp. 193 - 199 [Scientific article] , HIV-1 subtype C transmission network: The phylogenetic reconstruction strongly supports the epidemiological data. , «JOURNAL OF CLINICAL VIROLOGY», 2010, 48 (3[unibo.it]
  • Epidemiology of extrapulmonary tuberculosis. A comparative analysis with pre-AIDS era . Chest 99 , 1134 – 1138 . [CrossRef] [PubMed] [Google Scholar] Menzies R. I. , Fitzgerald J. M. , Mulpeter K. ( 1985 ).[jmm.microbiologyresearch.org]
  • However, extrapulmonary TB has a reverse epidemiological trend. The incidence of extrapulmonary TB in Hong Kong increased 2-fold during the period 1995–2005, whereas the incidence of reported pulmonary TB decreased by 10% during the same period.[academic.oup.com]
Sex distribution
Age distribution

Pathophysiology

  • The only book published devoted entirely to spontaneous bacterial peritonitis (SBP), this unique volume details the discovery, pathophysiology, diagnosis, prevalence, prognosis, treatment, and prevention of SBP, analyzing the various syndromes that constitute[books.google.com]
  • […] vol. 281 (pg. 1091 - 4 ) 12 Tuberculous peritonitis: prospective study of 32 cases in Iran , Ann Intern Med , 1972 , vol. 76 (pg. 567 - 72 ) 13 Ascites and spontaneous bacterial peritonitis , Steisenger & Fordtran's gastrointestinal and liver disease: pathophysiology[academic.oup.com]

Prevention

  • Highlights disorders, procedures, and substances that encourage or prevent bacterial translocation, the essence of SBP.[books.google.com]
  • Tuberculous miliary plastic peritonitis causes dense adhesions between bowel loops and prevents midgut volvulus in a pre-existing malrotation. Diagnosis can be a challenge and threshold for diagnostic laparoscopy should be low.[ncbi.nlm.nih.gov]
  • These sonographic findings may provide valuable information to help with further investigations and may prevent unnecessary laparotomies.[ncbi.nlm.nih.gov]
  • American Thoracic Society, Centers for Disease Control and Prevention and the Infectious Diseases Society. American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America: treatment of tuberculosis.[synapse.koreamed.org]
  • As with the first edition, it is hoped that this text will continue to represent a definitive resource for both the basic scientist and the clinician who deal with the prevention and treatment of mycobacterial infection.[books.google.com]

References

Article

  1. SiaI G, Wieland ML. Current concepts in the management of tuberculosis. Mayo Clin Proc. 2011;86(4):348-361.
  2. Sanai FM, Bzeizi KI. Systematic review: tuberculous peritonitis–presenting features, diagnostic strategies and treatment. Aliment Pharmacol Ther. 2005;22(8):685-700.
  3. Mehta JB, Dutt A, Harvill L, Mathews KM. Epidemiology of extrapulmonary tuberculosis. A comparative analysis with pre-AIDS era. Chest. 1991;99(5):1134–1138.
  4. Ormerod P. Tuberculosis in pregnancy and the puerperium. Thorax. 2001;56(6):494-499.
  5. Mamo JP, Brij SO, Enoch DA. Abdominal tuberculosis: a retrospective review of cases presenting to a UK district hospital. QJM. 2013;106(4):347–354.
  6. Rasheed S, Zinicola R, Watson D, Bajwa A, McDonald PJ. Intra-abdominal and gastrointestinal tuberculosis. Colorectal Dis. 2007;9(9):773–783.
  7. Demir K, Okten A, Kaymakoglu S, et al. Tuberculous peritonitis-report of 26 cases, detailing diagnostic and therapeutic problems. Eur J Gastroenterol Hepatol. 2001;13(5):581–585.
  8. Nafeh MA, Medhat A, Abdul-Hameed AG, Ahmad YA, Rashwan NM, Strickland GT. Tuberculous peritonitis in Egypt: value of laparoscopy in diagnosis. Am J Trop Med Hyg 1992;47(4):470–477.
  9. Chow KM, Chow VC, Hung LC, Wong SM, Szeto CC. Tuberculous peritonitis-associated mortality is high among patients waiting for the results of mycobacterial cultures of ascitic fluid samples. Clin Infect Dis. 2002;35(4):409–413.
  10. Demirkazik FB, Akhan O, Ozmen MN, Akata D. US and CT findings in the diagnosis of tuberculous peritonitis. Acta Radiol. 1996;37(4):517–520.
  11. Jain R, Sawhney S, Bhargava DK, Berry M. Diagnosis of abdominal tuberculosis: sonographic findings in patients with early disease. AJR. American journal of roentgenology. 1995;165(6):1391–1395.

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Last updated: 2018-06-21 23:38