Abdominal tuberculosis: utility of laparoscopy in the correct diagnosis

Abdominal Tuberculosis Mimicking Ovarian Cancer: A Case Report and Review of the Literature

Introduction

Tuberculosis (TB) is a disease with high morbidity and mortality resulting from infection by Mycobacterium tuberculosis. TB can disseminate to any organ system of the body resulting in extrapulmonary tuberculosis. Interestingly, CA-125, which is a biomarker for some cancer, also rises in benign diseases such as pulmonary and extrapulmonary tuberculosis which may complicate diagnosis. In this case report, we present an abdominal tuberculosis patient that was initially presented as ovarian cancer.

Case Report

A 30-year-old woman admitted to the emergency department with chief complaint of fatigue and shortness of breath since 3 months ago. She had lost around 20 kg weight in the past 5 months. She was previously suspected with ovarian cancer because of the characteristic features of malignancy, high levels of CA-125, and positive PET scan. She was later diagnosed with abdominal TB. Subsequently, the patient was given anti-TB drugs, and the patient showed clinical improvement.

Conclusion

In the case of an elevated CA-125, clinicians should consider extrapulmonary TB as a differential diagnosis of ovarian cancer, especially in countries with high burden of tuberculosis.

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.

A case report of peritoneal tuberculosis diagnosed by laparoscopy in a low prevalence setting

Peritoneal tuberculosis is a rare extrapulmonary manifestation of tuberculosis. Considering the diagnosis of peritoneal tuberculosis in a low prevalence setting can be vital for further clinical management in selected patients. In a young male with migration background, presenting with generalised abdominal pain, computed tomography revealed ascites, omental and peritoneal thickening and enlarged mesentery lymph nodes. Computed tomography also revealed a distal ureteral calculus at the right vesico-ureteral junction. Diagnostic laparoscopy showed a nodular degeneration of the visceral and parietal peritoneum and adhesions in the upper peritoneal cavity. Tissue biopsy of peritoneal lesions and omentum was performed. Histological examination revealed granulomas with central caseating necrosis. The ureteral stone was removed by means of ureteroscopy. Prompt diagnosis of peritoneal TB made possible to start anti-tuberculous chemotherapy without significant delay. The low prevalence of peritoneal TB demands a high index of suspicion in patients at risk presenting with nonspecific abdominal complaints, ascites and constitutional symptoms. Diagnostic laparoscopy leads to a quick diagnosis by direct visualisation of the peritoneal cavity and tissue biopsy. When available, it is the diagnostic procedure of choice to confirm tuberculous peritonitis. The concomitant presentation of tuberculous peritonitis and ureteral calculus can be explained by hypercalciuria in granulomatous disease.

Diagnostic and Therapeutic Strategies for Peritoneal Tuberculosis: A Review

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

Multiple surgical radical treatment in axillary lymph nodes: A case report

Lymph node tuberculosis is a common clinical bacterial infectious disease. Regional lymph node tuberculosis is often difficult to cure by surgically radical resection. In addition, its recurrence rate is higher, and it can easily cause lymphatic leakage. This case was considered to have left axillary lymph node tuberculosis. A combination of clinical examination, ultrasound, and magnetic resonance imaging examinations were performed before surgery. The surgical procedure performed was left axillary lymph node excision. Postoperative pathology confirmed the lymph node tuberculosis. The patient was given anti-tuberculosis drug treatment with no recurrence after 6 months follow-up. This provides new ideas and methods for the clinical treatment of regional lymph node tuberculosis.

Abdominopelvic Tuberculosis Secondary to a Nontuberculous Mycobacterium in an Immunocompetent Patient

Tuberculosis (TB) remained as one of the top 10 causes of death worldwide despite an overall decline in its incidence rate globally. Extrapulmonary TB is uncommon and only accounts for 10–20% of overall TB disease burden. Abdominopelvic TB is the sixth most common location of extrapulmonary TB. The symptoms and signs are often insidious and nonspecific. Diagnosing abdominopelvic TB can be very challenging at times and poses great difficulties to the clinician. Infection with nontuberculous Mycobacterium (NTM) is even rarer especially in an immunocompetent patient. We report a case of NTM in abdominopelvic TB. A 37-year-old foreign worker, para 3, presented with a one-week history of suprapubic pain associated with fever. An assessment showed presence of a right adnexal mass. She was treated as tuboovarian abscess with intravenous antibiotics. Unfortunately, she did not respond. She underwent exploratory laparotomy. Intraoperatively, features of the mass were suggestive of a right mature cystic teratoma with presence of slough and cheesy materials all over the abdominal cavity as well as presence of ascites. Diagnosis of NTM was confirmed with PCR testing using the peritoneal fluid. This case was a diagnostic dilemma due to the nonspecific clinical presentation. Management of such rare infection was revisited.

What remains to surgeons in the management of abdominal tuberculosis? A 10 years experience in an endemic area

BACKGROUND

Tuberculosis (TB) is a common endemic disease in Tunisia. Abdominal location is rare. Early diagnosis of abdominal TB remains difficult due to its non-specific clinical presentations. The aim of our study is to highlight the characteristics of the different presentations, to characterize tools contributing to a positive preoperative diagnosis, and finally to assess the role of surgery in the management of this entity.

MATERIALS AND METHODS

A retrospective review from 2005 to 2015 identified 90 cases of confirmed abdominal TB managed in the Department of General Surgery of the Habib Thameur Hospital. The diagnosis was established by histopathology examination for all cases. This study was approved by the ethical committee.

RESULTS

The mean age of the patient was 44.13 years with a sex ratio (M/F) of 0.34. We collected 56 cases of peritoneal TB, 12 cases of abdominal lymph node TB, 10 cases of intestinal TB, four cases of hepatic TB, and two cases of gallbladder's TB. For six patients, an association of many localizations was noted. The diagnosis was suspected on clinical, biological, and morphological arguments, but the confirmation was always made by surgical exploration and pathological examination of removed specimens. Surgical management was urgent in complicated cases (13.3%). Laparoscopy was performed in 71 cases (78.9%). Laparoscopic features of peritoneal TB were specific and always confirmed by histological examination.

CONCLUSION

Despite the wide range of examination available for the preoperative exploration of abdominal TB, diagnosis is usually late and difficult. TB is a medical condition. However, surgical exploration is frequently needed in the management.

The Role of ¹⁸F-FDG PET/CT in the Evaluation of Peritoneal Thickening of Undetermined Origin

The aim of this study was to assess the value of 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) for the differentiation of peritoneal thickening of undetermined origin. This retrospective study included 103 patients (44 men and 59 women, age 59.2 ± 14.8 years) who had undergone 18F-FDG PET/CT for the evaluation of peritoneal thickening of undetermined origin. All 18F-FDG PET/CT images were visually interpreted, and the maximal standardized uptake values (SUVmax) were measured. We compared the role of 18F-FDGPET/CT with that of CT alone in detecting peritoneal thickening of undetermined origin. We also compared the differences between malignant and tuberculous peritoneal thickening in PET/CT parameters and clinical characteristics. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy in detecting the primary cause of the peritoneal thickening were 76.2%, 78.9%, 94.1%, 42.9%, and 81.2%, respectively, for 18F-FDG PET/CT, and 58.3%, 84.2%, 94.2%, 31.4%, and 63.1%, respectively, for CT imaging. Malignant peritoneal thickening had significantly higher SUVmax than nontuberculous benign peritoneal thickening. However, tuberculous peritoneal thickening also had a high SUVmax. There were some factors that were significantly different between patients with tuberculous peritoneal thickening and those with malignant peritoneal thickening in our study; these included age, pattern of peritoneal thickening, and presence of ascites. 18F-FDG PET/CT is useful for detecting the underlying cause of peritoneal thickening. Special attention should be paid to peritoneal tuberculosis, which has a high SUVmax and may mimic malignant peritoneal thickening. Multiple PET/CT parameters which were different in patients with tuberculous and malignant causes could be taken into consideration to make the differential diagnosis.