Use of steroids for abdominal tuberculosis: a systematic review and meta-analysis

Significance of Epidemiological Background in Preventing the Misdiagnosis of Intestinal Tuberculosis as Crohn's Disease

The misdiagnosis of intestinal tuberculosis (ITB), such as Crohn's disease (CD), and subsequent treatment with immunosuppressive therapies can lead to severe outcomes. However, the differential diagnosis between these two conditions can be challenging. We herein report a patient from Myanmar who was initially diagnosed with CD due to the presence of non-caseating granulomas. The patient's symptoms were aggravated with steroid treatment, eventually leading to a diagnosis of ITB. In the international medical community, we encounter patients from countries, such as Myanmar, where tuberculosis is endemic. Therefore, it is necessary to understand the epidemiological background of each country to accurately distinguish between CD and ITB.

Successful Multidisciplinary Treatment of Small Bowel Obstruction With an Ileal Stricture Resulting in Bowel Perforation in the Setting of Multidrug-Resistant Gastrointestinal Tuberculosis: A Case Report

We present the case of a male in his 40s who recently emigrated from Russia and was actively undergoing treatment for multidrug-resistant (MDR) pulmonary tuberculosis (TB) with the BPaL-M (bedaquiline, pretomanid, linezolid, moxifloxacin, and pyridoxine) regimen who presented to the emergency department (ED) with abdominal pain, vomiting, and no bowel movements. A computed tomography (CT) scan of the abdomen and pelvis revealed a small bowel obstruction (SBO) from ileal stricture consistent with gastrointestinal (GI) TB. He did not require an emergent surgical intervention and was managed conservatively via bowel rest and initiation of total parenteral nutrition (TPN). An oral BPaL-M regimen was held and an intravenous (IV) regimen consisting of linezolid, moxifloxacin, meropenem, and ampicillin/sulbactam was started per infectious disease (ID) recommendations. He improved clinically over the next several days and was started on a diet that was initially well tolerated. Shortly after transitioning to a regular diet, he developed severe abdominal pain. A CT scan of the abdomen and pelvis revealed pneumoperitoneum and he was taken emergently to the operating room (OR) for exploratory laparotomy (ex-lap). A perforation was found in the terminal ileum and he underwent a right hemicolectomy. He returned to the OR two days later for ileocolic anastomosis and fascial closure. A diet was initiated once again which was tolerated well. He was then transitioned back to his oral BPaL-M regimen which was also tolerated well. He was discharged home on an oral diet after a 23-day hospital course with follow-up appointments with acute care surgery (ACS) and ID.

Paralytic Ileus during Treatment of Pulmonary and Renal Tuberculosis in a Non-Human Immunodeficiency Virus Patient: An Unusual Presentation of Tuberculosis-immune Reconstitution Inflammatory Syndrome

Paralytic ileus as tuberculosis-immune reconstitution inflammatory syndrome (TB-IRIS) is extremely rare. We herein report a 44-year-old man with pulmonary and renal tuberculosis who developed paralytic ileus 14 days after starting antituberculosis therapy (ATT) despite an initial favorable response to ATT. Paralytic ileus was successfully managed with conservative care. He initially required hemodialysis because of obstructive uropathy due to renal tuberculosis, but he was able to withdraw from dialysis after placement of ureteral stents. TB-IRIS can affect organs other than the original sites of tuberculosis, and the combined use of steroids may be effective for its prevention and treatment.

A Challenging Surgical Decision in a Child With Bowel Obstruction Secondary to Abdominal Tuberculosis and a Literature Review

Tuberculosis (TB) is an infectious disease and one of the top 10 causes of death worldwide. Abdominal TB (ATB) can involve the peritoneum, lymph nodes, luminal structures, and solid organs, with a predominance of intestinal and peritoneal forms of the disease. Most pediatric cases may present with peritoneal and lymph node disease. This case reports a five-year-old girl who is medically and surgically free. She had ATB complicated with a bowel obstruction that resulted in an eventful outcome of fistula formation. The family gave a travel history to Egypt two months prior to the emergency first presentation. ATB is considered a severe and challenging infectious disease that affects several systems. It is associated with high mortality and morbidity rates, specifically in the pediatric population. This case discusses the importance of considering the possible complications of ATB in pediatrics to overcome unfavorable outcomes.

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.

Diagnosis of peritoneal tuberculosis by real-time immuno-PCR assay based on detection of a cocktail of Mycobacterium tuberculosis CFP-10 and HspX proteins

BACKGROUND

Diagnosis of peritoneal TB is difficult owing to unusual clinical manifestations and low sensitivities obtained with most of the available diagnostic modalities. Hence, there is an urgent need to design a reliable diagnostic test so that an early therapy is initiated.

RESEARCH DESIGN AND METHODS

We designed a quantitative real-time immuno-PCR (RT-I-PCR) assay to detect a cocktail of Mycobacterium tuberculosis CFP-10 (Rv3874) and HspX (Rv2031c) proteins in clinical samples (ascitic fluids and peritoneal biopsies) of peritoneal TB patients, and results were compared with I-PCR/ELISA.

RESULTS

A wide range of CFP-10+ HspX (0.6 pg/mL to 9.9 ng/mL) was detected in clinical samples of peritoneal TB patients by RT-I-PCR, whereas ELISA exhibited a narrow range (3 ng/mL to 11.5 ng/mL). Sensitivities of 81.5% and 65.7% and specificities of 92.5% and 90% were obtained in a total of 78 cases (comprising 38 peritoneal TB and 40 non-TB controls) by RT-I-PCR and I-PCR, respectively. Markedly, sensitivity obtained by RT-I-PCR was significantly higher than I-PCR (p = 0.0143) and ELISA (p = 0.0005).

CONCLUSIONS

Our RT-I-PCR revealed good accuracy for the rapid diagnosis of peritoneal TB cases. After further improving the specificity and reducing the cost, this assay may develop into a diagnostic kit.

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.

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.

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.

Corticosteroids for COVID-19 Therapy: Potential Implications on Tuberculosis

On 11 March 2020, the World Health Organization announced the Corona Virus Disease-2019 (COVID-19) as a global pandemic, which originated in China. At the host level, COVID-19, caused by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), affects the respiratory system, with the clinical symptoms ranging from mild to severe or critical illness that often requires hospitalization and oxygen support. There is no specific therapy for COVID-19, as is the case for any common viral disease except drugs to reduce the viral load and alleviate the inflammatory symptoms. Tuberculosis (TB), an infectious disease caused by Mycobacterium tuberculosis (Mtb), also primarily affects the lungs and has clinical signs similar to pulmonary SARS-CoV-2 infection. Active TB is a leading killer among infectious diseases and adds to the burden of the COVID-19 pandemic worldwide. In immunocompetent individuals, primary Mtb infection can also lead to a non-progressive, asymptomatic latency. However, latent Mtb infection (LTBI) can reactivate symptomatic TB disease upon host immune-suppressing conditions. Importantly, the diagnosis and treatment of TB are hampered and admixed with COVID-19 control measures. The US-Center for Disease Control (US-CDC) recommends using antiviral drugs, Remdesivir or corticosteroid (CST), such as dexamethasone either alone or in-combination with specific recommendations for COVID-19 patients requiring hospitalization or oxygen support. However, CSTs can cause immunosuppression, besides their anti-inflammatory properties. The altered host immunity during COVID-19, combined with CST therapy, poses a significant risk for new secondary infections and/or reactivation of existing quiescent infections, such as LTBI. This review highlights CST therapy recommendations for COVID-19, various types and mechanisms of action of CSTs, the deadly combination of two respiratory infectious diseases COVID-19 and TB. It also discusses the importance of screening for LTBI to prevent TB reactivation during corticosteroid therapy for COVID-19.

Abdominal Tuberculosis: Experience from Two Tertiary-Care Hospitals in the Paris Region

Abdominal tuberculosis (ATB) is uncommon and not very well known by clinicians. We describe the characteristics, evolution, and treatment of patients with ATB in two large hospitals in the Paris region. We reviewed all records of patients treated for ATB, from January 01, 2010 to December 01, 2016, diagnosed by bacteriological and/or histological methods or highly suspected because of clinical/radiological features. We included 80 patients, with a median (IQR) age of 39 (29-50) years, with 56.2% being males. Among them, 63.7% had African origins, 15% Asian, and 11.2% European. Twenty-nine had a cause of immunosuppression (n = 21 HIV infection). The main abdominal localizations were lymph nodes (72.5%), peritoneum (62.5%), and solid organs (25%). Extra-abdominal localizations were recorded in 65 (81.2%) patients. Tuberculosis was proven bacteriologically in 71%, histologically in 50%, and solely clinical/radiological in 10% of cases. Patients received standard therapy for a median duration of 9 months, with a favorable outcome. Corticosteroid therapy was used in 15 cases, either for paradoxical reaction or to prevent complications. Abdominal TB was mainly represented by lymphatic and peritoneal localizations, proven bacteriologically, and associated with extra-abdominal localizations in most cases. The use of steroids remains controversial, but it does not seem systematically needed in case of abdominal involvement.

Plasma interferon-γ-inducible protein 10 (IP-10) levels correlate with disease severity and paradoxical reactions in extrapulmonary tuberculosis

BACKGROUND

With 1.5 million deaths worldwide in 2018, tuberculosis (TB) remains a major global public health problem. While pulmonary TB (PTB) is the most common manifestation, the proportion of extrapulmonary TB (EPTB) is increasing in low-burden countries. EPTB is a heterogeneous disease entity posing diagnostic and management challenges due to the lack of reliable biomarkers. In this study, we prospectively evaluated clinical data and treatment response which were correlated with different biomarkers.

METHODS

The study was conducted at the University Hospital of Cologne. 20 patients with EPTB were enrolled. We analyzed plasma interferon-γ-inducible protein 10 (IP-10) levels in plasma by ELISA for up to 12 months of treatment. In addition, the QuantiFERON^®-TB Gold Plus (QFT^® Plus) test was performed during the course of treatment. Clinical data were assessed prospectively and correlated with QFT^® Plus and IP-10 levels.

RESULTS

Plasma IP-10 levels were found to be significantly increased (p < 0.001) in patients with extensive disease compared to patients with limited disease (cervical lymph node TB) or healthy controls. In patients with clinically confirmed paradoxical reaction (PR), a further increase of IP-10 was noted. IFN-γ measured by the QFT^® Plus test did not decrease significantly during the course of treatment. Of note, in four EPTB patients (20%) without radiographic pulmonary involvement, sputum culture was positive for Mycobacterium tuberculosis.

CONCLUSION

Our data demonstrate that IP-10 may be a valuable biomarker for estimation of disease severity in EPTB and monitoring of the disease course in extensive forms. However, IP-10 may be less suitable for diagnosis and monitoring of EPTB patients with limited disease. The QFT^® Plus test does not appear to be a suitable marker for therapy monitoring. Sputum should be examined in EPTB patients even in case of normal diagnostic imaging of the chest.

Tuberculosis peritoneal y pleural en un paciente inmunocompetente con dolor abdominal crónico

La tuberculosis es un grave problema de salud pública más acentuado en los países en desarrollo. De las manifestaciones extrapulmonares las que comprometen la cavidad abdominal están dentro de las menos frecuentes y se asocian con factores de predisposición específica. Se requiere un alto nivel de sospecha diagnóstica en el abordaje inicial de esta enfermedad. Presentamos el caso de un adulto masculino sin condiciones de predisposición quien consultó por un cuadro de dolor abdominal crónico y los estudios complementarios manifestaron una tuberculosis peritoneal con compromiso pleural sin síntomas respiratorios.

Abdominal tuberculosis in a tertiary care centre in Saudi Arabia

OBJECTIVES

Abdominal tuberculosis (ATB) is the second most common type of extra-pulmonary tuberculosis. Though it does not usually pose a significant risk of infectivity, ATB can go unidentified and progress to disseminated infection. The aim of this study is to highlight the incidence and outcome of this infection in a tertiary care centre in the Kingdom of Saudi Arabia (KSA).

METHODS

In this retrospective study, we included all ATB patients admitted to our centre between January 1 ^st, 2010 and December 31, 2018. A total of 42 patients with a median age of 49 (range 18-83 years, 78.6% males) were identified.

RESULTS

The most common presentation was abdominal pain, weight loss, and abdominal distension. All the patients were HIV negative; however, 50% had a comorbid condition, mainly diabetes mellitus, chronic renal failure, and liver cirrhosis. Tuberculous peritonitis was the predominant type of ATB. Suspicious and potentially malignant abdominal masses appeared on the abdominal CT scans of six patients. This suggest that TB should be excluded in patients from endemic area presenting with abdominal masses. All patients received standard anti-tuberculous medication for an average duration of 7.4 months. The outcome was excellent with 88%% achieving complete response. Adjunctive corticosteroids were not used, and none of the patients had a surgical complication.

CONCLUSION

The diagnosis of ATB is challenging. It can mimic inflammatory bowel disease in young populations and malignancy in middle-aged and elderly population. For this reason, a high index of suspicion with prompt treatment is required to improve the prognosis and prevent complications.

Young Male Presenting with an Acute Diarrheal Illness with Unexplained Transudative Ascites: An Atypical Presentation of Appendicular Tuberculosis

Introduction

Appendicular tuberculosis is a rare form of extrapulmonary tuberculosis involving the gastrointestinal tract. Diagnosis of appendicular tuberculosis is difficult due to its atypical presentation. Histological confirmation remains the gold standard in diagnosis. Case Presentation. We report a 37-year-old Sri Lankan male presenting with a diarrheal illness with high fever for 8 days in the background of constitutional symptoms for 1-month duration. He was pale and had moderate amount of free fluid in the abdomen. Inflammatory markers were elevated, and CT abdomen revealed a thickened elongated appendix. Diagnostic paracentesis revealed a lymphocytic transudative ascites. A macroscopically minimally inflammed appendix removed at laparotomy and histology confirmed presence of tuberculous granulomata with caseation. He made an uneventful recovery by the anti-tuberculous therapy.

Conclusion

High degree of suspicion is needed in diagnosis of appendicular tuberculosis due to its nonspecific presentation, and we emphasize the need of histological assessment of the appendix resected for the case of clinical appendicitis, as it may prompt the diagnosis of a rare but treatable case of tuberculosis.

Corticosteroid therapy for the management of paradoxical inflammatory reaction in patients with pulmonary tuberculosis

Background

Paradoxical reaction after the initiation of tuberculosis treatment is defined as increased inflammation following effective antimycobacterial treatment. This is a phenomenon that can severely complicate a patient’s recovery, potentially leading to further morbidity and residual deficits. Paradoxical reaction remains poorly understood regarding its pathophysiology and management. Only a limited number of reports look critically at the available therapeutic options, with evidence of the efficacy of prednisolone therapy being primarily limited to extrapulmonary PR only.

Case

We describe two HIV negative patients who were admitted to our department with pulmonary tuberculosis, presenting with inflammatory patterns attributable to PR and their response to adjunctive steroid therapy.

Discussion and Conclusions

The presented cases further highlight the need for immunological studies and randomized trials for corticosteroid therapy are needed to better understand this phenomenon as well as provide an evidence-base for anti-inflammatory treatment. Furthermore, by means of this case series, we are also able to highlight the potential variability in the symptomatology of the lesser known PR phenomenon, in which we observed a hypotensive shock-like syndrome not previously described in literature.

Gastrointestinal Bleeding in a Patient With Gastric Lymphoma, Tuberculosis Enteritis, and Cytomegalovirus Enteritis

Bleeding from the small bowel can be challenging to identify by endoscopic or radiographic evaluation. We present the case of a patient with incompletely treated latent tuberculosis and medical history of T-cell lymphoma who developed gastrointestinal bleeding because of concurrent Burkitt lymphoma, tuberculosis enteritis, and cytomegalovirus enteritis. The interplay of these 3 diagnoses is discussed.

Abdominal tuberculosis with a Pseudo-Sister Mary Joseph nodule mimicking peritoneal carcinomatosis

A 46-year-old woman presented in severe abdominal pain on a background of 3 months of weight loss and intermittent vomiting. She had visited East Africa 6 months prior but reported no unwell contacts. On examination, she had generalised abdominal tenderness, distension and a painful paraumbilical swelling. CT scanning confirmed small bowel obstruction and revealed widespread peritoneal nodules, lymphadenopathy, ascites and a soft tissue paraumbilical mass. CA-125 tumour marker was elevated. However, transvaginal ultrasound scanning showed normal-appearing ovaries. She underwent a diagnostic laparoscopy for ascitic fluid analysis and biopsy of omental and peritoneal nodules, which revealed a lymphocytic exudate and caseating granulomas, respectively. Interferon-γ release assay and repeated stains for acid-fast bacilli were negative. She was commenced on antituberculous chemotherapy for a presumed diagnosis of abdominal tuberculosis. Positive culture results 2 weeks later confirmed Mycobacterium tuberculosis infection. The patient experienced a complete resolution of symptoms within 6 weeks of treatment.