Gastrointestinal and Abdominal Tuberculosis

Esophageal tuberculosis as a differential diagnosis of esophageal cancer

The case of a patient in the eighth decade of life who begins with dysphagia and progressive weight loss is presented, who underwent contrast-enhanced tomography where a tumor was observed in the esophagus, endoscopy with biopsy and a report of esophageal tuberculosis.

Primary gastroduodenal tuberculosis presenting as gastric outlet obstruction: A case report and review of literature

BACKGROUND

Mycobacterium tuberculosis (TB) is the causative agent of TB, a chronic granulomatous illness. This disease is prevalent in low-income countries, posing a significant global health challenge. Gastrointestinal TB is one of the three forms. The disease can mimic other intra-abdominal conditions, leading to delayed diagnosis owing to the absence of specific symptoms. While gastric outlet obstruction (GOO) remains a frequent complication, its incidence has declined with the advent of proton pump inhibitors and Helicobacter pylori eradication therapy. Gastroduodenal TB can cause upper gastrointestinal hemorrhage, obstruction, and malignancy-like tumors.

CASE SUMMARY

A 23-year-old male presented with recurrent epigastric pain, distension, nausea, vomiting, and weight loss, prompting a referral to a gastroenterologist clinic. Endoscopic examination revealed distorted gastric mucosa and signs of chronic inflammation. However, treatment was interrupted, possibly owing to vomiting or comorbidities such as human immunodeficiency virus infection or diabetes. Subsequent surgical intervention revealed a dilated stomach and diffuse thickening of the duodenal wall. Resection revealed gastric wall effacement with TB.

CONCLUSION

Primary gastric TB is rare, frequently leading to GOO. Given its rarity, suspicions should be promptly raised when encountering relevant symptoms, often requiring surgical intervention for diagnosis and treatment.

Peritoneal Tuberculosis in Western Countries: A Rare Case With Concurrent Helminthic Infection

This case report presents a rare case of peritoneal tuberculosis (TB) coexisting with a helminthic infection in a 25-year-old female residing in Australia, highlighting the diagnostic challenges posed by abdominal TB. Despite the low incidence of TB in Western countries, abdominal TB remains a diagnostic dilemma due to its nonspecific symptoms and potential mimicry of other abdominal pathologies. The case highlights the importance of considering TB as a differential diagnosis of unexplained abdominal symptoms, particularly in individuals with a history of travel or previous residence in high-endemic regions. A multidisciplinary approach involving infectious disease specialists, radiologists, and surgeons is essential for comprehensive management. Prompt initiation of anti-TB therapy is recommended once diagnosis is confirmed.

A case of peritoneal Burkitt's lymphoma mimic of peritoneal tuberculosis

Peritoneal lymphomatosis is a rare presentation of lymphoma that can mimic peritoneal tuberculosis. The computed tomography findings in both conditions include omental caking, thickening, and nodularity. We report the case of a 41-year-old man who presented with intermittent abdominal pain and distension. Abdominal CT initially suggested peritoneal tuberculosis due to the thickening of the peritoneum and greater omentum with multiple nodules. However, 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) images showed diffuse metabolic activity increase in the thickened peritoneum, omentum, and mesentery. An omental biopsy was performed under ultrasonography guidance, and histopathological examination revealed a high-grade Burkitt lymphoma. It is crucial to distinguish peritoneal lymphomatosis from tuberculosis, as the prognosis and management of the two conditions are vastly different.

Same Pathogen, Different Manifestations: A Case of Extrapulmonary Tuberculosis

Tuberculosis (TB) remains the most prevalent contagious disease worldwide and a significant cause of morbidity, ranking as the second most deadly disease globally. The transmission of the disease occurs through aerosols via the respiratory route, predominantly affecting pulmonary tissue. However, the pathogen can disseminate and infect any organ within the body. Up to 15% of patients exhibit extrapulmonary involvement. The case involves a 59-year-old male who presented to the emergency department complaining of abdominal pain and subfebrile episodes, without any other significant symptoms or findings on physical examination. Laboratory investigations revealed elevated inflammatory markers and abnormal liver biochemistry parameters. A computed tomography (CT) scan showed a neoformative lesion in the liver - a collection with a vascularized, thick, irregular wall. This raised the possibility of a potentially hypervascular hepatic neoformation or an encysted inflammatory lesion. The patient was started on empirical broad-spectrum antibiotics and was admitted to the Internal Medicine ward for further investigation. Later, the patient began to exhibit a decline in overall condition, a slowed and less complex speech pattern, loss of balance, and distal tremors in the upper limbs, as well as a symmetric and distal reduction in strength in all four limbs. A cerebral CT scan revealed no significant abnormalities, and a lumbar puncture yielded no immediate notable findings. Simultaneously, a repeated abdominal CT scan showed the previously known hepatic lesion, albeit with features more indicative of a multiloculated collection. An aspirative biopsy of the hepatic abscess was conducted. From the extensive analysis conducted, a positive PCR result for mycobacterium tuberculosis was identified in both the pus from the hepatic abscess and the cerebrospinal fluid. This led to the conclusion that the case presented was an instance of extrapulmonary TB involving the liver and the central nervous system. Following the identification of the causative agent, the patient commenced antibacterial therapy comprising rifampicin, ethambutol, and isoniazid with adjunctive dexamethasone. Despite targeted treatment and instituted supportive therapy, the patient exhibited an unfavorable progression and eventually succumbed 57 days after diagnosis. This case highlights an unusual manifestation of a patient with disseminated extrapulmonary TB, emphasizing the importance of early diagnostic suspicion for clinicians. The unfavorable disease progression despite appropriate targeted treatment prompts reflection on whether the delay in diagnosis and provision of anti-TB drugs may have played a major role in the prognosis of the patient.

Gastroduodenal and Colorectal Tuberculosis: Report of 2 Cases

Introduction

Tuberculosis remains a public health concern in developing countries, as well as in developed countries as a result of immigration from endemic areas. Gastroduodenal and colorectal tuberculosis are rare manifestations of gastrointestinal infection.

Case Presentation

We present 2 cases of gastric, duodenal, and colorectal tuberculosis. The first case, a 17-year-old male with no medical record, presented with chronic diarrhea and abdominal pain. At endoscopy, he had multiple ulcers in the stomach, colon, and rectum, which were positive to Mycobacterium tuberculosis. The second case was a 43-year-old HIV-positive male, with a history of intermittent fever, nausea, and vomiting. Upper gastrointestinal endoscopy revealed a deep ulcer on gastric fundus that tested positive to M. tuberculosis in the acid-fast bacilli staining.

Discussion/Conclusion

Gastroduodenal and colorectal tuberculosis, although rare, should be considered in the differential diagnosis in both immunosuppressed and immunocompetent patients. An adequate tissue sample and appropriate diagnostic tests are essential for the diagnosis and prompt start of first-line antituberculosis agents.

Doomed for carcinomatosis? An unusual presentation of abdominal tuberculosis

A 35-year old male from Brazil presented with intermittent abdominal pain. Abdominal computed tomography revealed a nodule adjacent to splenic hilum and multiple abdominal nodules, suspicious of carcinomatosis. The patient underwent gastroscopy and endoscopic ultrasound (EUS), that revealed an ill-defined hypoechogenic lesion adjacent to the spleen and two hypoechogenic subepithelial lesions located in the 4th layer of the stomach and duodenal bulb. Biopsies revealed non-necrotizing granulomatous inflammation with multinucleated giant cells. Soon after, a 18cm palpable mass within the rectus abdominis muscle was identified, and the biopsy was positive for Mycobacterium tuberculosis DNA, confirming the diagnosis of disseminated abdominal tuberculosis.

Comorbidity and drug resistance of smear-positive pulmonary tuberculosis patients in the yi autonomous prefecture of China: a cross-sectional study

BACKGROUND

Tuberculosis (TB) has a high morbidity and mortality rate, and its prevention and treatment focus is on impoverished areas. The Liangshan Yi Autonomous Prefecture is a typical impoverished area in western China with insufficient medical resources and high HIV positivity. However, there have been few reports of TB and drug resistance in this area.

METHODS

We collected the demographic and clinical data of inpatients with sputum smear positive TB between 2015 and 2021 in an infectious disease hospital in the Liangshan Yi Autonomous Prefecture. Descriptive analyses were used for the epidemiological data. The chi-square test was used to compare categorical variables between the drug-resistant and drug-susceptible groups, and binary logistic regression was used to analyse meaningful variables.

RESULTS

We included 2263 patients, 79.9% of whom were Yi patients. The proportions of HIV (14.4%) and smoking (37.3%) were higher than previously reported. The incidence of extrapulmonary TB (28.5%) was high, and the infection site was different from that reported previously. When drug resistance gene detection was introduced, the proportion of drug-resistant patients became 10.9%. Patients aged 15-44 years (OR 1.817; 95% CI 1.162-2.840; P < 0.01) and 45-59 years (OR 2.175; 95% CI 1.335-3.543; P < 0.01) had significantly higher incidences of drug resistance than children and the elderly. Patients with a cough of ≥ 2 weeks had a significantly higher chance of drug resistance than those with < 2 weeks or no cough symptoms (OR 2.069; 95% CI 1.234-3.469; P < 0.01). Alcoholism (OR 1.741; 95% CI 1.107-2.736; P < 0.05) and high bacterial counts on sputum acid-fast smears (OR 1.846; 95% CI 1.115-3.058; P < 0.05) were significant in the univariate analysis.

CONCLUSIONS

Sputum smear-positive TB predominated in Yi men (15-44 years) with high smoking, alcoholism, and HIV rates. Extrapulmonary TB, especially abdominal TB, prevailed. Recent drug resistance testing revealed higher rates in 15-59 age group and ≥ 2 weeks cough duration. Alcohol abuse and high sputum AFB counts correlated with drug resistance. Strengthen screening and supervision to curb TB transmission and drug-resistant cases in the region.

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.

Case report: a case report and literature analysis on intestinal tuberculosis intestinal perforation complicated by umbilical intestinal fistula and bladder ileal fistula

BACKGROUND

Intestinal tuberculosis is a chronic and specific infection caused by Mycobacterium tuberculosis invading the intestine. Due to the nonspecific clinical presentation, it is stressed that intestinal perforation complicates umbilical intestinal fistula and bladder ileal fistula is very rare and extremely difficult to be diagnosed. It is significant to identify the disease and take urgent intervene in the early stage.

CASE PRESENTATION

An 18-month-old boy patient presented with abdominal pain. Abdominal CT suggested abscess formation in the right lower abdomen and pelvis. The patient underwent resection of necrotic and stenotic intestinal segments with the creation of an ileostomy, cystostomy and vesicoureteral fistula repair for the presence of intestinal perforation complicated by vesicoureteral fistula and umbilical enterocutaneous fistula. Histopathology confirmed the intestinal tuberculosis. The patient was discharged successfully after 11 days post anti-tuberculosis treatment.

CONCLUSION

Our case report here is a rare case of umbilical intestinal fistula with bladder ileal fistula secondary to intestinal perforation from intestinal tuberculosis. The purpose of this report is to make the surgical community aware of atypical presentations of intestinal tuberculosis. If our peers encounter the similar situation, they can be prepared for corresponding diagnosis and treatment.

Intestinal and perianal tuberculosis: an uncommon clinical presentation and challenging diagnosis

We present the case of a 40-year-old immunocompetent man with complaints of perianal abscess, diarrhea, and weight loss for 3 months. He denied respiratory symptoms. Colonoscopy revealed ulcers and histopathology showed non-necrotizing granulomas and excluded acid-fast bacilli. Initially, the clinical and histological findings favored the diagnosis of Crohn's disease, however, further investigation by performing chest radiography in the context of a pre-immunomodulatory checklist, revealed pulmonary cavitations confirmed on computed tomography scan. Further mycobacteriological studies suggested the diagnosis of active pulmonary tuberculosis. Demonstration of the presence of Mycobacterium tuberculosis in the colon was possible by RT-PCR. Complete resolution of intestinal and perianal symptoms was achieved 2 weeks after treatment with anti-bacillary agents.

Clinicopathological profile of peritoneal tuberculosis and a new scoring model for predicting mortality: an international ID-IRI study

Existing literature about peritoneal tuberculosis (TBP) is relatively insufficient. The majority of reports are from a single center and do not assess predictive factors for mortality. In this international study, we investigated the clinicopathological characteristics of a large series of patients with TBP and determined the key features associated with mortality. TBP patients detected between 2010 and 2022 in 38 medical centers in 13 countries were included in this retrospective cohort. Participating physicians filled out an online questionnaire to report study data. In this study, 208 patients with TBP were included. Mean age of TBP cases was 41.4 ± 17.5 years. One hundred six patients (50.9%) were females. Nineteen patients (9.1%) had HIV infection, 45 (21.6%) had diabetes mellitus, 30 (14.4%) had chronic renal failure, 12 (5.7%) had cirrhosis, 7 (3.3%) had malignancy, and 21 (10.1%) had a history of immunosuppressive medication use. A total of 34 (16.3%) patients died and death was attributable to TBP in all cases. A pioneer mortality predicting model was established and HIV positivity, cirrhosis, abdominal pain, weakness, nausea and vomiting, ascites, isolation of Mycobacterium tuberculosis in peritoneal biopsy samples, TB relapse, advanced age, high serum creatinine and ALT levels, and decreased duration of isoniazid use were significantly related with mortality (p < 0.05). This is the first international study on TBP and is the largest case series to date. We suggest that using the mortality predicting model will allow early identification of high-risk patients likely to die of TBP.

Hepatic Manifestations of Systemic Diseases

In addition to being the primary target of infections such as viral hepatitis, the liver may also be affected by systemic disease. These include bacterial, mycotic, and viral infections, as well as autoimmune and infiltrative diseases. These conditions generally manifest as abnormal liver biochemistries, often with a cholestatic profile, and may present with additional signs/symptoms such as jaundice and fever. A high index of suspicion and familiarity with potential causal entities is necessary to guide appropriate testing, diagnosis, and treatment.

Differentiating peritoneal tuberculosis and peritoneal carcinomatosis based on a machine learning model with CT: a multicentre study

PURPOSE

It is still a challenge to make early differentiation of peritoneal tuberculosis (PTB) and peritoneal carcinomatosis (PC) clinically as well as on imaging and laboratory tests. We aimed to develop a model to differentiate PTB from PC based on clinical characteristics and primary CT signs.

METHODS

This retrospective study included 88 PTB patients and 90 PC patients (training cohort: 68 PTB patients and 69 PC patients from Beijing Chest Hospital; testing cohort: 20 PTB patients and 21 PC patients from Beijing Shijitan Hospital). The images were analyzed for omental thickening, peritoneal thickening and enhancement, small bowel mesentery thickening, the volume and density of ascites, and enlarged lymph nodes (LN). Meaningful clinical characteristics and primary CT signs comprised the model. ROC curve was used to validate the capability of the model in the training and testing cohorts.

RESULTS

There were significant differences in the following aspects between the two groups: (1) age; (2) fever; (3) night sweat; (4) cake-like thickening of the omentum and omental rim (OR) sign; (5) irregular thickening of the peritoneum, peritoneal nodules, and scalloping sign; (6) large ascites; and (7) calcified and ring enhancement of LN. The AUC and F1 score of the model were 0.971 and 0.923 in the training cohort and 0.914 and 0.867 in the testing cohort.

CONCLUSION

The model has the potential to distinguish PTB from PC and thus has the potential to be a diagnostic tool.

Bowel inflammatory presentations on computed tomography in adult patients with severe aplastic anemia during flared inflammatory episodes

BACKGROUND

Patients with severe aplastic anemia (SAA) frequently present with inflammatory episodes, and during flared inflammatory episodes, hematopoietic function is further exacerbated. The gastrointestinal tract is the most common site for infectious and inflammatory diseases, and its structural and functional features confer on it the most potent capacity to affect hematopoietic and immune functions. Computed tomography (CT) is a readily accessible approach to provide highly useful information in detecting morphological changes and guiding further work-ups.

AIM

To explore CT imaging presentations of gut inflammatory damage in adult SAA patients during inflammatory episodes.

METHODS

We retrospectively evaluated the abdominal CT imaging presentations of 17 hospitalized adult patients with SAA in search of the inflammatory niche when they presented with systemic inflammatory stress and exacerbated hematopoietic function. In this descriptive manuscript, the characteristic images that suggested the presence of gastrointestinal inflammatory damage and related imaging presentations of individual patients were enumerated, analyzed and described.

RESULTS

All eligible patients with SAA had CT imaging abnormalities that suggested the presence of an impaired intestinal barrier and increased epithelial permeability. The inflammatory damages were concurrently present in the small intestine, the ileocecal region and the large intestines. Some readily identified imaging signs, such as bowel wall thickening with mural stratification (“water holo sign”, “fat holo sign”, intramural gas and subserosal pneumatosis) and mesenteric fat proliferation (fat stranding and “creeping fat sign”), fibrotic bowel wall thickening, “balloon sign”, rugged colonic configuration, heterogeneity in the bowel wall texture, and adhered and clustered small bowel loop (including various patterns of “abdominal cocoon”), occurred at a high incidence, which suggested that the damaged gastrointestinal tract is a common inflammatory niche responsible for the systemic inflammatory stresses and the exacerbated hematopoietic failure in patients with SAA. Particularly, the “fat holo sign” was present in 7 patients, a rugged colonic configuration was present in 10 patients, the adhesive bowel loop was present in 15 patients, and extraintestinal manifestations suggestive of tuberculosis infections were present in 5 patients. According to the imaging features, a suggestive diagnosis of Crohn’s disease was made in 5 patients, ulcerative colitis in 1 patient, chronic periappendiceal abscess in 1 patient, and tuberculosis infection in 5 patients. Other patients were diagnosed with chronic enteroclolitis with acutely aggravated inflammatory damage.

CONCLUSION

Patients with SAA had CT imaging patterns that suggested the presence of active chronic inflammatory conditions and aggravated inflammatory damage during flared inflammatory episodes.

A Rare Case of Intestinal Tuberculosis with Chronic Partial Small Bowel Obstruction in a 37-Year-Old Ethiopian Man

Tuberculosis (TB) is a chronic granulomatous inflammatory disease that affects any part of our body. TB is a significant problem in developing countries. Intestinal TB accounts for 2% of TB cases worldwide. Terminal ileum and cecum are the two commonly affected regions because of abundant lymphoid tissue, physiologic stasis, limited digestive activity and increased fluid and electrolyte absorption rate. Intestinal obstruction is the leading complication of intestinal TB, and it occurs because of intestinal luminal narrowing, multiple strictures or adhesions. The clinical presentation of patients with intestinal TB and post-TB intestinal obstruction is non-specific. It can be acute, chronic, or acute on chronic. Uncomplicated cases of intestinal TB can be managed medically. Surgery is reserved for complicated cases of intestinal TB, which includes peritonitis, intestinal obstruction and perforations. Here, we present a 37-year-old man who presented with long-standing, intermittent crampy abdominal pain and vomiting. He was diagnosed with chronic partial small bowel obstruction secondary to possibly small bowel carcinoma. We did segmental ileal resection and end-to-end ileo-ileal anastomosis. Postoperatively, the histopathology result turned out to be intestinal TB. This case report aims to make physicians aware of the rare condition of small bowel obstruction secondary to intestinal TB. Clinicians need to have a high index of suspicion in any patient with long-standing symptoms of partial obstruction and consider surgery and anti-TB once diagnosed.

Diagnostic performance of adenosine deaminase for abdominal tuberculosis: A systematic review and meta-analysis

Background and aim

Abdominal tuberculosis (TB) is a common type of extrapulmonary TB with an insidious onset and non-specific symptoms. Adenosine deaminase (ADA) levels increase rapidly in the early stages of abdominal TB. However, it remains unclear whether ADA serves as a diagnostic marker for abdominal TB.

Methods

We performed a systematic literature search for relevant articles published in PubMed, Web of Science, Cochrane Library, and Embase up to April 2022. First, we used the Quality Assessment of Diagnostic Accuracy Studies tool-2 (QUADAS-2), to evaluate the quality of the included articles. Bivariate and hierarchical summary receiver operating characteristic (HSROC) models were then utilized to analyze pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR) and area under the receiver operating characteristic curve (AUROC). In addition, we explored a subgroup analysis for potential heterogeneity and publication bias among the included literature.

Results

Twenty-four articles (3,044 participants, 3,044 samples) which met the eligibility criteria were included in this study. The pooled sensitivity and specificity of ADA for abdominal TB detection were 93% [95% confidence interval (CI): 0.89-0.95] and 95% (95% CI: 0.93-0.96), respectively. PLR and NLR were 18.6 (95% CI: 14.0-24.6) and 0.08 (95% CI: 0.05-0.12), respectively. DOR and AUROC were 236 (95% CI: 134-415) and 0.98 (95% CI: 0.96-0.99), respectively. Furthermore, no heterogeneity or publication bias was found.

Conclusions

Our meta-analysis found ADA to be of excellent diagnostic value for abdominal TB and could be used as an auxiliary diagnostic tool.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42022297931.

Ascites of Unexplained Origin: A Case Report

Ascites is defined as a massive collection of fluid in the peritoneal cavity, and it is most commonly caused by portal hypertension due to liver cirrhosis, acute liver failure, and heart failure. We report a case of ascites in a 39-year-old male who presented to the ED complaining of abdominal distention, sporadic pain on the epigastric area, unintentional weight loss over the past two months, night sweats, and blood-mixed stool. We conducted several imaging investigations and laboratory studies and none of them revealed any significant findings except for the abdominal CT with contrast, which showed large ascites along with submucosal fat deposition in the long segment of the transverse colon, suggestive of chronic inflammation [probably inflammatory bowel disease (IBD)], omental caking, and thickening. Peritoneal malignancy was highly suspected.

A diagnostic/therapeutic paracentesis was performed, through which 8 L of fluid was drained. Cytology was also performed and this showed mostly reactive mesothelial cells, negative acid-fast bacilli (AFB) culture, and negative polymerase chain reaction (PCR). We also discuss the other investigations performed, none of which helped in establishing a diagnosis.

The Diagnostic Deceiver: Radiological Pictorial Review of Tuberculosis

Tuberculosis (TB) is a bacterial infection with Mycobacterium tuberculosis; it is a public health problem worldwide and one of the leading causes of mortality. Since December 2019, the COVID-19 pandemic has created unprecedented health challenges and disrupted the TB health services, especially in high-burden countries with ever-increasing prevalence. Extrapulmonary and even pulmonary TB are an important cause of nonspecific clinical and radiological manifestations and can masquerade as any benign or malignant medical case, thus causing disastrous conditions and diagnostic dilemmas. Clinical manifestations and routine laboratory tests have limitations in directing physicians to diagnose TB. Medical-imaging examinations play an essential role in detecting tissue abnormalities and early suspecting diagnosis of TB in different organs. Radiologists and physicians should be familiar with and aware of the radiological manifestations of TB to contribute to the early suspicion and diagnosis of TB. The purpose of this article is to illustrate the common radiologic patterns of pulmonary and extrapulmonary TB. This article will be beneficial for radiologists, medical students, chest physicians, and infectious-disease doctors who are interested in the diagnosis of TB.