Primary ileocecal tuberculosis

Paediatric abdominal tuberculosis in developed countries: case series and literature review

OBJECTIVE

To provide an insight into the presentation, diagnosis and management of paediatric abdominal tuberculosis (TB) in developed countries.

METHODS

The records of all children at the Montreal Children's Hospital (MCH) admitted with abdominal TB between 1990 and 2014 were reviewed. An automated and manual literature search from 1946 to 2014 was performed.

RESULTS

(1) CASE SERIES: six cases were identified at the MCH. All were male between 5 and 17 years of age. All were from populations known to have high rates of TB (aboriginal, immigrant). Three underwent major surgical interventions and three underwent ultrasound (US) or CT aspiration or biopsy for diagnosis. (2) LITERATURE REVIEW: 29 male (64%) and 16 female subjects (36%) aged between 14 months and 18 years were identified, including the MCH patients. All patients except one were from populations with a high incidence of TB. Most presented with a positive tuberculin skin test (90%), abdominal pain (76%), fever (71%) and weight loss (68%). On imaging, 22 (49%) were classified with gastrointestinal TB with colonic wall irregularity (41%) and 19 (42%) with peritoneal TB with ascites (68%). A positive culture was obtained in 33 (73%) patients. Three cases used CT- or US-guided aspiration or biopsy to obtain tissue samples. A surgical intervention was performed in 34 (76%) children; 13 (38%) of these were for diagnosis.

CONCLUSIONS

Diagnosis based on clinical features (abdominal pain, fever and weight loss) and CT- or US-guided aspiration or biopsy may encourage physicians to adopt a more conservative approach to abdominal TB.

Imaging findings of intestinal tuberculosis

Intestinal tuberculosis (TB) has 3 main forms: ulcerative, hypertrophic or ulcerohypertrophic, and fibrous stricturing. In the ulcerative form, barium examination reveals thickened folds, spasticity, and shallow ulcers involving the cecum and terminal ileum. Computerized tomography shows preferential thickening of the ileocecal valve and medial wall of the cecum as well as a few small regional nodes. In the hypertrophic or ulcerohypertrophic form, a hyperplastic reaction is seen in the exophytic masses around the ulcerated lumen on computed tomography. An inflammatory mass that extends into adjacent muscle suggests TB. In the sclerotic form, the main reaction is fibrosis with single or multiple short strictures. The cecum classically becomes amputated, conical, shrunken, and retracted. In comparison, Crohn's disease (CD) has a rather uniform and lesser thickening of the bowel wall. Mural stratification, vascular jejunization or the comb sign, and mesenteric fibrofatty proliferation are seen only in CD. The hypertrophic form may also mimic malignant neoplasms, such as lymphoma or carcinoma. Cecal carcinoma rarely extends beyond the ileocecal valve, however. In lymphoma, it can be seen as a greater degree of wall thickness with aneurysmatic dilation of the intestinal lumen. Single or multiple strictures are also seen as a CD complication. Advanced skip lesions adjacent to the stricture are usually diagnostic for CD.

Radiologic evaluation of the acute abdomen in the patient with acquired immunodeficiency syndrome (AIDS): the role of CT scanning

Abdominal complaints are common in the HIV-infected patient, and the signs and symptoms of disease may be masked by concurrent illness and a weak immune response, making accurate diagnosis difficult. Patients with acquired immunodeficiency syndrome (AIDS) are susceptible to diseases common to the general population; however, their generalized state of immunodeficiency places them at increased risk for many unusual disorders, predominately infectious and neoplastic. Radiologic evaluation, in particular, computed tomography (CT) with its ability to image the entire abdomen and pelvis, plays a crucial role in the prompt and accurate diagnosis and treatment of these patients.

Abdominal tuberculosis in children

Four boys with abdominal tuberculosis, one of whom had acquired immunodeficiency syndrome, are presented. Abdominal imaging findings on plain radiography, ultrasonography, computed tomography, and gastrointestinal contrast studies included tuberculous peritonitis and ascites in all patients, tuberculous adenopathy in two, gastrointestinal tuberculosis in two, and omental tuberculosis in two. The radiographic features particularly characteristic of abdominal tuberculosis were: (1) low attenuating adenopathy with rim enhancement, (2) omental or ileocecal inflammatory mass, (3) high density ascites, and (4) gastrointestinal enteritis involving the ileocecal region. All patients had acid-fast bacilli identified in cultures of bodily fluids and/or pathologic specimens and three patients had cultures positive for Mycobacterium tuberculosis. The patient with a negative culture had a positive PPD skin test and a surgical specimen showing caseating granulomata and acid-fast bacilli in the omentum. The radiologist must maintain a high degree of suspicion for abdominal tuberculosis particularly in normal or immunosuppressed children with acquired immunodeficiency syndrome. Fine needle aspiration and biopsy of abdominal adenopathy, inflammatory mass or ascites may be necessary for diagnosis.