Can D-dimer levels predict the treatment outcome in a patient with tuberculosis?

Tuberculous peritonitis is a leading cause of mortality and morbidity particularly in the developing world. Delay in initiation of treatment distinctively increases mortality. Treatment response to anti-tuberculosis drugs is usually observed by regression of symptoms and clearance of ascites. With initiation of treatment, laboratory values including CA-125 levels generally return to normal levels in 3 months. However, there is still no consensus about treatment response during the follow-up period. Serum D-dimer level is used as an inflammation marker in some cases. A case with Tuberculous peritonitis successfully monitorised by serum D-dimer levels is presented.

Clinical significance of serum CA-125 in Korean females with ascites

PURPOSE

Mycobacterium tuberculosis is endemic in Korea. Because tuberculous peritonitis is characterized by ascites, abdominal pain, abdominal mass and elevation of serum CA-125, it can be confused with ovarian malignancies. The aim of this study was to evaluate the significance of serum CA-125 level in the differential diagnosis of tuberculous peritonitis and ovarian malignancy in a Mycobacterium tuberculosis-endemic area.

MATERIALS AND METHODS

The medical records of patients diagnosed with tuberculous peritonitis (n=48) or epithelial ovarian malignancy (n=370) at Samsung Medical Center from January 2000 to October 2009 were retrospectively reviewed.

RESULTS

Median serum CA-125 level in the epithelial ovarian cancer group was significantly higher than that in the tuberculous peritonitis group (p ≤ 0.01). Only one patient (2.1%) in the tuberculous peritonitis group had a serum CA-125 level over 2000 U/mL. However, 109 patients (29.5%) in the epithelial ovarian cancer group had a serum CA-125 level over 2000 U/mL. At the CA-125 ranges of 400 to 599 and 600 to 799, the proportions of those with tuberculous peritonitis were 24% and 21.9%, respectively. At a serum CA-125 level over 1000 U/mL, however, the proportion of tuberculous peritonitis was much lower (2.1%).

CONCLUSION

Tuberculous peritonitis should be considered in the evaluation of female patients with ascites and high serum CA-125.

[Changes parameters of humoral immunity in abdominal tuberculosis]

We measured the levels of IL-1beta, IL-8, and TNF-alpha, as well as humoral immunity in blood serum of patients with abdominal tuberculosis before and after Koch's test. The content of TNF-alpha increased 2.5 times, the content of IL-8 decreased almost twice, and concentration of IL-1beta decreased three times compared to the controls. We found that Koch's test exacerbates pathogenic manifestations of chronic inflammation which shows changes in cytokine spectrum of blood and allows us to refine diagnosis of abdominal tuberculosis.

Comparison between peritoneal tuberculosis and primary peritoneal carcinoma: a 16-year, single-center experience

BACKGROUND

Peritoneal tuberculosis and primary peritoneal carcinoma can both present as an abdominal mass and ascites with elevated serum CA125. The purpose of our study was to evaluate the clinical features of peritoneal tuberculosis, compare them with features of primary peritoneal carcinoma, and establish definitive diagnostic procedures.

METHODS

We conducted a retrospective study in patients with peritoneal tuberculosis from January 1995 to October 2010 at Peking Union Medical College Hospital. During this time, the data of 38 patients with primary peritoneal carcinoma were reviewed.

RESULTS

The median age was 34 years (range, 19 - 80 years). The most common symptoms were abdominal distension (16/30, 53.3%) and an abdominal mass (12/30, 40.0%). The serum CA125 level was elevated in 25 patients (83.3%). The median level of cancer antigen CA125 was 392.5 U/ml (range, 0.6 - 850.0 U/ml). Abdominal ultrasound revealed a pelvic mass in 25 patients and ascites in 20 patients. Diagnostic laparoscopy was performed in 15 patients (50.0%) and exploratory laparotomy was performed in 12 patients (40.0%), and 3 patients (10.0%) who underwent laparoscopy converted to laparotomy because of severe adhesions. The intraoperative findings were adhesions, multiple white tubercles, and ascites. Frozen tissue sections were obtained in 17 patients, and 14 of whom showed chronic granulomatous reactions. Final pathological examinations confirmed the diagnosis.

CONCLUSIONS

Peritoneal tuberculosis should be considered as a differential diagnosis, especially for young women with an abdominal mass, ascites, and elevated serum CA125 levels. Laparoscopy is a useful diagnostic method for peritoneal tuberculosis, and intraoperative frozen sections are recommended when the diagnosis is in doubt.

Raised CA125 serum level in tubercular peritonitis

A 24-year old woman was admitted with a history of fever and pelvic pain. ESR and CA125 serum level were high and PPD test was negative. Ultra sound and CT evaluation detected free fluid in abdominopelvic cavity. Laparotomy showed fibrinous strands adhering to and fibrotic sac surrounding the components of abdominal cavity. Opening the sac, grey miliary nodules were spotted and pathologic examination revealed multiple granulomatous lesions. Diagnosed with TBP, patient underwent specific antibiotic therapy and her condition improved significantly following treatment. As laboratory findings and image analysis may be misleading in diagnosis of TBP, diagnostic approach of laparotomy and subsequent pathologic examination is of vital value--particularly in premenopausal female patients to preserve fertility.

A case of tuberculous peritonitis in a hemodialysis patient with high serum soluble interleukin-2 receptor and CA-125 levels

A hemodialysis patient with tuberculous peritonitis with hypercalcemia and high serum soluble interleukin-2 receptor (sIL-2R) and CA-125 levels is reported. 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. Laboratory examination and radiologic studies revealed markedly increased serum sIL-2R and CA-125 levels and exudative ascites, with high levels of adenosine deaminase (ADA) and CA-125, which was suggestive of malignancy or tuberculosis. She was finally diagnosed as having tuberculous peritonitis based on positivity for Mycobacterium tuberculosis in ascitic fluid. The ascites subsided with normalization of hypercalcemia and a marked decrease in serum sIL-2R and CA-125 levels in response to anti-tuberculosis treatment. This case indicates that serum sIL-2R and CA-125 levels can rise to levels suggestive of malignancy in tuberculous peritonitis, and that they can be used to monitor the response to anti-tuberculosis treatment.

[Adenosine deaminase is useful for the diagnosis of peritoneal tuberculosis in patients with end-stage renal failure]

INTRODUCTION

End-stage renal failure patients are particularly at risk for tuberculosis, especially for peritoneal tuberculosis. Microbiological diagnosis remains hazardous in many cases.

CASE REPORT

We report on a case of peritoneal tuberculosis in an end-stage renal failure patient. The diagnosis was suspected on the basis of adenosine deaminase dosage in peritoneal fluid, allowing an early presumptive treatment and a favourable outcome with a 3 years follow-up.

DISCUSSION

The measurement of adenosine deaminase activity in ascites represents a diagnostic advance in tuberculous peritonitis among end-stage renal failure patients.

Disseminated peritoneal tuberculosis mimicking advanced-stage endodermal sinus tumor: a case report

It is well known that peritoneal tuberculosis may mimic advanced-stage epithelial ovarian carcinoma because of similar clinical, radiologic, and laboratory findings. However, disseminated peritoneal tuberculosis mimicking advanced-stage endodermal sinus tumor (ESS) has not been reported previously. An 18-year-old nulliparous woman came with the complaint of pelvic pain and weight loss. Imaging studies demonstrated that she had multiple peritoneal implants and left adnexial mass. Also, laboratory studies showed elevated CA125 and alpha fetoprotein levels suggesting an initial diagnosis of ESS. However, intraoperative frozen section examination showed caseous necrosis, and she was diagnosed as having disseminated peritoneal tuberculosis. Two months after the initial exploration, the patient required liver transplantation because of hepatic failure due to widespread hepatic involvement of the tuberculosis. Concomitant peritoneal and hepatic involvement of tuberculosis may cause false elevation of multiple tumor markers of gynecological cancers and may lead to misdiagnosis and mismanagement of patients. Elevation of these markers should be carefully investigated especially in premenopausal women. To our knowledge, this is the first reported case of peritoneal tuberculosis misdiagnosed as endodermal sinus tumor.

Tuberculous peritonitis mimicking peritonitis carcinomatosis: a case report

A 13-year-old girl presented with non-specific symptoms of peritonitis, low grade fever and missed her normal menses. Computed tomography of her abdomen and pelvic cavity showed omental cake and a generalised thickened peritoneum. An elevated serum cancer antigen-125 (CA-125) level of 1248.5 U/ml was also noted and a diagnosis of peritonitis carcinomatosis was first suspected. Diagnostic laparoscopy revealed multiple tubercles over the whole peritoneum and the pathology report described granulomatous nodules with giant cells and epithelioid cells. Culture of the ascitic fluid revealed Mycobacterium tuberculosiswhich resulted in a final diagnosis of tuberculous peritonitis. The patient's fever and abdominal distension gradually subsided after anti-tuberculosis treatment. The serum CA-125 level also decreased significantly to 10.2 U/ml after treatment.

CONCLUSION

cancer antigen-125 levels may serve as a potential follow-up marker of disease activity and treatment response in tuberculous peritonitis.

Elevated serum cancer antigen 125 levels in advanced abdominal tuberculosis

A 48-yr-old female presented with a 1-yr history of pain in the hypochondrium and epigastrium. All routine investigations and computed tomography (CT) of the abdomen were done. CT findings revealed a well-defined cystic mass in the right ovary, and ascitis with features suggestive of secondaries over the omentum and peritoneal surface. The serum CA125 was 1255 U/mL (normal range 0-35 U/mL), which was indicative of ovarian malignancy. An exploratory laparotomy was performed. Histopathological examination of organs revealed the presence of granuloma. The patient was advised to undergo antitubercular treatment (ATT) and follow-up every month. After 1 mo of ATT, the CA125 level came down to 42 U/mL, which was near normal. As tuberculosis requires only a conservative management, we suggest that in cases of abdominopelvic mass with or without ascitis, high serum CA125 should always raise a suspicion of tuberculosis and a laparoscopy combined with peritoneal biopsy should be performed to confirm the diagnosis. This will prevent unnecessary laparotomies. Moreover, serum CA125 can be used to monitor the response of disease to antitubercular treatment.

[Video-laparoscopic diagnosis and follow-up of a peritoneal tuberculosis]

A 21-year-old woman suffering from abdominal pain and a fever of 39 degrees C was hospitalized. Ultrasonography and computed tomographic scan showed a large amount of ascites and one hepatic node. The serum CA 125 level was elevated. Protein Chain Reaction (PCR) searching tuberculosis antigen in ascitic fluid was normal. A diagnosis of peritoneal tuberculosis was supposed and an exploratory laparoscopic procedure performed. Peroperative observation of the ascites, with multiple sites of adhesion, and pathological examination of the hepatic nodule and peritoneum confirmed initial diagnosis. Antituberculous treatment was given for one year. A second laparoscopic procedure was performed and found no disease remaining.

Tuberculous peritonitis: part of the differential diagnosis in ovarian cancer

We report a case of tuberculous peritonitis in a young woman who was initially thought to have ovarian cancer. We emphasize the misleading raised CA 125 levels and radiologic pictures and the importance of frozen-section analysis for definitive diagnosis to avoid unnecessary surgery.

[Peritoneal tuberculosis: evaluation of the response to treatment by analysing the CA 125 levels]

A case of a 32 years old woman with fever and exudative ascites is described. Tuberculous peritonitis was confirmed by abdominal laparoscopy, peritoneal biopsy and Lowënstein culture. A serum CA 125 level was 861 U/ml before therapy. The CA 125 level decreased a 30% after three weeks of antituberculous treatment. This tumor marker may be used to follow disease activity in tuberculous ascites.

Pelvic-peritoneal tuberculosis simulating ovarian carcinoma: report of three cases with elevation of the CA 125

We report three cases of women with abdominal pathology in which an elevated serum CA 125 tumor marker could have led to an erroneous diagnosis of ovarian carcinoma. However, after peritoneal biopsies were taken, tuberculosis was diagnosed. Furthermore, specific tuberculostatic treatment normalized serum CA 125 levels.

Diagnostic features of tuberculous peritonitis in the absence and presence of chronic liver disease: a case control study

PURPOSE

To determine diagnostic features of tuberculous peritonitis (TBP) in the absence and presence of chronic liver disease.

PATIENTS AND METHODS

Thirty-four patients with TBP (13 without [Group I] and 21 with chronic liver disease [Group II] and 26 controls with cirrhosis and uninfected ascites (Group III) were studied.

RESULTS

The clinical features in Groups I and II were similar and all patients had elevated ascitic fluid total mononuclear cell count. In Groups I, II, and III, respectively, ascitic fluid protein was > 25 g/L in 100% (13/13), 70% (14/20), and 0% (0/26); serum-ascites albumin gradient (SAAG) was > 11 g/L in 0% (0/13), 52% (11/21), and 96% (25/26), (0% [0/13], 71% [15/21], and 96% [25/26] after correction for serum globulin); and ascitic fluid lactate dehydrogenase (LDH) level was > 90 U/L in 100% (12/12), 84% (16/19), and 0% (0/20), respectively. In Groups I and II combined, ascitic fluid acid-fast stain was negative in all but Mycobacterium tuberculosis culture was positive in 45% (10/22); peritoneal nodules occurred in 94% (31/33), granulomas in 93% (28/30), and positive peritoneal M tuberculosis culture in 63% (10/16).

CONCLUSIONS

In patients with suspected TBP, ascitic fluid protein of > 25 g/L, SAAG of < 11 g/L and LDH of > 90 U/L have high sensitivity for the disease. With coexistent chronic liver disease, a lower protein level and higher SAAG are usually not helpful but LDH > 90 U/L is a useful parameter for screening. Diagnosis is best confirmed by laparoscopy with peritoneal biopsy and M tuberculosis culture.

Increased CA 125 in a patient with tuberculous peritonitis: case report and review of published works

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. Her CA 125 was greatly increased at 873 IU/ml and the ascites was a lymphocytic exudate but cytology failed to show malignant cells. Operative biopsy showed numerous noncaseating granulomas in the omentum but no mycobacterial organisms were seen. Empiric antituberculous treatment was started before positive culture results were received and when treatment had ended both the ascites and pleural effusion had resolved and the CA 125 had fallen to 7 IU/ml. Review of published works showed several other examples of tuberculous peritonitis associated with increased CA 125 and the possible cause of raised CA 125 in this condition is discussed.

Elevated serum CA-125 in tuberculous peritonitis: report of a case

A 37-year-old female presented with a 2-month history of abdominal distention. Omentum masses with massive ascites were found and ovarian cancer with peritoneal carcinomatosis was suspected. Her serum CA-125 level was over 500 U/ml before therapy. Tuberculous peritonitis was diagnosed via peritoneal biopsy. The serum CA-125 level returned to normal after antituberculous therapy. Elevated serum CA-125 does not always indicate ovarian malignancy. This tumor marker may be used to monitor the disease activity in non-neoplastic ascitic states.

Recovery of adrenocortical function following treatment of tuberculous Addison's disease

We report two cases of Addison's disease occurring in association with proven Mycobacterium tuberculosis infection. Both were treated with modern chemotherapeutic agents and were shown to have developed normal adrenal cortical function after several years. We suggest that adrenal function should be tested after modern anti-tuberculous therapy of this disease.

Elevated CA125 serum levels in a patient with tuberculous peritonitis

We report a case of tuberculous peritonitis in a 59-year-old post-menopausal woman. Her serum CA125 level was raised and fell in response to antituberculous therapy.

Serum-ascites albumin difference in tuberculous peritonitis

Recent studies have shown that the serum-ascites albumin difference provides better diagnostic discrimination than the ascites total protein concentration in the separation of "transudative" (portal hypertension) ascites and "exudative" (non-portal hypertension) ascites. Published studies to date have reported the serum-ascites albumin difference in only two patients with tuberculous ascites. We looked at the serum-ascites albumin difference in our series of patients with tuberculous peritonitis. All had a low difference (less than 1.1), similar to patients with malignancy.