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      Tuberculous peritonitis in a German patient with primary biliary cirrhosis: a case report

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          Abstract

          Background

          The number of cases of tuberculosis as a complication in people with immunodeficiency, people on immunosuppressive therapy and among the immigrant population is increasing in Germany. However, tuberculous peritonitis rarely occurs without these risks, particularly in Germans. The incidence of tuberculous peritonitis in Germany is very low; tuberculosis of the intestinal tract was found in approximately 0.8 % of tuberculosis cases in 2004. The diagnosis of tuberculous peritonitis is often delayed on account of non-specific clinical symptoms. The absence of specific biological markers, long incubation times for cultures and non-specific radiographic or ultrasonographic signs increase the morbidity associated with this treatable condition.

          Case presentation

          We report a case of tuberculous peritonitis in a 73-year-old female German patient. Her medical history revealed primary biliary cirrhosis (PBC) since 1992. On admission, she complained of abdominal pain, vomiting, ascites and peripheral edema. The patient has been in a seriously reduced general condition and had fever up to 39.6°C. A few weeks earlier, the patient was in another hospital with the same complaint. Inflammatory parameters were elevated, but the procalcitonin level was normal. Blood culture was always negative, as was the tuberculin test. Ultrasonography of the abdomen showed massive ascites with multiple septa. The patient underwent a computed tomography (CT) scan of the abdomen which showed a thickened intestinal wall in the sigmoid colon and a pronounced enhancement of the peritoneum. Computed tomography scans of the lung showed only slight bilateral pleural effusion. Because of the anaesthetic and bleeding risk due to thrombocytopenia, laparoscopy was not immediately undertaken. The culture from ascites was positive for M. tuberculosis after three weeks.

          Conclusion

          In primary biliary cirrhosis patients with non-specific clinical symptoms, such as vomiting, abdominal pain, ascites, weight loss, and fever, tuberculous peritonitis must be considered in the initial differential diagnosis, although these symptoms may be attributed to cirrhosis of the liver with spontaneous bacterial peritonitis. Ultrasonographic and CT scab findings are not specific for tuberculous peritonitis, but an awareness of the ultrasonographic features and the features of the CT scan may help in the diagnosis of tuberculous peritonitis and avoid clinical mismanagement.

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          Most cited references15

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          Value of adenosine deaminase (ADA) in ascitic fluid for the diagnosis of tuberculous peritonitis: a meta-analysis.

          Adenosine deaminase (ADA) levels are used for diagnosing tuberculosis in several locations and although many studies have evaluated ADA levels in ascitic fluid. These studies have defined arbitrary cut-off points creating difficulties in the clinical application of the results. The goals of this study are: to determine the usefulness of ADA levels in ascitic fluid as a diagnostic test for peritoneal tuberculosis (PTB) and define the best cut-off point. A systematic review was done on the basis of 2 independent searches. We selected prospective studies that included consecutive patients. Diagnosis of PTB had to be confirmed by bacteriologic or histologic methods and ADA levels determined by the Giusti method. Inclusion/exclusion criteria were applied by 2 independent reviewers. A receiver operating characteristic curve was constructed to establish the optimal cut-off point and the likelihood ratios (LRs) estimated using fixed-effect pooled method. Twelve prospective studies were found. Four of them met the inclusion criteria and were thus included in the meta-analysis. They included 264 patients, of which 50 (18.9%) had PTB. ADA levels showed high sensitivity (100%) and specificity (97%) using cut-off values from 36 to 40 IU/L. The included studies were homogeneous. Optimal cut-off point was determined at 39 IU/L, and LRs were 26.8 and 0.038 for values above and below this cut-off. This study supports the proposition that ADA determination is a fast and discriminating test for diagnosing PTB with an optimal cut-off value of 39 IU/L.
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            Diagnosis of abdominal tuberculosis: experience from 11 cases and review of the literature.

            To analyze the experience within our hospital and to review the literature so as to establish the best means of diagnosis of abdominal tuberculosis. The records of 11 patients (4 males, 7 females, mean age 39 years, range 18-65 years) diagnosed with abdominal tuberculosis in Harran University Hospital between January 1996 and October 2003 were analyzed retrospectively and the literature was reviewed. Ascites was present in all cases. Other common findings were weight loss (81%), weakness (81%), abdominal mass (72%), abdominal pain (72%), abdominal distension (63%), anorexia (45%) and night sweat (36%). The average hemoglobin was 8.2 g/dL and the average ESR was 50 mm/h (range 30-125). Elevated levels of cancer antigen CA-125 were determined in four patients. Abdominal ultrasound showed abnormalities in all cases: ascites in all, tuboovarian mass in five, omental thickening in 3, and enlarged lymph nodes (mesenteric, para-aortic) in 2. CT scans showed ascites in all, pelvic mass in 5, retroperitoneal lymphadenopathy in 4, mesenteric stranding in 4, omental stranding in 3, bowel wall thickening in 2 and mesenteric lymphadenopathy in 2. Only one patient had a chest radiograph suggestive of a new TB lesion. Two had a positive family history of pulmonary TB. None had acid-fast bacilli (AFB) in the sputum and the tuberculin test was positive in only two. Laparotomy was performed in 6 cases, laparoscopy in 4 and ultrasound-guided fine needle aspiration in 2. In those patients subjected to operation, the findings were multiple diffuse involvement of the visceral and parietal peritoneum, white 'miliary nodules' or plaques, enlarged lymph nodes, ascites, 'violin string' fibrinous strands, and omental thickening. Biopsy specimens showed granulomas, while ascitic fluid showed numerous lymphocytes. Both were negative for acid-fast bacilli by staining. PCR of ascitic fluid was positive for Mycobacterium tuberculosis (M. tuberculosis) in all cases. Abdominal TB should be considered in all cases with ascites. Our experience suggests that PCR of ascitic fluid obtained by ultrasound-guided fine needle aspiration is a reliable method for its diagnosis and should at least be attempted before surgical intervention.
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              Diagnostic dilemma of abdominal tuberculosis in non-HIV patients: an ongoing challenge for physicians.

              To assess the clinical features, yield of the diagnostic tests and outcome of abdominal tuberculosis in non-HIV patients. Adult patients with discharge diagnosis of abdominal tuberculosis (based upon; positive microbiology, histo-pathology, imaging or response to trial of anti TB drugs) during the period 1999 to 2004 were analyzed. Patient's characteristics, laboratory investigations, radiological, endoscopic and surgical findings were evaluated. Abdominal site involved (intestinal, peritoneal, visceral, and nodal) and response to treatment was also noted. There were 209 patients enrolled. One hundred and twenty-three (59%) were females. Symptoms were abdominal pain 194 (93%), fever 134 (64%), night sweats 99 (48%), weight loss 98 (47%), vomiting 75 (36%), ascites 74 (35%), constipation 64 (31%), and diarrhea 25 (12%). Sub-acute and acute intestinal obstruction was seen in 28 (13%) and 12 (11%) respectively. Radiological evidence of pulmonary tuberculosis was found in 134 (64%) patients. Basis of diagnosis of abdominal tuberculosis were radiology (Chest and barium X-Rays, Ultrasound and CT scan abdomen) in 111 (53%) and histo-pathology (tissue obtained during surgery, colonoscopy, CT or ultrasound guided biopsy, laparoscopy and upper gastro intestinal endoscopy) in 87 (42%) patients. Mycobacterium culture was positive in 6/87 (7%) patients and response to therapeutic trial of anti tubercular drugs was the basis of diagnosis in 5 (2.3%) patients. Predominant site of involvement by abdominal TB was intestinal in 103 (49%) patients, peritoneal in 87 (42%) patients, solid viscera in 10 (5%) and nodal in 9 (4%) patients. Response to medical treatment was found in 158 (76%) patients and additionally 35 (17%) patients also underwent surgery. In a 425 +/- 120 d follow-up period 12 patients died (eight post operative) and no case of relapse was noted. Abdominal TB has diverse and non- specific symptomatology. No single test is adequate for diagnosis of abdominal tuberculosis in all patients. Abdominal TB in non-HIV patients remains an ongoing diagnostic dilemma requiring a high index of clinical suspicion.
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                Author and article information

                Journal
                J Med Case Reports
                Journal of Medical Case Reports
                BioMed Central
                1752-1947
                2008
                31 January 2008
                : 2
                : 32
                Affiliations
                [1 ]Department of Internal Medicine, Gastroenterology Unit, Marienhospital, Ruhr University, Herne, Germany
                [2 ]Department of Radiology, Marienhospital, Ruhr University, Herne, Germany
                Article
                1752-1947-2-32
                10.1186/1752-1947-2-32
                2267201
                18237424
                ae16b694-5f04-4f14-9254-4850a3be04b1
                Copyright © 2008 Vogel et al; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 29 June 2007
                : 31 January 2008
                Categories
                Case Report

                Medicine
                Medicine

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