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      Gallbladder tuberculosis in a dialysis patient: a case-report

      case-report

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          Abstract

          Background

          The diagnosis of gallbladder tuberculosis remains elusive even to the most experienced clinicians. Our aim is to describe our experience of this rare disease, and to raise awareness of the increasing likelihood of tuberculosis in chronic kidney disease (CKD) patient.

          Case presentation

          We report a rare case of gallbladder tuberculosis in a chronic kidney disease patient on hemodialysis. This combination is rarely reported in literature. No signs of abdominal tuberculosis were observed besides a clinical profile consistent with CKD in our patient. The clinical signs of uremia masks those of abdominal tuberculosis and render the pre-operative diagnosis of tuberculosis more difficult.

          Conclusions

          The clinical signs of uremia conceal those of abdominal tuberculosis. The diagnosis of tuberculosis in CKD patients hinges mainly on a high index of suspicion, perioperative findings and histological examination.

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          Most cited references9

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          Tuberculosis and chronic kidney disease: an emerging global syndemic.

          The link between chronic kidney disease (CKD) and tuberculosis (TB) has been known for more than 40 years, but the interaction between these 2 diseases is still poorly understood. Dialysis and renal transplant patients appear to be at a higher risk of TB, in part related to immunosuppression along with socioeconomic, demographic, and comorbid factors. Meanwhile, TB screening and diagnostic test performance is suboptimal in the CKD population, and there is limited evidence to guide protocols. Given the increasing prevalence of CKD in TB endemic areas, a merging of CKD and TB epidemics could have significant public health implications, especially in low- to middle-income countries such as India and China, that are experiencing rapid increases in CKD prevalence and account for more than one-third of global TB prevalence. To begin addressing TB-CKD, a clear understanding of the relationship between these 2 conditions needs to be established, and consistent, evidence-based screening and treatment guidelines need to be developed.
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            Diagnosis of tuberculosis in dialysis patients: current strategy.

            Patients with ESRD undergoing chronic dialysis are much more prone to develop tuberculosis (TB) than the general population. In these patients, the diagnosis of TB disease is often difficult because of prevailing extrapulmonary involvement and nonspecific symptoms. The prevalence of latent TB infection (LTBI) in ESRD patients is elevated, and those who become infected are at high risk of developing active disease. Therefore, screening for LTBI in this population is recommended, aiming to prevent progression to active TB and secondary contamination of others. The tuberculin skin test (TST), the classic diagnostic tool for LTBI, has several major drawbacks, including poor sensitivity (because of a high prevalence of anergy in dialysis patients) and specificity [with false-positive tests in those vaccinated with bacille Calmette-Guérin (BCG)]. In the past 10 years or so, new immunological tests using IFN-gamma release assays (IGRAs) have become available and have shown superior sensitivity and specificity for the diagnosis of TB compared with the TST in several studies, some very recent ones including ESRD patients. Therefore, current strategy in dialysis patients should use these tests instead of TST for LTBI screening and as an aid for the diagnosis of active TB.
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              Interferon-gamma release assays for diagnosing mycobacterium tuberculosis infection in renal dialysis patients.

              End-stage renal disease (ESRD) patients are at high risk for tuberculosis (TB). IFN-gamma release assays that assess immune responses to specific TB antigens offer potential advantages over tuberculin skin testing (TST) in screening such patients for Mycobacterium tuberculosis infection. This study sought to determine whether IFN-gamma release assay results are more closely associated with recent TB exposure than TST results. Prospective cohort investigation of patients at a hemodialysis center with a smear-positive case of TB. Patients without a history of TB underwent initial and repeat testing with TST, and with the IFN-gamma assays QuantiFERON-TB Gold (QFT-G) and ELISPOT test. Outcome measures included the prevalence of positive test results, identification of factors associated with positive results, and test result discordance. A total of 100 (47% foreign born; median age, 55 yr; age range, 18 to 83 yr) of 124 eligible patients were enrolled. Twenty-six persons had positive TST results, 21 had positive QFT-G results, and 27 had positive ELISPOT results. Patients with TB case contact were likely to have a positive QFT-G result (P = 0.02) and ELISPOT results (P = 0.04), whereas TB case contact was not associated with positive TST results (P = 0.7). Positive TST results were associated with foreign birth (P = 0.04) and having had a TST in the previous year (P = 0.04). Positive IFN-gamma assay results were more closely associated with recent TB exposure than were positive TST results. QFT-G and ELISPOT might offer a better method for detecting TB infection in ESRD patients.
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                Author and article information

                Contributors
                tewodross@njmu.edu.cn
                jiangkuirong@njmu.edu.cn
                miaoyi@njmu.edu.cn
                weijishu@njmu.edu.cn
                Journal
                BMC Surg
                BMC Surg
                BMC Surgery
                BioMed Central (London )
                1471-2482
                7 April 2020
                7 April 2020
                2020
                : 20
                : 67
                Affiliations
                [1 ]The First Affiliated Hospital of Nanjing Medical University, School of International Education, Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu China
                [2 ]GRID grid.412676.0, ISNI 0000 0004 1799 0784, Pancreas Center, , The First Affiliated Hospital of Nanjing Medical University, ; 300 Guangzhou Road, Nanjing, 210029 Jiangsu China
                Article
                722
                10.1186/s12893-020-00722-x
                7137183
                32264878
                baec7c83-be40-4860-b554-2c24b6e75845
                © The Author(s) 2020

                Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

                History
                : 9 October 2019
                : 23 March 2020
                Categories
                Case Report
                Custom metadata
                © The Author(s) 2020

                Surgery
                gallbladder tuberculosis,chronic kidney disease (ckd),end-stage renal disease (esrd),gallbladder cancer,abdominal tuberculosis,immunodeficiency,hemodialysis

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