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Tuberculosis (TB), an infectious disease caused by Mycobacterium tuberculosis, is estimated to infect one-third of the world’s population. TB generally affects the lungs. However, it can have extrapulmonary manifestations.[[1–2]] New Zealand has had a declining incidence of community-acquired TB since the 1960s.[[3]] The decline in TB cases is largely due to increased living standards, control of bovine TB and treatment advances. Patients diagnosed in recent years are often recent immigrants and/or from low socioeconomic groups with overcrowded housing.[[2–3]] The abdominal manifestation of TB is infrequent with diverse symptoms ranging from non-localised abdominal pain to ascites and fevers.[[4]] This case highlights the difficulties in diagnosing peritoneal TB requiring PCR-based testing.[[5,6]]

Case report

A 35-year-old Indian female with a background of a previous splenectomy for idiopathic thrombocytopenic purpura presented to hospital with a two-week history of fevers/rigors and worsening diffuse generalised abdominal pain. Important clinical and investigative findings are presented below.

Figure 1: A computed tomographic scan of the abdomen and pelvis with contrast shows extensive stranding and diffuse, nodular peritoneal thickening and enhancement (Panel A) and a large amount of ascites as noted by the arrow (Panel B).

View Table 1.

Due to ongoing abdominal pain and the development of peritonism, the patient proceeded to diagnostic laparoscopy. Intraoperative observations included multiple peritoneal and omental nodules with widespread peritonitis without purulent or enteric contamination. Large volume serous ascites was present, and a methylene leak test showed no evidence of perforation. Appendicectomy, peritoneal and omental biopsies, ascitic fluid sampling was performed. Analysis of biopsies and ascitic samples was carried out with haematoxylin and eosin staining and PCR TB testing. View Table 2.

Post-operative inflammatory markers continued to rise with ongoing fevers. A subsequent serial chest X-ray showed evidence of pneumonia with dense opacities visible in the left lower lobe. No organisms were isolated from surgical, PBC, mid-stream urine cultures. A diagnosis of peritoneal tuberculosis with a superimposed hospital-acquired pneumonia was made. Treatment was initiated and comprised rifampicin plus isoniazid, ethambutol and pyrazinamide. The patient was then referred to Public Health and Infectious Diseases services for ongoing follow-up and underwent weekly laboratory tests.

Discussion

This case highlights the challenges in diagnosing atypical TB infections. TB is rare in developed countries, with only 350 cases reported in 2018 compared to the estimated 10 million cases worldwide.[[7]] Abdominal TB comprises 0.1% to 0.7% of all cases and the resulting peritonitis it can cause is primarily spread throughout the body hematogenously from an original pulmonary infection or due to reactivation of latent TB in the peritoneum.[[5,6]] Progression of abdominal TB can lead to ulceration, bleeding and perforation.[[8,9]] Due to New Zealand’s small population and the low numbers of abdominal TB, there is a paucity of information regarding the incidence in this country.[[4]]

Current literature suggests that long-standing symptoms make the diagnosis of peritoneal TB more likely. However, in this case the patient presented with a two-week history of abdominal pain. This case demonstrates that a longitudinal history is not always expected, and the combination of a short history and non-specific symptoms of peritoneal TB made this infection difficult to distinguish from other acute abdominal pathologies. In addition, the development of PCR testing is a common tool for the rapid diagnosis of TB. Providing a reliable sensitive augmentation to culturing samples.[[10]] In this case, numerous samples were cultured and were TB negative. However, TB PCR effectively showed M. tuberculosis in samples from the diagnostic laparoscopy. This report reminds clinicians that, although it is rare, undiagnosed abdominal tuberculosis has a mortality rate of 8% to 50%, and therefore should be a diagnostic differential in patients with abdominal pain, fever and ascites of any duration, especially if the patient has known epidemiological risk factors.[[9]] In addition, reliable diagnostic screening for TB should include PCR of all patient samples.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Luke Hawley: House officer, Department of General Surgery, North Shore Hospital, Waitematā District Health Board. Josh Narayan: House officer, Department of General Surgery, North Shore Hospital, Waitematā District Health Board. Suheelan Kulasegaran: Registrar, Department of General Surgery, North Shore Hospital, Waitematā District Health Board. Richard Harman: General Surgeon, Department of General Surgery, North Shore Hospital, Waitematā District Health Board. Jamie-Lee Rahiri: Registrar, Department of General Surgery, North Shore Hospital, Waitematā District Health Board and Postdoctoral Fellow, Department of Surgery, University of Auckland. Teresa M Holm: Registrar, Department of General Surgery, North Shore Hospital, Waitematā District Health Board and Postdoctoral Fellow, Department of Department of Molecular Medicine and Pathology, FMHS, University of Auckland.

Acknowledgements

We would like to thank our patient who has provided written consent for medical information to be published in this manuscript.

Correspondence

Dr Teresa Holn, MBChB, PhD, Department of General Surgery, North Shore Hospital, Waitematā District Health Board, Department of Molecular Medicine and Pathology, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.

Correspondence Email

t.holm@auckland.ac.nz

Competing Interests

Nil.

1) Houben RM, Dodd PJ. The global burden of latent tuberculosis infection: a re-estimation using mathematical modelling. PLoS medicine. 2016 Oct 25;13(10):e1002152.

2) World Health Organization. Global tuberculosis report 2020 [Internet]. Who.int: 2021 [cited 2021 Aug 22]. Available from: https://www.who.int/publications/i/item/9789240013131.

3) Das D, Baker M, Calder L. Tuberculosis epidemiology in New Zealand: 1995-2004. N Z Med J. 2006 Oct 13;119(1243).

4) Bevin J, Dalton S, Wakeman C, Perry W. Diagnosis of abdominal tuberculosis in Christchurch New Zealand: a case series. N Z Med J. 2018 Apr 13;131:48-52.

5) Peto HM, Pratt RH, Harrington TA, LoBue PA, Armstrong LR. Epidemiology of extrapulmonary tuberculosis in the United States,1993–2006.Clinical Infectious Diseases. 2009 Nov 15;49(9):1350-7.

6) Chávez RI, Rivera AB. Gastrointestinal and peritoneal tuberculosis. Revista de gastroenterologia del Peru: organo oficial de la Sociedad de Gastroenterologia del Peru. 1994;14(2):99-113.

7) Ministry of Health [Internet]. New Zealand; 2019 Aug [cited 2020 April 21]. Tuberculosis, Part of the Communicable Disease Control Manual. Available from: https://www.health.govt.nz/our-work/diseases-and-conditions/communicable-disease-control-manual/tuberculosis

8) Sanai FM, Bzeizi KI. Systematic review: tuberculous peritonitis–presenting features, diagnostic strategies and treatment. Alimentary pharmacology & therapeutics. 2005 Oct;22(8):685-700.

9) Chow KM, Chow VC, Hung LC, Wong SM, Szeto CC. Tuberculous peritonitis–associated mortality is high among patients waiting for the results of mycobacterial cultures of ascitic fluid samples. Clinical infectious diseases. 2002 Aug 15;35(4):409-13.

10) Cheng VC, Yam WC, Hung IF, Woo PC, Lau SK, Tang BS, Yuen KY. Clinical evaluation of the polymerase chain reaction for the rapid diagnosis of tuberculosis. Journal of clinical pathology. 2004 Mar 1;57(3):281-5.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

Tuberculosis (TB), an infectious disease caused by Mycobacterium tuberculosis, is estimated to infect one-third of the world’s population. TB generally affects the lungs. However, it can have extrapulmonary manifestations.[[1–2]] New Zealand has had a declining incidence of community-acquired TB since the 1960s.[[3]] The decline in TB cases is largely due to increased living standards, control of bovine TB and treatment advances. Patients diagnosed in recent years are often recent immigrants and/or from low socioeconomic groups with overcrowded housing.[[2–3]] The abdominal manifestation of TB is infrequent with diverse symptoms ranging from non-localised abdominal pain to ascites and fevers.[[4]] This case highlights the difficulties in diagnosing peritoneal TB requiring PCR-based testing.[[5,6]]

Case report

A 35-year-old Indian female with a background of a previous splenectomy for idiopathic thrombocytopenic purpura presented to hospital with a two-week history of fevers/rigors and worsening diffuse generalised abdominal pain. Important clinical and investigative findings are presented below.

Figure 1: A computed tomographic scan of the abdomen and pelvis with contrast shows extensive stranding and diffuse, nodular peritoneal thickening and enhancement (Panel A) and a large amount of ascites as noted by the arrow (Panel B).

View Table 1.

Due to ongoing abdominal pain and the development of peritonism, the patient proceeded to diagnostic laparoscopy. Intraoperative observations included multiple peritoneal and omental nodules with widespread peritonitis without purulent or enteric contamination. Large volume serous ascites was present, and a methylene leak test showed no evidence of perforation. Appendicectomy, peritoneal and omental biopsies, ascitic fluid sampling was performed. Analysis of biopsies and ascitic samples was carried out with haematoxylin and eosin staining and PCR TB testing. View Table 2.

Post-operative inflammatory markers continued to rise with ongoing fevers. A subsequent serial chest X-ray showed evidence of pneumonia with dense opacities visible in the left lower lobe. No organisms were isolated from surgical, PBC, mid-stream urine cultures. A diagnosis of peritoneal tuberculosis with a superimposed hospital-acquired pneumonia was made. Treatment was initiated and comprised rifampicin plus isoniazid, ethambutol and pyrazinamide. The patient was then referred to Public Health and Infectious Diseases services for ongoing follow-up and underwent weekly laboratory tests.

Discussion

This case highlights the challenges in diagnosing atypical TB infections. TB is rare in developed countries, with only 350 cases reported in 2018 compared to the estimated 10 million cases worldwide.[[7]] Abdominal TB comprises 0.1% to 0.7% of all cases and the resulting peritonitis it can cause is primarily spread throughout the body hematogenously from an original pulmonary infection or due to reactivation of latent TB in the peritoneum.[[5,6]] Progression of abdominal TB can lead to ulceration, bleeding and perforation.[[8,9]] Due to New Zealand’s small population and the low numbers of abdominal TB, there is a paucity of information regarding the incidence in this country.[[4]]

Current literature suggests that long-standing symptoms make the diagnosis of peritoneal TB more likely. However, in this case the patient presented with a two-week history of abdominal pain. This case demonstrates that a longitudinal history is not always expected, and the combination of a short history and non-specific symptoms of peritoneal TB made this infection difficult to distinguish from other acute abdominal pathologies. In addition, the development of PCR testing is a common tool for the rapid diagnosis of TB. Providing a reliable sensitive augmentation to culturing samples.[[10]] In this case, numerous samples were cultured and were TB negative. However, TB PCR effectively showed M. tuberculosis in samples from the diagnostic laparoscopy. This report reminds clinicians that, although it is rare, undiagnosed abdominal tuberculosis has a mortality rate of 8% to 50%, and therefore should be a diagnostic differential in patients with abdominal pain, fever and ascites of any duration, especially if the patient has known epidemiological risk factors.[[9]] In addition, reliable diagnostic screening for TB should include PCR of all patient samples.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Luke Hawley: House officer, Department of General Surgery, North Shore Hospital, Waitematā District Health Board. Josh Narayan: House officer, Department of General Surgery, North Shore Hospital, Waitematā District Health Board. Suheelan Kulasegaran: Registrar, Department of General Surgery, North Shore Hospital, Waitematā District Health Board. Richard Harman: General Surgeon, Department of General Surgery, North Shore Hospital, Waitematā District Health Board. Jamie-Lee Rahiri: Registrar, Department of General Surgery, North Shore Hospital, Waitematā District Health Board and Postdoctoral Fellow, Department of Surgery, University of Auckland. Teresa M Holm: Registrar, Department of General Surgery, North Shore Hospital, Waitematā District Health Board and Postdoctoral Fellow, Department of Department of Molecular Medicine and Pathology, FMHS, University of Auckland.

Acknowledgements

We would like to thank our patient who has provided written consent for medical information to be published in this manuscript.

Correspondence

Dr Teresa Holn, MBChB, PhD, Department of General Surgery, North Shore Hospital, Waitematā District Health Board, Department of Molecular Medicine and Pathology, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.

Correspondence Email

t.holm@auckland.ac.nz

Competing Interests

Nil.

1) Houben RM, Dodd PJ. The global burden of latent tuberculosis infection: a re-estimation using mathematical modelling. PLoS medicine. 2016 Oct 25;13(10):e1002152.

2) World Health Organization. Global tuberculosis report 2020 [Internet]. Who.int: 2021 [cited 2021 Aug 22]. Available from: https://www.who.int/publications/i/item/9789240013131.

3) Das D, Baker M, Calder L. Tuberculosis epidemiology in New Zealand: 1995-2004. N Z Med J. 2006 Oct 13;119(1243).

4) Bevin J, Dalton S, Wakeman C, Perry W. Diagnosis of abdominal tuberculosis in Christchurch New Zealand: a case series. N Z Med J. 2018 Apr 13;131:48-52.

5) Peto HM, Pratt RH, Harrington TA, LoBue PA, Armstrong LR. Epidemiology of extrapulmonary tuberculosis in the United States,1993–2006.Clinical Infectious Diseases. 2009 Nov 15;49(9):1350-7.

6) Chávez RI, Rivera AB. Gastrointestinal and peritoneal tuberculosis. Revista de gastroenterologia del Peru: organo oficial de la Sociedad de Gastroenterologia del Peru. 1994;14(2):99-113.

7) Ministry of Health [Internet]. New Zealand; 2019 Aug [cited 2020 April 21]. Tuberculosis, Part of the Communicable Disease Control Manual. Available from: https://www.health.govt.nz/our-work/diseases-and-conditions/communicable-disease-control-manual/tuberculosis

8) Sanai FM, Bzeizi KI. Systematic review: tuberculous peritonitis–presenting features, diagnostic strategies and treatment. Alimentary pharmacology & therapeutics. 2005 Oct;22(8):685-700.

9) Chow KM, Chow VC, Hung LC, Wong SM, Szeto CC. Tuberculous peritonitis–associated mortality is high among patients waiting for the results of mycobacterial cultures of ascitic fluid samples. Clinical infectious diseases. 2002 Aug 15;35(4):409-13.

10) Cheng VC, Yam WC, Hung IF, Woo PC, Lau SK, Tang BS, Yuen KY. Clinical evaluation of the polymerase chain reaction for the rapid diagnosis of tuberculosis. Journal of clinical pathology. 2004 Mar 1;57(3):281-5.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

Tuberculosis (TB), an infectious disease caused by Mycobacterium tuberculosis, is estimated to infect one-third of the world’s population. TB generally affects the lungs. However, it can have extrapulmonary manifestations.[[1–2]] New Zealand has had a declining incidence of community-acquired TB since the 1960s.[[3]] The decline in TB cases is largely due to increased living standards, control of bovine TB and treatment advances. Patients diagnosed in recent years are often recent immigrants and/or from low socioeconomic groups with overcrowded housing.[[2–3]] The abdominal manifestation of TB is infrequent with diverse symptoms ranging from non-localised abdominal pain to ascites and fevers.[[4]] This case highlights the difficulties in diagnosing peritoneal TB requiring PCR-based testing.[[5,6]]

Case report

A 35-year-old Indian female with a background of a previous splenectomy for idiopathic thrombocytopenic purpura presented to hospital with a two-week history of fevers/rigors and worsening diffuse generalised abdominal pain. Important clinical and investigative findings are presented below.

Figure 1: A computed tomographic scan of the abdomen and pelvis with contrast shows extensive stranding and diffuse, nodular peritoneal thickening and enhancement (Panel A) and a large amount of ascites as noted by the arrow (Panel B).

View Table 1.

Due to ongoing abdominal pain and the development of peritonism, the patient proceeded to diagnostic laparoscopy. Intraoperative observations included multiple peritoneal and omental nodules with widespread peritonitis without purulent or enteric contamination. Large volume serous ascites was present, and a methylene leak test showed no evidence of perforation. Appendicectomy, peritoneal and omental biopsies, ascitic fluid sampling was performed. Analysis of biopsies and ascitic samples was carried out with haematoxylin and eosin staining and PCR TB testing. View Table 2.

Post-operative inflammatory markers continued to rise with ongoing fevers. A subsequent serial chest X-ray showed evidence of pneumonia with dense opacities visible in the left lower lobe. No organisms were isolated from surgical, PBC, mid-stream urine cultures. A diagnosis of peritoneal tuberculosis with a superimposed hospital-acquired pneumonia was made. Treatment was initiated and comprised rifampicin plus isoniazid, ethambutol and pyrazinamide. The patient was then referred to Public Health and Infectious Diseases services for ongoing follow-up and underwent weekly laboratory tests.

Discussion

This case highlights the challenges in diagnosing atypical TB infections. TB is rare in developed countries, with only 350 cases reported in 2018 compared to the estimated 10 million cases worldwide.[[7]] Abdominal TB comprises 0.1% to 0.7% of all cases and the resulting peritonitis it can cause is primarily spread throughout the body hematogenously from an original pulmonary infection or due to reactivation of latent TB in the peritoneum.[[5,6]] Progression of abdominal TB can lead to ulceration, bleeding and perforation.[[8,9]] Due to New Zealand’s small population and the low numbers of abdominal TB, there is a paucity of information regarding the incidence in this country.[[4]]

Current literature suggests that long-standing symptoms make the diagnosis of peritoneal TB more likely. However, in this case the patient presented with a two-week history of abdominal pain. This case demonstrates that a longitudinal history is not always expected, and the combination of a short history and non-specific symptoms of peritoneal TB made this infection difficult to distinguish from other acute abdominal pathologies. In addition, the development of PCR testing is a common tool for the rapid diagnosis of TB. Providing a reliable sensitive augmentation to culturing samples.[[10]] In this case, numerous samples were cultured and were TB negative. However, TB PCR effectively showed M. tuberculosis in samples from the diagnostic laparoscopy. This report reminds clinicians that, although it is rare, undiagnosed abdominal tuberculosis has a mortality rate of 8% to 50%, and therefore should be a diagnostic differential in patients with abdominal pain, fever and ascites of any duration, especially if the patient has known epidemiological risk factors.[[9]] In addition, reliable diagnostic screening for TB should include PCR of all patient samples.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Luke Hawley: House officer, Department of General Surgery, North Shore Hospital, Waitematā District Health Board. Josh Narayan: House officer, Department of General Surgery, North Shore Hospital, Waitematā District Health Board. Suheelan Kulasegaran: Registrar, Department of General Surgery, North Shore Hospital, Waitematā District Health Board. Richard Harman: General Surgeon, Department of General Surgery, North Shore Hospital, Waitematā District Health Board. Jamie-Lee Rahiri: Registrar, Department of General Surgery, North Shore Hospital, Waitematā District Health Board and Postdoctoral Fellow, Department of Surgery, University of Auckland. Teresa M Holm: Registrar, Department of General Surgery, North Shore Hospital, Waitematā District Health Board and Postdoctoral Fellow, Department of Department of Molecular Medicine and Pathology, FMHS, University of Auckland.

Acknowledgements

We would like to thank our patient who has provided written consent for medical information to be published in this manuscript.

Correspondence

Dr Teresa Holn, MBChB, PhD, Department of General Surgery, North Shore Hospital, Waitematā District Health Board, Department of Molecular Medicine and Pathology, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.

Correspondence Email

t.holm@auckland.ac.nz

Competing Interests

Nil.

1) Houben RM, Dodd PJ. The global burden of latent tuberculosis infection: a re-estimation using mathematical modelling. PLoS medicine. 2016 Oct 25;13(10):e1002152.

2) World Health Organization. Global tuberculosis report 2020 [Internet]. Who.int: 2021 [cited 2021 Aug 22]. Available from: https://www.who.int/publications/i/item/9789240013131.

3) Das D, Baker M, Calder L. Tuberculosis epidemiology in New Zealand: 1995-2004. N Z Med J. 2006 Oct 13;119(1243).

4) Bevin J, Dalton S, Wakeman C, Perry W. Diagnosis of abdominal tuberculosis in Christchurch New Zealand: a case series. N Z Med J. 2018 Apr 13;131:48-52.

5) Peto HM, Pratt RH, Harrington TA, LoBue PA, Armstrong LR. Epidemiology of extrapulmonary tuberculosis in the United States,1993–2006.Clinical Infectious Diseases. 2009 Nov 15;49(9):1350-7.

6) Chávez RI, Rivera AB. Gastrointestinal and peritoneal tuberculosis. Revista de gastroenterologia del Peru: organo oficial de la Sociedad de Gastroenterologia del Peru. 1994;14(2):99-113.

7) Ministry of Health [Internet]. New Zealand; 2019 Aug [cited 2020 April 21]. Tuberculosis, Part of the Communicable Disease Control Manual. Available from: https://www.health.govt.nz/our-work/diseases-and-conditions/communicable-disease-control-manual/tuberculosis

8) Sanai FM, Bzeizi KI. Systematic review: tuberculous peritonitis–presenting features, diagnostic strategies and treatment. Alimentary pharmacology & therapeutics. 2005 Oct;22(8):685-700.

9) Chow KM, Chow VC, Hung LC, Wong SM, Szeto CC. Tuberculous peritonitis–associated mortality is high among patients waiting for the results of mycobacterial cultures of ascitic fluid samples. Clinical infectious diseases. 2002 Aug 15;35(4):409-13.

10) Cheng VC, Yam WC, Hung IF, Woo PC, Lau SK, Tang BS, Yuen KY. Clinical evaluation of the polymerase chain reaction for the rapid diagnosis of tuberculosis. Journal of clinical pathology. 2004 Mar 1;57(3):281-5.

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