Abdominal tuberculosis Revisited

Clinical scenario :
A 23-year-old male presented with fever and malaise of 2 weeks duration.Patient was put on inj Ceftriaxone 1.5 gm bid for 15 days by a physician but the patient had no relief in his symptoms and presented to our centre.
On examination, he was conscious, oriented and hemodynamically stable. There was no icterus or lymphadenopathy. JVP was normal.
Chest and CVS were normal.
Abdominal examination showed a doughy feel of the abdomen and shifting dullness was positive.
Investigations:

• The patient had normal hemogram but ESR was raised to 55mm for the first hour
• LFT was normal.
• Ultrasound abdomen was done which revealed moderate ascites with mated lymph nodes
•   The ascitic fluid: Straw coloured with protein >3g/dl, and total cell count of 150-4000/ μl, consisting predominantly of lymphocytes. 
• ADA was  strongly Positive 
• CT scan abdomen: Confirmed mated lymphadenopathy Ascites

Hospital course: Patient was started on Antitubercular treatment and his fever settled and is following our OPD for the last 6 months now.

Teaching message:

• Practice evidence-based medicine.
• Evaluate before starting antibiotics
• Peritoneal tuberculosis is the most common presentation of abdominal tuberculosis and includes the involvement of the peritoneal cavity, mesenterium and omentum .
• The lymph node disease pattern is variable at CT, most frequently demonstrating lymph node enlargement (40-60%) with hypoattenuation in the centre and hyperattenuation in the periphery, after intravenous contrast injection, which is typical but not pathognomonic of caseous necrosis 
• The ascites in TB shows serum-ascites albumin gradient is less than 1.1 g/dl. The yield of organisms on smear and culture is low. Staining for acid-fast bacilli is positive in less than 3 per cent of cases. A positive culture is obtained in less than 20 per cent of cases, and it takes 6-8 wk for the mycobacterium colonies to appear.  

• Lymphoma, metastasis, pyogenic infection and Whipple's disease are the main differential diagnoses.

Fig A & B CT scan showing abdominal Tuberculosis lymphadenopathy 

• Tuberculosis (TB) is a re-emerging global emergency which is further complicated by AIDS/HIV infection and the use of immunosuppressant drugs.

• The value of laparoscopy in the diagnosis of abdominal tuberculosis is well established. Some authors consider it as the most specific diagnostic test for abdominal TB with its advantage of histological confirmation.

Fig 3 Laparoscopic view of Abdominal Tuberculosis 

Further reading click the Link:   A Mohamed, N Bhat, M Abukhater, M Riaz. Role of Laparoscopy in Diagnosis of Abdominal Tuberculosis.. The Internet Journal of Infectious Diseases. 2009 Volume 8 Number 2.

This case was contributed by 
Dr Mir Ghulam Mohammad
Senior Consultant Anesthesiologist 
& Intensive care Physician
J&K Health services Kashmir