The remaining 5 patients were diagnosed by ascitic fluid diagnostic features (exudative fluid, predominance of lymphocytes, and no tumour cells), positive tuberculous skin test and/or tuberculous exposure, and radiological imaging, suggestive of TB and a positive response to antituberculous treatment.
Antituberculous treatment was given to all of the patients. It consisted of isoniazid, rifampicin, ethambutol, and pyrazinamide for 2 months and isoniazid and rifampicin for a period of 9 to 12 months without any complications. No patient showed a relapse of disease during the follow-up period (6–15 months).
Abdominal TB is, for the most part, caused by M bovis, and the major route of transmission is the ingestion of infected milk or milk products. Abdominal TB may involve the gastrointestinal tract, peritoneum, lymph nodes, or solid viscera; however, peritoneum and abdominal lymph nodes are the most common sites. In the paediatric literature, abdominal TB has been described infrequently in 2 of 1000 and 5 of 1700 patients in industrialised countries (6–8); this is attributable to the eradication of M bovis by slaughter of infected cattle and pasteurisation of milk. However, in developing countries, this form of TB is still present. In our study, the most common sites were peritoneum and lymph nodes. One patient had multifocal disease with liver, spleen, CNS, and pleural involvement, and another patient had intestinal, lymph node, spleen, lung, and pleural involvement; these presentations are rare. The mean age of presentation in our study (9.8 years) was comparable to the reported common age group (6–11 years) (9,10).
Abdominal TB spreads through close contact and a positive family history is likely in most cases; however, in our study, positive family history was found only in 1 patient. We can speculate that the major cases of abdominal TB are probably due to M bovis, which has not been eradicated in Tunisia, and children are contaminated by drinking nonpasteurized milk.
The clinical spectrum of abdominal TB is wide and nonspecific. The initial symptoms of abdominal TB are nonspecific, such as abdominal distension caused by ascites, pain, fever, and weight loss (11–14). The clinical presentation of our patients was similar, and abdominal pain and distension were the most common presenting complaint in the present study (9 patients). Fever was seen in 4 and weight loss with asthenia in 7 patients.
TB is regarded as a disease with insidious onset and chronic presentation, most patients having symptoms for a few weeks to months, sometimes years; Lambrianides et al (15) even stated that TB is rarely an emergency. However, in our study, 1 patient presented with acute abdomen. Abdominal masses mimicking Burkitt lymphoma were reported in a paediatric group; this presentation makes the diagnosis of TB more difficult. In our series, 2 patients presented with abdominal mass mimicking lymphoma and the defined diagnosis was obtained by histopathological studies. Because of the nonspecific symptoms and physical findings, diagnosis is often delayed. Delay may range from 1 month to 6 years (16–18); mean delay in the present study was 3 months (range 4 days–1 year).
Abdominal ultrasonography is a noninvasive and easily available method of detecting abdominal fluid and lymphadenopathy. It can be used for the diagnosis of peritoneal TB as a first-step investigation method. The most specific sonographic findings of abdominal TB are ascites with fine septations and lymphadenopathy with hypoechogenic centres indicating caseating necrosis (19).
Barium studies are sensitive to ileocaecal and colonic lesions (20). Double-contrast barium enema in ileocaecal TB shows a shortened ascending colon, deformed (irregular, shortened, and narrowed) caecum, deformed and incompetent ileocaecal valve, dilated ileum, and a distorted ileocaecal junction with increased (obtuse) ileocaecal angle (21). Barium studies were performed in 4 patients and revealed ileocaecal changes in 1.
Analysis of ascitic fluid in peritoneal TB often shows exudative features with lymphocytic predominance and serum ascites albumin gradient of <1.1 g/dL (22). The ascites samples acquired from 8 patients had exudative features. High levels of adenosine deaminase in the ascitic fluid were shown to be compatible with the diagnosis of peritoneal TB with high sensitivity (100%) and specificity (97%); however, the analysis of adenosine deaminase activity is expensive and is not available in Tunisia (22–24).
In our study, abdominal TB could be confirmed bacteriologically only in 3 patients. Other studies (25–27) have also faced similar difficulties in the microbiological confirmation of the disease; most of them relied on histopathological diagnosis.
In children with relevant history, laparoscopy has been found to be a rewarding investigation tool (28) with a high success rate in histopathological diagnosis on the tissues retrieved for biopsy. It has brought down the rate of unnecessary laparotomies in children, thanks to practice and experience, its role may also be extended to other therapeutic purposes (stricturoplasty and adhesiolysis). In our study, histopathological diagnosis by laparotomy was performed in 3 patients.
Classical 4-drug chemotherapy was used in all children in the present study and a favourable outcome was observed in 12. Neurological sequelae were observed in only 1 patient who had multifocal TB with CNS involvement.
Abdominal TB should be strongly considered in children in the 5- to 10-year-old age group presenting with vague abdominal pain, weight loss, low-grade fever, and abdominal distension. In areas with a low prevalence of abdominal TB, tissue or microbiological diagnosis is highly justified before the start of a course of therapy. However, in places where the disease is common and confirmatory investigations are inadequately available, the treatment may be initiated, based on strong clinical diagnosis and supportive investigations. In such situations, it is the response to therapy that indirectly proves the diagnosis.
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Keywords:© 2010 Lippincott Williams & Wilkins, Inc.
abdominal; children; lymph node; peritoneal; tuberculosis