Abdominal tuberculosis is not uncommon in developing countries (1-3) and is still found in developed countries, particularly among immigrants (4-6). In general, it can occur as either tuberculous peritonitis or gastrointestinal tuberculosis, but both manifestations may coexist in the same patient. It may present as acute gastrointestinal obstruction or perforation, simulating acute appendicitis, acute peritonitis, enterocolitis, or intersusception (7-9). Early diagnosis in children may be difficult, largely because of variable vague symptoms and nonspecific signs (7-9).
Tuberculous peritonitis accounts for only 0.5-1% of patients admitted to hospitals for tuberculosis but is considered one of the important diseases of the peritoneum (1,10). Although it can occur at any age, it is chiefly a disease of young adults and females are more affected (11). There are very few reports of tuberculous peritonitis in children. We report two patients who presented with ascites, abdominal pain, fever, and weight loss and in whom laparoscopy and biopsy of peritoneum showed features consistent with tuberculosis.
A 5-year-old Sudanese girl was seen with a 4-month history of diffuse abdominal pain and distension, fever, anorexia, and weight loss (4 kg). She had no other symptoms. Apart from treated tuberculosis in one of her aunts, there was no significant family or past history. The patient had had all the recommended vaccinations, including Bacillus Calmette-Guerin (BCG) at birth.
On physical examination she was mildly pale, afebrile, had no lymphadenopathy; weighed 13 kg, and her height was 93 cm (both were below the 5th percentile). The abdomen was mildly tender with moderate to massive ascites but no organomegaly; the rest of the physical examination was normal.
The laboratory investigations revealed mild hypochromic normocytic anemia (Hb 10.3 g/dl), normal leukocyte and differential counts, and an erythrocyte sedimentation rate (ESR) of 68 mm in 1 h. Hemoglobin electrophoresis, glucose-6-phosphate dehydrogenase (G6PD), and various biochemical parameters including serum iron were normal. Tuberculin test using 3 units of purified protein derivative (PPD) was strongly positive (over 20 mm at 48 h). The ascitic fluid was turbid and yellow in color; protein content was 4.5 g/dl and LDH was 775 U/L; the cells were predominantly lymphocytes; there were no malignant cells or acid-fast bacilli (AFB). Microscopy and cultures of sputum, gastric aspirate, and ascitic fluid were negative for AFB. HIV test was negative. Chest x-ray and barium meal and follow through were normal. Sonography and computerized tomograph (CT) scan of the abdomen showed paraaortic lymphadenopathy, adhesions, calcification, and ascites.
A diagnostic laparoscopy performed under general anesthesia showed moderate ascites, diffuse adhesions, and multiple pinhead-size whitish nodules involving the entire abdominal cavity highly suggestive of tuberculous peritonitis (Fig. 1). Histological examination of these nodules confirmed tuberculosis (Fig. 2). She was treated with isoniazide (INH), rifampicin, ethambutol, pyrazinamide and vitamin B6. At reevaluation after 3 months, she was afebrile, asymptomatic, and had gained 4.5 kg. On completion of therapy, repeat abdominal CT scan was completely normal.
A 10-year-old Saudi girl, presented with a 6-month history of recurrent epigastric pain, anorexia, weight loss (6.8 kg), low grade fever, and nausea. She had completed all her vaccinations including BCG given at birth. There was no significant past or family history.
On examination, she looked fairly well, was mildly pale, afebrile, and had small shotty lymph nodes in both submandibular regions. Her weight was 20.4 kg and height 119.5 cm (both were below the 5th percentile). The abdomen was distended, and she had hepatomegaly and ascites but not splenomegaly. The rest of her physical examination was unremarkable.
The laboratory investigations revealed mild hypochromic microytic anemia (Hb 10.8 g/dl), normal leukocyte and differential counts, sickle cell trait, and normal G6DP; ESR was 65 mm in 1 h. Microscopy and cultures of sputum and gastric aspirate were negative for AFB. Chest x-ray and barium meal and follow through were unremarkable. Using 5 units of PPD, tuberculin skin test was markedly positive (35 mm induration). Ascitic aspirate was yellowish in color with a protein content of 4.7 g/dl and LDH of 536 U/L; the cells were predominantly lymphocytes, and there were no malignant cells or AFB. HIV test was negative. The remaining biochemical tests including serum iron were normal.
Abdominal sonography and CT scan showed generalized lymphadenopathy with scattered calcification, hepatomegaly, and ascites. Under general anesthesia, diagnostic laparoscopy showed mild to moderate ascites, small scattered whitish nodules, involving the entire abdominal cavity and diffuse, marked adhesions-all features compatible with tuberculous peritonitis, which was confirmed histologically. She was treated as in case 1. After 3 months therapy, she had improved markedly; she was afebrile, had gained 5.7 kg, and ESR was 10 mm/hr. A CT scan after 12 months showed no ascites or organomegally and marked regression of the enlarged lymph nodes.
Tuberculous peritonitis, although a common disease of the peritoneum, is a rare manifestation of tuberculosis. It occurs in exudative or plastic forms characterized by ascites or marked adhesions, respectively, and their frequency of occurrence varies in different reports (8-13). The presenting symptoms of peritoneal tuberculosis vary, but none is diagnostically definitive. Our two patients presented with vague abdominal pain with distension, malaise, fever, and weight loss, nonspecific features that have been found in tuberculous peritonitis (7-9,12). In addition to tuberculosis, the differential diagnosis of these features would also include neoplasm and chronic fibroplastic inflammation of the liver. Biochemical, hematological, and bacteriological tests tend to be of limited help in making a definite diagnosis. The presence of anemia in our patients seems to be a constant finding but is not of diagnostic significance, particularly, in our environment (8,9,12-14). The chest radiographs were unremarkable, but in 10-50% of cases they may show evidence of associated pulmonary tuberculosis (8,9,12). The observation of paraaortic lymphadenopathy with calcification in the abdominal CT scan confirms the findings of others (7-9). Hepatomegaly, which were observed in one case, is not a frequent finding. The main positive laboratory tests in our cases were a rinsed ESR, strongly positive PPD test, and an exudative ascites. Positive PPD may be present in only 50% of children who have abdominal tuberculosis (8,13), and the strongly positive PPD, as found in our patients, would be highly suggestive of tuberculosis. However, our patients had had BCG at birth and so an additional more specific evidence of tuberculosis was sought to confirm the diagnosis, hence the laparascopy. The laparoscopic features observed in the two cases, although consistent with tuberculosis, could also be seen in other conditions such as carcinomatous peritonitis, miliary Crohn's disease, starch peritonitis, schistosomiasis, and rare chronic granulomatous peritonitis (11).
The definitive diagnosis of tuberculous peritonitis requires either positive histology or microbiology (15). In our two cases, and biopsies taken from the peritoneum were consistent with tuberculosis; microbiological examination for AFB was, however, negative. The success rate of bacterial identification in other series varies from 4% to 75% (15-17). Procedures for obtaining peritoneal biopsy vary (4,18,19) but various reports indicate that laporoscopy is the best (1,4,8,20,21). Complications have been rare and minor (1,20,21), and we did not encounter any in our cases.
The recommended therapy for intestinal tuberculosis consists of four of the first line antituberculous drugs for 3 months, then two drugs for a total of 12 months (22). This regimen, which was used in our two cases, usually leads to a dramatic improvement within 3 months. Short-course chemotherapy for 6 months has also been found to be safe and effective (13).
In conclusion, peritoneal tuberculosis is relatively rare in children compared to adults but in endemic areas it should be considered in any child presenting with nonspecific symptoms, particularly ascites, failure to thrive, anemia, and the other features manifested in these patients.
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