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Laya BF, Concepcion NDP, Andronikou S, Abdul Manaf Z, Atienza MIM, Sodhi KS. Imaging recommendations and algorithms for pediatric tuberculosis: part 2-extrathoracic tuberculosis. Pediatr Radiol 2023; 53:1782-1798. [PMID: 37074457 DOI: 10.1007/s00247-023-05650-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 03/16/2023] [Accepted: 03/17/2023] [Indexed: 04/20/2023]
Abstract
Despite advances in diagnosis and treatment in recent years, tuberculosis (TB) remains a global health concern. Children are amongst the most vulnerable groups affected by this disease. Although TB primarily involves the lungs and mediastinal lymph nodes, it can affect virtually any organ system of the body. Along with clinical history combined with physical examination and laboratory tests, various medical imaging tools help establish the diagnosis. Medical imaging tests are also helpful for follow-up during therapy, to assess complications and exclude other underlying pathologies. This article aims to discuss the utility, strengths and limitations of medical imaging tools in the evaluation of suspected extrathoracic TB in the pediatric population. Imaging recommendations for the diagnosis will be presented along with practical and evidence-based imaging algorithms to serve as a guide for both radiologists and clinicians.
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Affiliation(s)
- Bernard F Laya
- Section of Pediatric Radiology, Institute of Radiology, St. Luke's Medical Center - Quezon City, 279 E. Rodriguez Sr. Ave., Quezon City, 1112, Philippines
- Department of Radiology, St. Luke's Medical Center College of Medicine William H. Quasha Memorial, Quezon City, Philippines
- Section of Pediatric Radiology, Institute of Radiology, St. Luke's Medical Center - Global City, Rizal Drive cor. 32nd St. and 5th Ave., 1634, Taguig, Philippines
| | - Nathan David P Concepcion
- Section of Pediatric Radiology, Institute of Radiology, St. Luke's Medical Center - Quezon City, 279 E. Rodriguez Sr. Ave., Quezon City, 1112, Philippines.
- Section of Pediatric Radiology, Institute of Radiology, St. Luke's Medical Center - Global City, Rizal Drive cor. 32nd St. and 5th Ave., 1634, Taguig, Philippines.
| | - Savvas Andronikou
- Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, and the Children's Hospital of Philadelphia, Philadelphia, USA
| | - Zaleha Abdul Manaf
- Al Islam Specialist Hospital, Kuala Lumpur, Malaysia
- Faculty of Medicine, Bioscience & Nursing, MAHSA University, Kuala Lumpur, Malaysia
| | - Maria Isabel M Atienza
- Institute of Pediatrics and Child Health, St Luke's Medical Center - Quezon City, 279 E. Rodriguez Sr. Ave., Quezon City, 1112, Philippines
- Department of Pediatrics, St. Luke's Medical Center College of Medicine William H. Quasha Memorial, Quezon City, Philippines
| | - Kushaljit Singh Sodhi
- Department of Radiodiagnosis, PGIMER, Chandigarh, India
- Mallinckrodt Institute of Radiology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
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Rathi V, Yadav V, Deep BS, Bhatt S, Giri S. CT Appearances in Treated Abdominal Tuberculosis: A Radiologist's Dilemma. JOURNAL OF GASTROINTESTINAL AND ABDOMINAL RADIOLOGY 2021. [DOI: 10.1055/s-0041-1736496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Abstract
Objective To study the CT appearances of the abdomen after completion of antitubercular therapy (ATT) in adult patients.
Methods Multidetector CT scan abdomen was done in 20 adults within 1 month of completing ATT. CT appearances were compared with pretreatment scans which were available in 7 cases.
Results We found that residual ileocecal wall thickening and enhancement was significant (p < 0.05) after treatment in cases of ileocecal tuberculosis (TB). Mild decrease in wall thickness and diameter of the involved dilated small bowel loops was seen. Numerous large, matted nodes with necrosis persisted in the mesentery and retroperitoneum in treated TB, but reduction in the size of nodes was appreciated.
Conclusion Our results help to fill the vacuum in the database of CT appearances in treated abdominal TB. Persistence of bowel changes and lymph nodes should not be mistaken for recurrence of TB or residual disease.
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Affiliation(s)
- Vinita Rathi
- Department of Radio Diagnosis, University College of Medical Sciences & GTB Hospital, Dilshad Garden, Delhi, India
| | - Varun Yadav
- Department of Radio diagnosis, University College of Medical Sciences, Delhi, India
| | - Bonny S. Deep
- Department of Radio diagnosis, University College of Medical Sciences, Delhi, India
- Department of Radio diagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Shuchi Bhatt
- Department of Radio diagnosis, University College of Medical Sciences, Delhi, India
| | - Subhash Giri
- Department of Medicine, University College of Medical Sciences & GTB Hospital, Dilshad Garden, Delhi, India
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James V, Samuel J, Ong GYK. Pediatric Abdominal Tuberculosis With Calcified Intra-abdominal Lymph Nodes Identified by Point-of-Care Ultrasound. Pediatr Emerg Care 2021; 37:226-229. [PMID: 33780407 DOI: 10.1097/pec.0000000000002320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Tuberculosis of the abdomen is one of the most common extrapulmonary manifestations of tuberculosis. Even in areas where tuberculosis is endemic, intra-abdominal tuberculous can pose a diagnostic and management challenge because of the lack of presence of overt clinical signs and availability of expertise for point of care diagnostics. Point-of-care ultrasound (POCUS) of the abdomen performed by emergency physicians is increasingly being used for a variety of clinical presentations to facilitate accurate diagnoses in the emergency department. CASE REPORT We describe the case of a patient presenting to the pediatric emergency department with acute abdominal pain, in whom POCUS helped expedite the diagnosis of abdominal tuberculosis. CONCLUSIONS In the right clinical setting, the concurrent presence of intra-abdominal lymphadenopathy, ascites, mesenteric thickening, ileocecal thickening, and splenic microabscesses on ultrasound imaging should lead to consideration of the diagnosis of intra-abdominal tuberculosis. Although typically diagnosed on computed tomography or magnetic resonance imaging, in our case, POCUS helped facilitate the bedside diagnosis of abdominal tuberculosis in the emergency department.
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Affiliation(s)
- Vigil James
- From the Children's Emergency, KK Women's and Children's Hospital, Singapore
| | - John Samuel
- Department of Radiodiagnosis, Christian Fellowship Hospital, Oddanchatram, Tamilnadu, India
| | - Gene Yong-Kwang Ong
- From the Children's Emergency, KK Women's and Children's Hospital, Singapore
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Salman MA, Salman AA, Hamdy A, Abdel Samie RM, Ewid M, Abouregal TE, Seif El Nasr SM, Elkassar H, Abdallah A, Yousef M, Mohammed Ismail AA, Alsebaey A, Matter M. Predictive value of omental thickness on ultrasonography for diagnosis of unexplained ascites, an Egyptian centre study. Asian J Surg 2020; 43:13-19. [PMID: 30910377 DOI: 10.1016/j.asjsur.2019.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 02/26/2019] [Accepted: 03/04/2019] [Indexed: 02/08/2023] Open
Abstract
Etiology of ascites of unknown origin varies with geographic area and ethnic origin. Tuberculous peritonitis and peritoneal carcinomatosis constitute a considerable proportion of patients. Differentiation between both is a major challenge. The role of omental thickness (OT) by ultrasonography to predict risk of malignancy in unexplained ascites. This prospective study was done at Kasr Alainy School of Medicine, Cairo University and included 100 adults with unexplained ascites and thickened omentum (>15 mm) on ultrasonography. An expert performed ultrasonography to assess peritoneum and peritoneal cavity and measure OT. Ascites was assessed regarding volume, echogenicity, and loculation. The ascitic fluid was analyzed to measure lactate dehydrogenase, adenosine deaminase, and total leukocytic count. Laparoscopic exploration with biopsy was done for final diagnosis that divided the patients into; TB Group (n = 44) and peritoneal carcinomatosis group (n = 56). Main Outcome Measures were to determine degree of omental thickness as a predictor of malignancy risk in unexplained ascites and other ultrasonographic features to predict malignancy risk including omental echogenicity and results of diagnostic ascitic tapping. We found that OT was greater in the PC group compared to the TB group (24.6 ± 4.6 mm vs. 17.9 ± 3.0 mm, respectively, p < 0.001). Higher frequency of hypoechogenicity, irregular peritoneal surface, omental cakes, and lymph nodes was seen in PC Group. ADA, TLC, and relative lymphocyte count were higher in TB group. Omental thickness ≥19.5 mm has a sensitivity of 89.3%, specificity of 84.1% to diagnose PC. We can conclude that omental thickness >19 mm is a sensitive and specific predictor of malignancy in patients with unexplained ascites.
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Affiliation(s)
| | | | - Ahmed Hamdy
- Internal Medicine Department, Faculty of Medicine, Cairo University, Egypt.
| | | | - Mohammed Ewid
- Internal Medicine Department, Cairo University, Egypt; Sulaiman Al Rajhi Colleges, Saudi Arabia.
| | | | | | - Hesham Elkassar
- Internal Medicine Department, Faculty of Medicine, Cairo University, Egypt.
| | - Ahmed Abdallah
- General Surgery Department, Faculty of Medicine, Cairo University, Egypt.
| | - Mohamed Yousef
- Tropical Medicine Department, Faculty of Medicine, Cairo University, Egypt.
| | | | - Ayman Alsebaey
- Gastroenterology and Hepatology Department, National Liver Institute, Menoufia University, Egypt.
| | - Mohamed Matter
- Radiodiagnosis Department, Faculty of Medicine, Alazhar University, Egypt.
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Salman MA, Salman AA, Hamdy A, Abdel Samie RM, Ewid M, Abouregal TE, Seif El Nasr SM, Elkassar H, Abdallah A, Yousef M, Mohammed Ismail AA, Alsebaey A, Matter M. Predictive value of omental thickness on ultrasonography for diagnosis of unexplained ascites, an Egyptian centre study. Asian J Surg 2020. [DOI: https:/doi.org/10.1016/j.asjsur.2019.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
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Salman MA, Salman AA, Hamdy A, Abdel Samie RM, Ewid M, Abouregal TE, Seif El Nasr SM, Elkassar H, Abdallah A, Yousef M, Mohammed Ismail AA, Alsebaey A, Matter M. Predictive value of omental thickness on ultrasonography for diagnosis of unexplained ascites, an Egyptian centre study. Asian J Surg 2020. [DOI: https://doi.org/10.1016/j.asjsur.2019.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
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Long B, Liang SY, Koyfman A, Gottlieb M. Tuberculosis: a focused review for the emergency medicine clinician. Am J Emerg Med 2019; 38:1014-1022. [PMID: 31902701 DOI: 10.1016/j.ajem.2019.12.040] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 12/19/2019] [Accepted: 12/19/2019] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Tuberculosis (TB) is a common disease worldwide, affecting nearly one-third of the world's population. While TB has decreased in frequency in the United States, it remains an important infection to diagnose and treat. OBJECTIVE This narrative review discusses the evaluation and management of tuberculosis, with an emphasis on those factors most relevant for the emergency clinician. DISCUSSION TB is caused by Mycobacterium tuberculosis and is highly communicable through aerosolized particles. A minority of patients will develop symptomatic, primary disease. Most patients will overcome the initial infection or develop a latent infection, which can reactivate. Immunocompromised states increase the risk of primary and reactivation TB. Symptoms include fever, prolonged cough, weight loss, and hemoptysis. Initial diagnosis often includes a chest X-ray, followed by serial sputum cultures. If the patient has a normal immune system and a normal X-ray, active TB can be excluded. Newer tests, including nucleic acid amplification testing, can rapidly diagnose active TB with high sensitivity. Treatment for primary and reactivation TB differs from latent TB. Extrapulmonary forms can occur in a significant proportion of patients and involve a range of different organ systems. Patients with human immunodeficiency virus are high-risk and require specific considerations. CONCLUSIONS TB is a disease associated with significant morbidity and mortality. The emergency clinician must consider TB in the appropriate setting, based on history and examination. Accurate diagnosis and rapid therapy can improve patient outcomes and reduce the spread of this communicable disease.
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Affiliation(s)
- Brit Long
- Brooke Army Medical Center, Department of Emergency Medicine, 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States.
| | - Stephen Y Liang
- Division of Emergency Medicine, Washington University School of Medicine, Saint Louis, MO, United States; Division of Infectious Diseases, Washington University School of Medicine, Saint Louis, MO, United States.
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas, TX 75390, United States
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States
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Van Hoving DJ, Griesel R, Meintjes G, Takwoingi Y, Maartens G, Ochodo EA. Abdominal ultrasound for diagnosing abdominal tuberculosis or disseminated tuberculosis with abdominal involvement in HIV-positive individuals. Cochrane Database Syst Rev 2019; 9:CD012777. [PMID: 31565799 PMCID: PMC6766789 DOI: 10.1002/14651858.cd012777.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Accurate diagnosis of tuberculosis in people living with HIV is difficult. HIV-positive individuals have higher rates of extrapulmonary tuberculosis and the diagnosis of tuberculosis is often limited to imaging results. Ultrasound is such an imaging test that is widely used as a diagnostic tool (including point-of-care) in people suspected of having abdominal tuberculosis or disseminated tuberculosis with abdominal involvement. OBJECTIVES To determine the diagnostic accuracy of abdominal ultrasound for detecting abdominal tuberculosis or disseminated tuberculosis with abdominal involvement in HIV-positive individuals.To investigate potential sources of heterogeneity in test accuracy, including clinical setting, ultrasound training level, and type of reference standard. SEARCH METHODS We searched for publications in any language up to 4 April 2019 in the following databases: MEDLINE, Embase, BIOSIS, Science Citation Index Expanded (SCI-EXPANDED), Social Sciences Citation Index (SSCI), Conference Proceedings Citation Index- Science (CPCI-S), and also ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform to identify ongoing trials. SELECTION CRITERIA We included cross-sectional, cohort, and diagnostic case-control studies (prospective and retrospective) that compared the result of the index test (abdominal ultrasound) with one of the reference standards. We only included studies that allowed for extraction of numbers of true positives (TPs), true negatives (TNs), false positives (FPs), and false negatives (FNs). Participants were HIV-positive individuals aged 15 years and older. A higher-quality reference standard was the bacteriological confirmation of Mycobacterium tuberculosis from any clinical specimen, and a lower-quality reference standard was a clinical diagnosis of tuberculosis without microbiological confirmation. We excluded genitourinary tuberculosis. DATA COLLECTION AND ANALYSIS For each study, two review authors independently extracted data using a standardized form. We assessed the quality of studies using a tailored Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. We used the bivariate model to estimate pooled sensitivity and specificity. When studies were few we simplified the bivariate model to separate univariate random-effects logistic regression models for sensitivity and specificity. We explored the influence of the type of reference standard on the accuracy estimates by conducting separate analyses for each type of reference standard. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We included 11 studies. The risks of bias and concern about applicability were often high or unclear in all domains. We included six studies in the main analyses of any abnormal finding on abdominal ultrasound; five studies reported only individual lesions.The six studies of any abnormal finding were cross-sectional or cohort studies. Five of these (83%) were conducted in low- or middle-income countries, and one in a high-income country. The proportion of participants on antiretroviral therapy was none (1 study), fewer then 50% (4 studies), more than 50% (1 study), and not reported (5 studies). The first main analysis, studies using a higher-quality reference standard (bacteriological confirmation), had a pooled sensitivity of 63% (95% confidence interval (CI) 43% to 79%; 5 studies, 368 participants; very low-certainty evidence) and a pooled specificity of 68% (95% CI 42% to 87%; 5 studies, 511 participants; very low-certainty evidence). If the results were to be applied to a hypothetical cohort of 1000 people with HIV where 200 (20%) have tuberculosis then:- About 382 individuals would have an ultrasound result indicating tuberculosis; of these, 256 (67%) would be incorrectly classified as having tuberculosis (false positives).- Of the 618 individuals with a result indicating that tuberculosis is not present, 74 (12%) would be incorrectly classified as not having tuberculosis (false negatives).In the second main analysis involving studies using a lower-quality reference standard (clinical diagnosis), the pooled sensitivity was 68% (95% CI 45% to 85%; 4 studies, 195 participants; very low-certainty evidence) and the pooled specificity was 73% (95% CI 41% to 91%; 4 studies, 202 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS In HIV-positive individuals thought to have abdominal tuberculosis or disseminated tuberculosis with abdominal involvement, abdominal ultrasound appears to have 63% sensitivity and 68% specificity when tuberculosis was bacteriologically confirmed. These estimates are based on data that is limited, varied, and low-certainty.The low sensitivity of abdominal ultrasound means clinicians should not use a negative test result to rule out the disease, but rather consider the result in combination with other diagnostic strategies (including clinical signs, chest x-ray, lateral flow urine lipoarabinomannan assay (LF-LAM), and Xpert MTB/RIF). Research incorporating the test into tuberculosis diagnostic algorithms will help in delineating more precisely its value in diagnosing abdominal tuberculosis or disseminated tuberculosis with abdominal involvement.
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Affiliation(s)
- Daniel J Van Hoving
- University of Cape Town and Stellenbosch UniversityDivision of Emergency MedicineFaculty of Health Sciences, University of Cape TownAnzio Road ObservatoryCape TownSouth Africa7701
| | - Rulan Griesel
- University of Cape TownDivision of Clinical Pharmacology, Department of MedicineCape TownSouth Africa
| | - Graeme Meintjes
- University of Cape TownDepartment of MedicineCape TownSouth Africa
| | - Yemisi Takwoingi
- University of BirminghamInstitute of Applied Health ResearchEdgbastonBirminghamUKB15 2TT
| | - Gary Maartens
- University of Cape TownDivision of Clinical Pharmacology, Department of MedicineCape TownSouth Africa
| | - Eleanor A Ochodo
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Faculty of Medicine and Health SciencesPO Box 241Cape TownSouth Africa8000
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Dawani A, Gupta AK, Jana M. Imaging in Pediatric Extra-Pulmonary Tuberculosis. Indian J Pediatr 2019; 86:459-467. [PMID: 30697676 DOI: 10.1007/s12098-019-02858-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 01/03/2019] [Indexed: 12/16/2022]
Abstract
Extrapulmonary tuberculosis in children tends to be more severe than the adults. It can affect almost any organ system of the body. The clinical manifestations are often non-specific. Imaging findings are also not always very specific. This article describes the imaging spectrum of pediatric extrapulmonary tuberculosis.
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Affiliation(s)
- Anuradha Dawani
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Arun Kumar Gupta
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Manisha Jana
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, 110029, India.
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Moreno-Corrales M, Gómez-Landa F, Sánchez-Valdivieso E. Tuberculosis tubaria y peritoneal que simula carcinomatosis. Linfopenia con trombocitosis como auxiliar en el diagnóstico diferencial. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2018. [DOI: 10.1016/j.gine.2016.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Clinical and laboratory presentation of abdominal tuberculosis in Shillong, Meghalaya: Experience from Northeast India. INDIAN JOURNAL OF MEDICAL SPECIALITIES 2017. [DOI: 10.1016/j.injms.2017.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Spalgais S, Agarwal U, Sarin R, Chauhan D, Yadav A, Jaiswal A. Role of routine abdominal ultrasonography in intensified tuberculosis case finding algorithms at HIV clinics in high TB burden settings. BMC Infect Dis 2017; 17:351. [PMID: 28521786 PMCID: PMC5437391 DOI: 10.1186/s12879-017-2433-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 04/30/2017] [Indexed: 04/19/2023] Open
Abstract
Background High proportion of TB in people living with HIV (PLHIV) is undiagnosed. Due to this active TB case finding is recommended for HIV clinics in high TB burden countries. Presently sputum examination and chest radiography are frontline tests recommended for HIV infected TB presumptives. Abdominal TB which occurs frequently in PLHIV may be missed even by existing programmatic intensified case finding protocols. This study evaluated the routine use of ultrasonography (USG) for active case finding of abdominal TB in HIV clinics. Methods Retrospective analysis of eight years’ data from an HIV Clinic in a TB hospital in India. Patients underwent chest x-ray, sputum examination, USG abdomen and routine blood tests at entry to HIV care. Case forms were scrutinized for diagnosis of TB, USG findings and CD4 cell counts. Abdominal TB was classified as probable or possible TB. Probable TB was based on presence of two major USG (abdomen) findings suggestive of active TB, or one major USG finding with at least two minor USG findings or at least two symptoms, or any USG finding with microbiologically confirmed active TB at another site. Possible TB was based on the presence of one major USG finding, or the presence of two minor USG findings with at least two symptoms. Bacteriological confirmation was not obtained. Results Eight hundred and eighty-nine people PLHIV underwent a baseline USG abdomen. One hundred and thirteen of 340 cases already diagnosed with TB and 87 of the 91 newly diagnosed with TB at time of HIV clinic registration had abdominal TB. Non-abdominal symptoms like weight loss, fever and cough were seen in 53% and 22% cases had no symptoms at all. Enlarged abdominal lymph nodes with central caseation, ascitis, splenic microabsesses, bowel thickening and hepatosplenomegaly were the USG findings in these cases. Conclusions Abdominal TB is a frequent TB site in PLHIV presenting with non-abdominal symptoms. It can be easily detected on basis of features seen on a simple abdominal ultrasound. Abdominal USG should be essential part of intensified TB case finding algorithms for HIV infected people living in high TB burden settings.
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Affiliation(s)
- Sonam Spalgais
- National Institute of TB and Respiratory Diseases, Sri Aurobindo Marg, New Delhi, 110030, India
| | - Upasna Agarwal
- National Institute of TB and Respiratory Diseases, Sri Aurobindo Marg, New Delhi, 110030, India. .,Kusuma School of Biological Sciences IIT Delhi, New Delhi, Hauz Khaz, 110016, India.
| | - Rohit Sarin
- National Institute of TB and Respiratory Diseases, Sri Aurobindo Marg, New Delhi, 110030, India
| | - Devesh Chauhan
- National Institute of TB and Respiratory Diseases, Sri Aurobindo Marg, New Delhi, 110030, India
| | - Anita Yadav
- National Institute of TB and Respiratory Diseases, Sri Aurobindo Marg, New Delhi, 110030, India
| | - Anand Jaiswal
- National Institute of TB and Respiratory Diseases, Sri Aurobindo Marg, New Delhi, 110030, India
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Shreshtha S, Ghuliani D. Abdominal tuberculosis: A retrospective analysis of 45 cases. Indian J Tuberc 2016; 63:219-224. [PMID: 27998492 DOI: 10.1016/j.ijtb.2016.09.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 09/15/2016] [Indexed: 12/15/2022]
Abstract
Abdominal tuberculosis is defined as infection of the peritoneum, hollow or solid abdominal organs with Mycobacterium tuberculosis. The peritoneum and the ileocaecal region are the most likely sites of infection and are involved in the majority of the cases by haematogenous spread or through swallowing of infected sputum from primary pulmonary tuberculosis. Pulmonary tuberculosis is apparent in less than half of the patients. Patients usually present with abdominal pain, and the cause is usually identified through a combination of radiologic, endoscopic, microbiologic, histologic and molecular techniques. Anti-microbial treatment is the same as for pulmonary tuberculosis. Surgery is occasionally required.
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Affiliation(s)
- Suruchi Shreshtha
- Assistant Professor, General Surgery, Dr Baba Saheb Ambedkar Medical College & Hospital, Delhi, India.
| | - Deepak Ghuliani
- Associate Professor, General Surgery, Maulana Azad Medfical College, Delhi, India.
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Chaudhary P, Kumar R, Ahirwar N, Nabi I, Gautam S, Munjewar C, Kumar A. A retrospective cohort study of 756 cases of abdominal tuberculosis: Two decades single centre experience. ACTA ACUST UNITED AC 2016; 63:245-250. [DOI: 10.1016/j.ijtb.2016.09.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 09/15/2016] [Indexed: 12/20/2022]
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Rockwood N, du Bruyn E, Morris T, Wilkinson RJ. Assessment of treatment response in tuberculosis. Expert Rev Respir Med 2016; 10:643-54. [PMID: 27030924 DOI: 10.1586/17476348.2016.1166960] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Antibiotic treatment of tuberculosis has a duration of several months. There is significant variability of the host immune response and the pharmacokinetic-pharmacodynamic properties of Mycobacterium tuberculosis sub-populations at the site of disease. A limitation of sputum-based measures of treatment response may be sub-optimal detection and monitoring of Mycobacterium tuberculosis sub-populations. Potential biomarkers and surrogate endpoints should be benchmarked against hard clinical outcomes (failure/relapse/death) and may need tailoring to specific patient populations. Here, we assess the evidence supporting currently utilized and future potential host and pathogen-based models and biomarkers for monitoring treatment response in active and latent tuberculosis. Biomarkers for monitoring treatment response in extrapulmonary, pediatric and drug resistant tuberculosis are research priorities.
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Affiliation(s)
- Neesha Rockwood
- a Department of Medicine , Imperial College London , London , UK.,b Clinical Infectious Diseases Research Initiative, Institute of Infectious Diseases and Molecular Medicine and Department of Medicine , University of Cape Town , Observatory , South Africa
| | - Elsa du Bruyn
- b Clinical Infectious Diseases Research Initiative, Institute of Infectious Diseases and Molecular Medicine and Department of Medicine , University of Cape Town , Observatory , South Africa
| | - Thomas Morris
- a Department of Medicine , Imperial College London , London , UK
| | - Robert J Wilkinson
- a Department of Medicine , Imperial College London , London , UK.,b Clinical Infectious Diseases Research Initiative, Institute of Infectious Diseases and Molecular Medicine and Department of Medicine , University of Cape Town , Observatory , South Africa.,c The Francis Crick Institute Mill Hill Laboratory , London , UK
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Abstract
Bowel ultrasound is cheap, relatively quick, allows dynamic evaluation of the bowel, has no radiation burden, is well tolerated by patients, and allows repeat imaging. Bowel ultrasound requires a systematic assessment of the entire bowel using high-frequency probes. In addition, hydrosonography and contrast-enhanced ultrasound may be performed. We present the normal sonographic appearances of large and small bowel and the sonographic appearances of acute appendicitis, Crohn's disease, celiac disease, intussusception, infectious enteritis, intestinal tuberculosis, small bowel ileus and obstruction, small bowel ischemia, and malignant tumors.
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Affiliation(s)
- Anita Wale
- Department of Radiology, St Georges Hospital, London, UK.
| | - James Pilcher
- Department of Radiology, St Georges Hospital, London, UK
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Abstract
Tuberculous peritonitis is a serious condition with rising prevalence in recent years. It is especially common in those patients with risk factors such as an immunocompromised state, chronic kidney disease, or cirrhosis/liver disease. Spread is typically hematogenous from pulmonary foci. We report on a 34-year-old man who presented with initial complaints of cough, low-grade fevers, abdominal pain, and nausea/vomiting. Chest x-ray showed a cluster of nodular opacities on the right upper lobe, and a CT scan showed diffuse thickening and nodularity of the omentum with prominent mesenteric lymph nodes, consistent with tuberculous peritonitis.
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Diagnostic value of multidetector computed tomography in differentiation of benign and malignant omental lesions. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2015. [DOI: 10.1016/j.ejrnm.2015.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Ketata W, Rekik WK, Ayadi H, Kammoun S. [Extrapulmonary tuberculosis]. REVUE DE PNEUMOLOGIE CLINIQUE 2015; 71:83-92. [PMID: 25131362 DOI: 10.1016/j.pneumo.2014.04.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 04/12/2014] [Accepted: 04/19/2014] [Indexed: 06/03/2023]
Abstract
Each year, there are more than eight million new cases of tuberculosis and 1.3 million deaths. There is a renewed interest in extrapulmonary forms of tuberculosis as its relative frequency increases. Among extrapulmonary organs, pleura and lymph nodes are the most common. Their diagnosis is often difficult and is based on clinical, radiological, bacteriological and histological findings. Extrapulmonary lesions are paucibacillary and samplings, in most cases, difficult to obtain, so diagnosis is often simply presumptive. Nucleic acid amplification tests, which are fast and specific, have greatly facilitated the diagnosis of some forms of extrapulmonary tuberculosis. However, their sensitivity is poor and a negative test does not eliminate the diagnosis. Treatment is the same as for pulmonary forms, but its duration is nine to 12 months for central nervous system and for bone tuberculosis. Corticosteroids are indicated in meningeal and pericardial localizations. Complementary surgery is used for certain complicated forms.
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MESH Headings
- Diagnosis, Differential
- Global Health
- Humans
- Incidence
- Pericarditis, Tuberculous/diagnosis
- Pericarditis, Tuberculous/epidemiology
- Prevalence
- Risk Factors
- Tuberculosis/diagnosis
- Tuberculosis/epidemiology
- Tuberculosis/mortality
- Tuberculosis/therapy
- Tuberculosis, Gastrointestinal/diagnosis
- Tuberculosis, Gastrointestinal/epidemiology
- Tuberculosis, Lymph Node/diagnosis
- Tuberculosis, Lymph Node/epidemiology
- Tuberculosis, Meningeal/diagnosis
- Tuberculosis, Meningeal/epidemiology
- Tuberculosis, Osteoarticular/diagnosis
- Tuberculosis, Osteoarticular/epidemiology
- Tuberculosis, Pleural/diagnosis
- Tuberculosis, Pleural/epidemiology
- Tuberculosis, Pulmonary/diagnosis
- Tuberculosis, Pulmonary/epidemiology
- Tuberculosis, Spinal/diagnosis
- Tuberculosis, Spinal/epidemiology
- Tuberculosis, Urogenital/diagnosis
- Tuberculosis, Urogenital/epidemiology
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Affiliation(s)
- W Ketata
- Service de pneumo-allergologie, CHU Hédi Chaker, faculté de médecine de Sfax, 3029 Sfax, Tunisie.
| | - W K Rekik
- Service de pneumo-allergologie, CHU Hédi Chaker, faculté de médecine de Sfax, 3029 Sfax, Tunisie
| | - H Ayadi
- Service de pneumo-allergologie, CHU Hédi Chaker, faculté de médecine de Sfax, 3029 Sfax, Tunisie
| | - S Kammoun
- Service de pneumo-allergologie, CHU Hédi Chaker, faculté de médecine de Sfax, 3029 Sfax, Tunisie
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Ileocecal, colonic, and peritoneal tuberculosis: role of imaging in diagnosis. A case report and literature review. J Med Ultrason (2001) 2014; 41:77-82. [PMID: 27277637 DOI: 10.1007/s10396-013-0468-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Accepted: 04/18/2013] [Indexed: 10/26/2022]
Abstract
Tuberculosis is a widespread infectious disease that still remains a deadly global health problem and a condition that is life-threatening if misdiagnosed. Extrapulmonary manifestations are prevalent in the endemic areas but limited to the immunocompromised and immigrants in economically developed areas. False diagnostic situations rely on non-specific investigatory findings, the wide spectrum of clinical manifestations, and problems in discriminating between inflammation and neoplasms of the bowel. For an early diagnosis, a high index of suspicion and correlation of clinical and imaging aspects, as well as findings from colonoscopy, tissue biopsy, and microbiologic assessments, are necessary. We present a case of a patient with non-specific abdominal symptoms, mimicking a clinical syndrome of neoplastic impregnation, finally diagnosed as ileal tuberculosis with peritoneal involvement. We stress the importance of ultrasonography as a primary method of investigation, having an important role in raising the suspicion of an infectious bowel disease, as well as the role of contrast-enhanced ultrasound examination.
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Allah MH, Salama ZA, El-Hindawy A, Al Kady N. Role of peritoneal ultrasonography and ultrasound-guided fine needle aspiration cytology/biopsy of extravisceral masses in the diagnosis of ascites of undetermined origin. Arab J Gastroenterol 2012; 13:116-24. [PMID: 23122452 DOI: 10.1016/j.ajg.2012.08.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2012] [Revised: 07/03/2012] [Accepted: 08/05/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND STUDY AIMS Ascites may be of undetermined origin despite comprehensive study. This study aimed to assess the accuracy and safety of conventional and interventional high-frequency peritoneal ultrasound in the diagnosis of patients with ascites of unclear origin. PATIENTS AND METHODS A total of 62 patients were prospectively enrolled; they underwent conventional (3.5-5MHz) and high-frequency (6-8MHz) transabdominal peritoneal ultrasound to suggest the nature of ascites supplemented by fine needle aspiration cytology (FNAC) of ascites and/or core biopsy of the omentum or other extra-visceral masses for final histopathologic diagnosis. Laparoscopy or laparotomy was needed if biopsy was inconclusive. RESULTS Ultrasound-guided procedures were diagnostic in 55 (87.7%) patients. Thirty-six (58.1%) were benign, of whom 86% had tuberculous peritonitis, 26 (41.9%) were malignant, of whom 76.9% had peritoneal metastasis. High-frequency ultrasound was able to propose ultrasonographic criteria in a trial to diagnose the nature of ascites. Our proposed ultrasonographic criteria were based on the amount and texture of ascites in addition to the omental and mesenteric features. These were able to suggest the diagnosis with 80.7% sensitivity for malignant ascites and 75% specificity for benign ascites. Moreover, histopathological examination of tissues obtained by ultrasound-guided procedures increased the sensitivity to 88.5% and the specificity to 88.9% in diagnosing malignant and benign disease, respectively, with an overall diagnostic accuracy of 88.6%. These procedures were considered to be safe as only one major (haemoperitoneum) and two minor complications (temporary ascitic fistula) were reported. CONCLUSION High-frequency peritoneal ultrasound together with the minimally invasive ultrasound-guided FNAC/biopsy of extra-visceral lesions may be considered an effective and safe tool in the diagnosis of ascites of undetermined origin.
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Affiliation(s)
- Maha Hasab Allah
- Endemic Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt.
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Scheepers S, Andronikou S, Mapukata A, Donald P. Abdominal lymphadenopathy in children with tuberculosis presenting with respiratory symptoms. ULTRASOUND : JOURNAL OF THE BRITISH MEDICAL ULTRASOUND SOCIETY 2011. [DOI: 10.1258/ult.2011.011011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Diagnosis of pulmonary tuberculosis (PTB) in children is challenging and radiographs are often normal or non-specific. Access to the chest using ultrasound is difficult, but access to the abdomen is simple and carries no radiation burden. Diagnosis of PTB using abdominal lymphadenopathy as a surrogate for mediastinal lymphadenopathy may present a simple and accurate additional diagnostic technique that is of value in developing countries. We determined the prevalence of abdominal lymphadenopathy in paediatric patients with confirmed TB presenting with respiratory symptoms. Chest radiographs and abdominal ultrasounds of 47 children with confirmed TB and respiratory symptoms were reviewed. The prevalence of abdominal TB was determined and comparisons made between thoracic and abdominal lymphadenopathy to determine the relative value of ultrasound. On ultrasound, the prevalence of abdominal lymphadenopathy was 19% and solid organ involvement was found in 23% of patients. Some 70% of children had thoracic lymphadenopathy on chest radiography, with 89% of patients having evidence of PTB. If chest radiography were to be considered the radiological reference standard, abdominal ultrasonography had a sensitivity of 18% (95% CI 7.0–35.5%) with a specificity of 79% (95% CI 49.2–95.1%) for thoracic lymphadenopathy. Ultrasound and chest radiography in combination detected a total of 36 patients with lymphadenopathy, with a 6% improvement in the rate of lymphadenopathy detection; however, this was not statistically significant. The prevalence of abdominal TB of 23% is noteworthy. We suggest that abdominal ultrasound has a definitive adjunctive role in investigating children with suspected TB.
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Affiliation(s)
- Shaun Scheepers
- Department of Radiology, University of Stellenbosch, Tygerberg Academic Hospital, Francie Van Zijl Drive, Tygerberg 7505, Western Cape, South Africa
| | - Savvas Andronikou
- Department of Radiology, University of the Witwatersrand, York Road, Parktown 2193, Johannesburg, South Africa
| | - Ayanda Mapukata
- Department of Radiology, University of Stellenbosch, Tygerberg Academic Hospital, Francie Van Zijl Drive, Tygerberg 7505, Western Cape, South Africa
| | - Peter Donald
- Department of Paediatrics and Child Health, University of Stellenbosch, Tygerberg Children's Hospital, Francie Van Zijl Drive, Tygerberg, 7505, Western Cape, South Africa
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24
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Abstract
JUSTIFICATION Revised National Tuberculosis Control Program (RNTCP) has focused on adults with smear positivity a tool not so well used in children with tuberculosis. There is a need to redefine standardization of diagnosis and management protocols for childhood tuberculosis. PROCESS Indian Academy of Pediatrics constituted a Working Group to develop consensus statement on childhood tuberculosis (TB). Members of the Group were given individual responsibilities to review the existing literature on different aspects of the childhood TB. The group deliberated and developed a consensus which was circulated to all the members for review. Efforts were made to ensure that the recommendations are standardized. OBJECTIVES To produce recommendations and standard protocols for reasonably accurate diagnosis and rational treatment of tuberculosis in children. RECOMMENDATIONS Fever and or cough > 2 weeks with loss of weight and recent contact with infectious case should arouse suspicion of TB. Chest Xray and trial with broad-spectrum antibiotic for 7-10 days is justified. In case of clinical and radiological non-response, Mantoux test and sputum or gastric aspirate for AFB is recommended. If AFB is positive, diagnosis is confirmed. If AFB is negative but chest Xray is suggestive and Mantoux test is positive, it is a probable case and if these tests are negative, alternate diagnosis must be sought and referral made to an expert. Ideally it is recommended to use 1TU of PPD for Mantoux test but 2 or 5 TU may be acceptable (but less preferred). Cut-off point of 10 mms for natural infection may be used for test done with 1, 2 or 5 TU. There is no linear relation of reaction to tuberculin strength and so no more than 5 TU should be used. BCG test is not recommended. Diagnosis must not be made without an attempt to look for AFB in gastric aspirate or sputum, as it is possible to get AFB even in primary complex. Elisa and PCR tests for TB are not recommended. There is no place for trial of anti tubercular therapy. Lymphnode enlargement > 2 cm with or without typical findings suggestive of TB and failure of antibiotic response demands FNAC for histopathology and bacteriology. Clinical suspicion of tubercular meningitis (TBM) should be confirmed by CSF examination and CT scan though none of these investigations are confirmatory and hence should not be considered in isolation. CSF tests for TB antibody and PCR are not recommended for routine use. Diagnosis of abdominal TB is made on circumstantial evidence and there are no standard guidelines. For treatment, disease is divided into three categories. The Category I and III are recommended for different types of new cases i.e. those who have received treatment for not more than 4 weeks. Category III includes primary pulmonary complex, one site peripheral lymphadenitis and pleural effusion, while all other forms of TB are included in Category I, that corresponds to smear positive TB in adults. This is because AFB is often found in many Category I disease in children. Category II includes defaulters, relapses and failure cases irrespective of the site of disease. Standard protocol is followed for each of these categories. Intermittent thrice weekly therapy with higher dose has been found to be equally effective as daily therapy and so is recommended in DOTS Direct Observed Therapy Short term. Compliance of treatment must be ensured. Repeat chest X-ray is ideal at the end of therapy. Liver function tests are not routinely recommended. Recommendations are also made for special situations such as MDRTB, TB and HIV and neonate born to mother suffering from TB.
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Stuart S, Booth TC, Cash CJC, Hameeduddin A, Goode JA, Harvey C, Malhotra A. Complications of Continuous Ambulatory Peritoneal Dialysis. Radiographics 2009; 29:441-60. [DOI: 10.1148/rg.292085136] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Barreiros AP, Braden B, Schieferstein-Knauer C, Ignee A, Dietrich CF. Characteristics of intestinal tuberculosis in ultrasonographic techniques. Scand J Gastroenterol 2009; 43:1224-31. [PMID: 18609146 DOI: 10.1080/00365520802158606] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE There is a paucity of data on the sonographic criteria for the diagnosis of intestinal tuberculosis. The purpose of this study was to further characterize the potential sonographic signs of intestinal tuberculosis and to increase the diagnostic sensitivity and specificity of ultrasound. MATERIAL AND METHODS Seven patients with a final diagnosis of gastrointestinal tuberculosis and a control group of 18 patients suffering from tuberculosis limited to the lungs were prospectively evaluated for sonographic criteria of intestinal tuberculosis and the findings were compared with those in 50 healthy controls. RESULTS The following signs of intestinal tuberculosis were detectable: asymmetric thickened bowel wall (100%), intramural abscesses (86%), fistula (43%), extramural abscesses (29%), mesenteric thickening (29%), "white bowel" sign (29%), hypoechoic edema of Kerckring's folds with mesenterial thrombosis (14%), enlarged mesenteric lymph nodes with inhomogeneous echotexture and circumscribed hypoechoic spots <3 mm (86%), ascites (29%) and enlarged spleen (14%). These signs were exclusively present in patients with intestinal tuberculosis as compared with patients with tuberculosis limited to the lungs or with healthy controls. We could confirm the endoscopically reported right-sided prevalence of these wall thickenings. In contrast to the reported literature, a much higher prevalence of these sonographic signs was found as they were present in all patients. Six of 7 patients (86%) showed enlarged mesenteric lymph nodes. This was particularly interesting as mesenteric lymph nodes have not been described as being enlarged in the majority of other differential diagnoses of the ileocecal region. CONCLUSIONS The combination of bowel-wall thickening of the ileocecal region with intramural abscesses with or without fistula, abscesses and mesenteric thickening accompanied by enlarged mesenteric lymph nodes was highly predictive of intestinal tuberculosis.
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Affiliation(s)
- Ana Paula Barreiros
- First Department of Internal Medicine, Johnannes Gutenberg-University Mainz, Mainz, Germany
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Sanai FM, Bzeizi KI. Systematic review: tuberculous peritonitis--presenting features, diagnostic strategies and treatment. Aliment Pharmacol Ther 2005; 22:685-700. [PMID: 16197489 DOI: 10.1111/j.1365-2036.2005.02645.x] [Citation(s) in RCA: 230] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The peritoneum is one of the most common extrapulmonary sites of tuberculous infection. Peritoneal tuberculosis remains a significant problem in parts of the world where tuberculosis is prevalent. Increasing population migration, usage of more potent immunosuppressant therapy and the acquired immunodeficiency syndrome epidemic has contributed to a resurgence of this disease in regions where it had previously been largely controlled. Tuberculous peritonitis frequently complicates patients with underlying end-stage renal or liver disease that further adds to the diagnostic difficulty. The diagnosis of this disease, however, remains a challenge because of its insidious nature, the variability of its presentation and the limitations of available diagnostic tests. A high index of suspicion is needed whenever confronted with unexplained ascites, particularly in high-risk patients. Based on a systematic review of the literature, we recommend: tuberculous peritonitis should be considered in the differential diagnosis of all patients presenting with unexplained lymphocytic ascites and those with a serum-ascites albumin gradient (SAAG) of <11 g/L; culture growth of Mycobacterium of the ascitic fluid or peritoneal biopsy as the gold standard test; further studies to determine the role of polymerase chain reaction, ascitic adenosine deaminase and the BACTEC radiometric system for acceleration of mycobacterial identification as means of improving the diagnostic yield; increasing utilization of ultrasound and computerized tomographic scan for the diagnosis and as a guidance to obtain peritoneal biopsies; low threshold for diagnostic laparoscopy; treatment for 6 months with the first-line antituberculous drugs (isoniazid, rifampicin, ethambutol and pyrazinamide) in uncomplicated cases.
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Affiliation(s)
- F M Sanai
- Division of Hepatology, Department of Internal Medicine, Riyadh, Saudi Arabia.
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Blanc P, Perrin I, Barlet L, Talbotec C, Goulet O, Paupe A, Lenclen R, Carbajal R. Tuberculose péritonéale de l'enfant : à propos de deux cas. Arch Pediatr 2004; 11:822-5. [PMID: 15234379 DOI: 10.1016/j.arcped.2004.03.124] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2003] [Accepted: 03/20/2004] [Indexed: 11/16/2022]
Abstract
UNLABELLED Peritoneal tuberculosis is an uncommon presentation of extra-pulmonary tuberculosis in children. It usually presents as ascites, abdominal pain, anorexia and weight loss. CASES REPORT We report two adolescent patients who presented with ascites, fever, weight loss and abdominal distension. In one case, the diagnosis was late, and confirmed by ascites culture. In the second case, a laparoscopy was performed and showed whitish nodules involving the entire abdominal cavity, compatible with peritoneal tuberculosis, later confirmed bacteriologically. CONCLUSION Peritoneal tuberculosis presents with nonspecific symptoms. Because laboratory investigations may not be helpful, diagnosis may be difficult. Peritoneal-fluid adenosine deaminase (ADA) determination and coelioscopy seem to be the best way to make a rapid diagnosis.
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Affiliation(s)
- P Blanc
- Service de pédiatrie, site de Poissy, centre hospitalier Poissy-Saint-Germain-en-Laye, 10, rue du Champ-Gaillard, BP 3082, 78303 Poissy, France.
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Liu KH, Chan YL, Chan WB, Kong WL, Kong MO, Chan JCN. Sonographic measurement of mesenteric fat thickness is a good correlate with cardiovascular risk factors: comparison with subcutaneous and preperitoneal fat thickness, magnetic resonance imaging and anthropometric indexes. Int J Obes (Lond) 2003; 27:1267-73. [PMID: 14513076 DOI: 10.1038/sj.ijo.0802398] [Citation(s) in RCA: 102] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Visceral fat, notably mesenteric fat, which is drained by the portal circulation, plays a critical role in the pathogenesis of metabolic syndrome through increased production of free fatty acids, cytokines and vasoactive peptides. We hypothesize that mesenteric fat thickness as measured by ultrasound scan could explain most of the obesity-related health risk. We explored the relationships between cardiovascular risk factors and abdominal fat as determined by sonographic measurements of thickness of mesenteric, preperitoneal and subcutaneous fat deposits, total abdominal and visceral fat measurement by magnetic resonance imaging (MRI) and anthropometric indexes. DESIGN A cross-sectional study. SUBJECTS Subjects included 18 healthy men and 19 women (age: 27-61 y, BMI: 19-33.4 kg/m(2)). MEASUREMENTS The maximum thickness of mesenteric, preperitoneal and subcutaneous fat was measured by abdominal ultrasound examination. MRI examinations of whole abdomen and pelvis were performed and the amount of total abdominal and visceral fat was quantified. The body mass index, waist circumference and waist-hip ratio were recorded. Cardiovascular risk factors were assessed by physical examination and blood taking. RESULTS Men had more adverse cardiovascular risk profile, higher visceral fat volume and thicker mesenteric fat deposits than women. Among all the investigated obesity indexes, the mesenteric fat thickness showed the highest correlations with total cholesterol, LDL-C, triglycerides, fasting plasma glucose, HbA(1c) and systolic blood pressure in men, and with triglycerides and HbA(1c) in women. On stepwise multiple regression analysis with different obesity indexes as independent variables, 30-65% of the variances of triglycerides, total cholesterol, LDL-C and HbA(1c) in men, and triglycerides in women were explained by the mesenteric fat thickness. CONCLUSION Compared with sonographic measurement of subcutaneous and preperitoneal fat thickness, MRI measurement of total abdominal and visceral fat and anthropometric indexes, sonographic measurement of mesenteric fat thickness showed better associations with some of the cardiovascular risk factors. It may potentially be a useful tool to evaluate regional distribution of obesity in the assessment of cardiovascular risk.
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Affiliation(s)
- K H Liu
- Department of Diagnostic Radiology and Organ Imaging, The Chinese University of Hong Kong, The Prince of Wales Hospital, Shatin, NT, Hong Kong SAR.
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Abstract
AIM: To evaluate the clinical, radiological and microbiological properties of abdominal tuberculosis (TB) and to discuss methods needed to get the diagnosis.
METHODS: Thirty-one patients diagnosed as abdominal TB between March 1998 and December 2001 at the Gastroenterology Department of Kartal State Hospital, Istanbul, Turkey were evaluated prospectively. Complete physical examination, medical and family history, blood count erythrocyte sedimentation rate, routine biochemical tests, Mantoux skin test, chest X-ray and abdominal ultrasonography (USG) were performed in all cases, whereas microbiological examination of ascites, upper gastrointestinal endoscopy, colonoscopy or barium enema, abdominal tomography, mediastinoscopy, laparoscopy or laparotomy were done when needed.
RESULTS: The median age of patients (14 females, 17 males) was 34.2 years (range 15-65 years). The most frequent symptoms were abdominal pain and weight loss. Eleven patients had active pulmonary TB. The most common abdominal USG findings were ascites and hepatomegaly. Ascitic fluid analysis performed in 13 patients was found to be exudative and acid resistant bacilli were present in smear and cultured only in one patient with BacTec (3.2%). Upper gastrointestinal endoscopy yielded nonspecific findings in 16 patients. Colonoscopy performed in 20 patients showed ulcers in 9 (45%), nodules in 2 (10%) and, stricture, polypoid lesions, granulomatous findings in terminal ileum and rectal fistula each in one patient (5%). Laparoscopy on 4 patients showed dilated bowel loops, thickening in the mesentery, multiple ulcers and tubercles on the peritoneum. Patients with abdominal TB were divided into three groups according to the type of involvement. Fifteen patients (48%) had intestinal TB, 11 patients (35.2%) had tuberculous peritonitis and 5 (16.8%) tuberculous lymphadenitis. The diagnosis of abdominal TB was confirmed microbiologically in 5 (16%) and histo-pathologically in 19 patients (60.8%). The remaining nine patients (28.8%) had been diagnosed by a positive response to antituberculous treatment.
CONCLUSION: Neither clinical signs, laboratory, radiological and endoscopic methods nor bacteriological and histopathological findings provide a gold standard by themselves in the diagnosis of abdominal TB. However, an algorithm of these diagnostic methods leads to considerably higher precision in the diagnosis of this insidious disease which primarily necessitate a clinical awareness of this serious health problem.
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MESH Headings
- Adolescent
- Adult
- Aged
- Antitubercular Agents/therapeutic use
- Female
- Humans
- Male
- Middle Aged
- Peritonitis, Tuberculous/diagnosis
- Peritonitis, Tuberculous/diagnostic imaging
- Peritonitis, Tuberculous/drug therapy
- Peritonitis, Tuberculous/microbiology
- Prospective Studies
- Radiography
- Tuberculosis, Gastrointestinal/diagnosis
- Tuberculosis, Gastrointestinal/diagnostic imaging
- Tuberculosis, Gastrointestinal/drug therapy
- Tuberculosis, Gastrointestinal/microbiology
- Tuberculosis, Lymph Node/diagnosis
- Tuberculosis, Lymph Node/diagnostic imaging
- Tuberculosis, Lymph Node/drug therapy
- Tuberculosis, Lymph Node/microbiology
- Turkey
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Abstract
Familiarity with the pathophysiology of peritoneal disease is the basis of successful ultrasound (US) study of the peritoneum. The pouch of Douglas, diaphragmatic surfaces, the paracolic gutters, and the regions of the mesentery and omentum should receive careful scrutiny in the patient at risk for a peritoneal disease process. An optimal US technique requires assessment of the entire peritoneum with a transducer selected to reflect the depth of the region of interest. US may demonstrate minute quantities of free intraperitoneal fluid and is therefore capable of providing sensitive quantitative information about ascites. Qualitative information may also be inferred, as blood, pus, and neoplastic cells demonstrate correlation with particulate ascites on gray-scale US scans. Peritoneal nodules, plaques, and thickening may be detected on the visceral or parietal peritoneal surfaces, especially when high-frequency probes are used. Transvaginal study in women increases the sensitivity of US for detection of peritoneal disease. In women who have unexplained sepsis or are at risk for carcinomatosis, transvaginal scanning should routinely be added to the regular abdominal and pelvic studies regardless of the findings of those studies. Peritoneal carcinomatosis, primary peritoneal neoplasms, pseudomyxoma peritonei, and peritonitis have characteristic appearances at US.
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Affiliation(s)
- Anthony E Hanbidge
- Department of Medical Imaging, Toronto General Hospital, University Health Network, University of Toronto, 200 Elizabeth St, Toronto, Ontario, Canada M5G 2C4
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Sinan T, Sheikh M, Ramadan S, Sahwney S, Behbehani A. CT features in abdominal tuberculosis: 20 years experience. BMC Med Imaging 2002; 2:3. [PMID: 12427257 PMCID: PMC139990 DOI: 10.1186/1471-2342-2-3] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2002] [Accepted: 11/12/2002] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND: Abdominal tuberculosis (TB) is endemic in the developing world and is reemerging in the West. Since computed tomography (CT) has the ability to demonstrate changes in the peritonium, mesentry, lymphnodes, bowel and solid organs and is being increasingly used for primary evaluation of abdominal conditions, it is important to be familiar with the CT features of the disease. METHODS: CT findings were retrospectively analysed in 49 patients with proved abdominal TB. Patients with genitourinary TB and with AIDS/HIV were not included in the study. RESULTS: Peritoneal involvement was the most common feature (77.5%) with ascites (wet peritonitis) seen in more than half the cases (55.2%). The rest showed peritoneal, mesenteric or omental thickening or mass formation but no ascites (dry peritonitis). Other findings included lymphadenopathy (46.9% mainly of diffuse nature, bowel wall thickening (38%) and solid organ involvement (20.4%). CONCLUSIONS: CT reliably demonstrates the entire range of findings which need interpretation in the light of clinical and laboratory data.
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Affiliation(s)
- Tariq Sinan
- Department of Radiology, Kuwait University, Jabriya, Kuwait
| | - Mehraj Sheikh
- Department of Radiology, Kuwait University, Jabriya, Kuwait
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34
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Batra A, Gulati MS, Sarma D, Paul SB. Sonographic appearances in abdominal tuberculosis. JOURNAL OF CLINICAL ULTRASOUND : JCU 2000; 28:233-245. [PMID: 10800002 DOI: 10.1002/(sici)1097-0096(200006)28:5<233::aid-jcu5>3.0.co;2-c] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Affiliation(s)
- A Batra
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
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35
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Abstract
Transvaginal ultrasonography (US) is a noninvasive, readily available imaging technique that has greatly enhanced diagnostic sensitivity and accuracy for both gynecologic and nongynecologic disease. High-frequency US probes placed in the vagina allow high-resolution assessment of all the pelvic viscera, including portions of the gut and urinary tract. In addition, they allow visualization of the peritoneum of the pelvic pouch and the pelvic side walls without interference from bowel gas or adipose tissue. Evaluation of these areas requires a modified US technique that includes the use of the highest-frequency probes with angulation of the transducer to allow assessment of the region of interest. In women of childbearing age, the similarity of symptoms in gynecologic and gastrointestinal tract disease in particular underscores the potential utility of transvaginal US, which may, for example, help differentiate appendicitis in a pelvic appendix from pelvic inflammatory disease. Transvaginal US may also help determine the correct course of therapy, thereby improving patient management. Other indications for transvaginal US include assessment for pelvic appendicitis and diverticulitis, rectal and perianal complications of Crohn disease, and ureteric and bladder calculi and tumors as well as evaluation of the anal sphincters in women with fecal incontinence. Transvaginal US is also superior to routine US in the detection and characterization of ascites and peritoneal disease. Transvaginal US examination should include the entire pelvic cavity and contents, especially in women at risk for pelvic sepsis or peritoneal disease.
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Affiliation(s)
- N Damani
- Department of Medical Imaging, The Toronto Hospital, University of Toronto, Ontario, Canada
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