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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 7  |  Issue : 1  |  Page : 95-96

Pneumoperitoneum during treatment of abdominal tuberculosis in a Non-HIV patient: Natural progression or paradoxical worsening?


Division of Infectious Diseases, Changi General Hospital, Singapore

Date of Web Publication7-Mar-2018

Correspondence Address:
Dr Shuwei Zheng
2 Simei Street 3, 529889
Singapore
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmy.ijmy_191_17

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  Abstract 


Paradoxical reactions during tuberculosis (TB) treatment are well-described in the HIV seropositive population but less so in the HIV seronegative group. Abdominal TB rarely presents as spontaneous perforation; cases occurring during anti-TB therapy are even rarer. We describe the clinical progress of a case of an HIV-negative patient who developed acute peritonitis while on anti-TB treatment for peritoneal TB through a series of clinical, radiological and histological images. Visceral perforation can occur as a complication of TB treatment. A high index of suspicion with early surgical intervention is crucial in the management of such cases.

Keywords: Abdominal tuberculosis, paradoxical worsening, peritoneal tuberculosis


How to cite this article:
Zheng S, Shafi H. Pneumoperitoneum during treatment of abdominal tuberculosis in a Non-HIV patient: Natural progression or paradoxical worsening?. Int J Mycobacteriol 2018;7:95-6

How to cite this URL:
Zheng S, Shafi H. Pneumoperitoneum during treatment of abdominal tuberculosis in a Non-HIV patient: Natural progression or paradoxical worsening?. Int J Mycobacteriol [serial online] 2018 [cited 2019 Jul 15];7:95-6. Available from: http://www.ijmyco.org/text.asp?2018/7/1/95/226782




  Introduction Top


Paradoxical reactions during tuberculosis (TB) treatment are well-described in the HIV seropositive population but less so in the HIV seronegative group. Abdominal TB rarely presents as spontaneous perforation; cases occurring during anti-TB therapy are even rarer. We present an interesting case of a patient who initially presented with pyrexia of unknown origin and lymphocytic ascites. This patient was eventually diagnosed with abdominal TB but unfortunately developed pneumoperitoneum a week after treatment.


  Case Report Top


A patient presented with pyrexia of unknown origin while undergoing rehabilitation at a step-down care facility without any localizing symptoms. This elderly woman had no significant medical history. Two weeks prior, she had presented with recurrent falls, functional decline, and hyponatremia. A computed tomography (CT) scan of the abdomen and pelvis at that point as part of her evaluation revealed the presence of low-volume ascites and several para-aortic lymphadenopathy up to 1 cm in size. The hyponatremia improved with parenteral hydration and she was transferred to another facility for rehabilitation. She was transferred back to our institution for further evaluation of prolonged fever.

On examination, her temperature was 36.4°C; her blood pressure was 158/68 mmHg, pulse rate was 73 beats/min and was oxygenating well on room air. Clinical examination was unremarkable apart from the presence of mild ascites.

Initial laboratory tests were unremarkable apart from hypoalbuminemia, mild nonparathyroid hormone-mediated hypercalcemia and a raised erythrocyte sedimentation rate of 103 mm/h. A chest radiograph did not reveal significant abnormalities. Repeated blood cultures were unyielding. HIV serological testing was negative. A repeat CT scan of the chest, abdomen, and pelvis a month after the earlier scan showed interval worsening of ascites, ill-defined omental stranding, peritoneal thickening, and para-aortic lymphadenopathy [Figure 1]a.
Figure 1: (a) Coronary view of computed tomography abdomen/pelvis showing multiple paraaortic lymphadenopathy; (b) intraoperative findings revealed thickened peritoneal lining and the presence of generalized peritoneal inflammation and white nodular deposits over the visceral surfaces, consistent with peritoneal tuberculosis; (c and d) histology of the omental tissue revealing multiple granulomas with minimal necrosis; (e) sagittal view of computed tomography abdomen showing extensive pneumoperitoneum suggesting visceral perforation

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She went on to have an ascitic tap, revealing the following biochemical results: fluid lactate dehydrogenase, 250 units/L; protein, 62.0 g/L; albumin, 16 g/L; glucose, 3.9 mmol/L; and cell count, 2390 unit/mm3, of lymphocytic predominance (90%). Serum albumin was 21 g/L, implying a low serum-ascites albumin gradient of 5 g/L. Fluid bacterial gram stain and culture, acid-fast bacilli (AFB) smear, nucleic acid amplification test (NAAT) for Mycobacterial tuberculosis (MTB), and fungal smears were negative. Fluid cytology revealed predominantly lymphoid cells.

She underwent diagnostic laparoscopic peritoneal biopsy. Intraoperative findings revealed thickened peritoneal lining and the presence of generalized peritoneal inflammation and white nodular deposits over the visceral surfaces, consistent with peritoneal TB [Figure 1]b. She was empirically started on rifampicin, isoniazid, pyrazinamide and ethambutol postsurgery in view of the laparoscopic findings. Histology of the omental tissue revealed the presence of numerous granulomata [Figure 1]c and [Figure 1]d. AFB smears and NAAT for MTB from intraoperative tissue specimens were negative.

A week later, she developed drowsiness, abdominal tenderness, and hypotension. An urgent CT scan of the abdomen showed diffuse omental and mesenteric stranding. There was also extensive pneumoperitoneum, more than what would be expected given the interval since surgery [Figure 1]e. She continued to deteriorate despite intensive care and demised before further surgical intervention. Two weeks after her demise, mycobacterial cultures return positive for pansusceptible MTB sequentially from both the initial ascitic tap and omental biopsy, confirming the diagnosis of peritoneal TB.


  Discussion Top


Peritoneal TB is the sixth most common site for extrapulmonary TB in the United States.[1] Abdominal pain, weight loss and fever are the commonest clinical manifestations. A lymphocytic ascitic yield has a reported sensitivity of 68.34%. Ascitic white cell count may vary from <100 cells/mm3 to 5000 cells/mm3 although most patients have it between 500 and 1500 cells/mm3. Laparoscopy allows a visual diagnosis to be achieved in 92.7% of cases and histology is 93% sensitive.[2]

Intestinal perforation occurring following the commencement of anti-tuberculous treatment has been reported in immunocompetent hosts, but this is a rare phenomenon.[3],[4],[5] Cheng et al. reviewed 122 cases of paradoxical deterioration of TB in non-HIV-infected individuals. In their series, only 2 cases were patients with abdominal TB and none presented with perforated viscus.[6] In another study, paradoxical reaction in non-HIV patients was more likely in patients with extrapulmonary TB.[7]

Pneumoperitoneum in our patient is unlikely the result of a postsurgical complication as this occurred a week after and the initial surgery did not involve bowel manipulation. We speculate that this was less likely the case of failed medical treatment as eventual culture isolated pansusceptible MTB, but an instance of paradoxical reaction.

Visceral perforation can occur as a complication of TB treatment. A high index of suspicion with early surgical intervention is crucial in the management of such cases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mehta JB, Dutt A, Harvill L, Mathews KM. Epidemiology of extrapulmonary tuberculosis. A comparative analysis with pre-AIDS era. Chest 1991;99:1134-8.  Back to cited text no. 1
[PUBMED]    
2.
Sanai FM, Bzeizi KI. Systematic review: Tuberculous peritonitis – Presenting features, diagnostic strategies and treatment. Aliment Pharmacol Ther 2005;22:685-700.  Back to cited text no. 2
[PUBMED]    
3.
Doré P, Meurice JC, Rouffineau J, Carretier M, Babin P, Barbier J, et al. Intestinal perforation occurring at the beginning of treatment: A severe complication of bacillary tuberculosis. Rev Pneumol Clin 1990;46:49-54.  Back to cited text no. 3
    
4.
Seabra J, Coelho H, Barros H, Alves JO, Gonçalves V, Rocha-Marques A, et al. Acute tuberculous perforation of the small bowel during antituberculosis therapy. J Clin Gastroenterol 1993;16:320-2.  Back to cited text no. 4
    
5.
Liao CS. Recurent small intestinal perforations during anti-tuberculous treatment. Formos J Surg 2012;45:161-3.  Back to cited text no. 5
    
6.
Cheng VC, Ho PL, Lee RA, Chan KS, Chan KK, Woo PC, et al. Clinical spectrum of paradoxical deterioration during antituberculosis therapy in non-HIV-infected patients. Eur J Clin Microbiol Infect Dis 2002;21:803-9.  Back to cited text no. 6
[PUBMED]    
7.
Cheng VC, Yam WC, Woo PC, Lau SK, Hung IF, Wong SP, et al. Risk factors for development of paradoxical response during antituberculosis therapy in HIV-negative patients. Eur J Clin Microbiol Infect Dis 2003;22:597-602.  Back to cited text no. 7
[PUBMED]    


    Figures

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This article has been cited by
1 Antituberculars
Reactions Weekly. 2018; 1697(1): 58
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