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 Table of Contents  
LETTER TO EDITOR
Year : 2018  |  Volume : 7  |  Issue : 2  |  Page : 198-199

Peritoneal tuberculosis or carcinomatosis: A diagnostic conundrum


1 Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Cytology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication13-Jun-2018

Correspondence Address:
Pankaj Gupta
Department of Gastroenterology, Section of Radiology, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmy.ijmy_62_18

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How to cite this article:
Gupta P, Rana S, Agarwal P. Peritoneal tuberculosis or carcinomatosis: A diagnostic conundrum. Int J Mycobacteriol 2018;7:198-9

How to cite this URL:
Gupta P, Rana S, Agarwal P. Peritoneal tuberculosis or carcinomatosis: A diagnostic conundrum. Int J Mycobacteriol [serial online] 2018 [cited 2019 Oct 15];7:198-9. Available from: http://www.ijmyco.org/text.asp?2018/7/2/198/234336



Dear Editor,

Tuberculosis is an important health problem in developing countries. There are several manifestations of tuberculosis. Almost any organ system may be involved. Abdominal tuberculosis may present as nodal disease, peritoneal disease, or organ-specific disease. In this context, the differential diagnosis of peritoneal disease is particularly challenging. Peritoneal tuberculosis closely mimics peritoneal carcinomatosis and vice versa. We present one such challenging case, where despite proven nodal tuberculosis, the peritoneal disease was a manifestation of disseminated malignancy.

A 50-year-old female, a diagnosed case of gallstone disease, was evaluated for pyrexia of unknown origin and was started on antitubercular therapy (ATT) 5 months back based on the identification of necrotic cervical and abdominal lymphadenopathy [[Figure 1]a, arrows] and detection of acid-fast bacilli (AFB) on the cervical lymph node biopsy specimen. Two months later, she developed ATT hepatitis. A modified ATT regimen was restarted at our center. At the last visit, she complained of abdominal discomfort, loss of weight, and appetite.
Figure 1: Axial computed tomography images (a-c) show necrotic retroperitoneal lymphadenopathy (pretreatment, a), omental/peritoneal thickening (b), and gallbladder wall thickening (d). Cytology image shows tumor cells

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Her laboratory data revealed normal serum bilirubin with elevated serum alanine aminotransferase (195 U/L, normal <35) and AST (181 U/L, normal <35) as well as alkaline phosphatase (891 U/L, normal 30–120 U/L). Abdominal computed tomography (CT) revealed no significant retroperitoneal lymph nodes. There was mild ascites with peritoneal and omental thickening as well as nodularity [[Figure 1]b, arrow]. There was moderate degree of circumferential mural thickening of gallbladder with bilobar intrahepatic biliary dilatation [[Figure 1]c, arrow]. Common bile duct was dilated till the lower end. Endoscopic ultrasound (EUS) revealed enlarged periportal lymph node. Ultrasound (US)-guided fine-needle aspiration cytology (FNAC) of the gallbladder wall revealed atypical cells along with sheets of reactive mesothelial cells. Immunocytochemistry was negative. Omental sampling revealed only few reactive mesothelial cells. No granulomas were seen. Stain for AFB was negative. EUS-guided FNAC from gallbladder wall revealed no malignant cells. Ascitic fluid cytology was negative for malignant cells. On follow-up, 6 weeks later, the patient complained of increasing abdominal discomfort and distension. Repeat US revealed persistent gallbladder wall thickening and a well-defined hypoechoic lesion in the segment 5 of liver and bulky left ovary. US-guided FNAC of the liver lesion and the left ovary was performed. Cytological examination of the aspirate from liver lesion revealed singly scattered tumor cells with focal clustering ([Figure 1]d, arrows). The tumor cells were moderately to markedly pleomorphic with coarse chromatin, prominent nucleoli, and moderate amount of cytoplasm, suggestive of adenocarcinoma. Tumor cells with similar morphology were seen in the left ovarian aspirate.

Tuberculosis is an important health problem in both developed and developing countries. A significant proportion of the world's population is infected with tubercle bacilli. India accounts for the largest proportion of patients with tuberculosis.[1] Tuberculosis most commonly manifests as lymphadenopathy. Necrotic lymphadenopathy is the hallmark of tuberculosis. Besides retroperitoneal and mesenteric lymphadenopathy, abdominal disease presents with peritoneal involvement characterized as wet, fibrotic, and dry type.[2] The peritoneal disease may present as ascites; peritoneal thickening, enhancement; omental fat standing, nodules, caking; mesenteric masses and adhesions. Other manifestations include gastrointestinal involvement leading to bowel wall thickening and obstruction. Ileocecal region is the most commonly involved site. Hepatobiliary, adrenal and genitourinary involvement, is less common.

Findings of peritoneal disease are nonspecific and similar appearance may be produced by nontubercular peritonitis, peritoneal carcinomatosis, and mesothelioma. Mesenteric changes, macronodules in omentum, smooth omental outline, low-density center, and calcification in peritoneal masses have been reported to be the features favoring tubercular peritonitis over peritoneal carcinomatosis.[3] A sensitivity of 69% and 91% was reported for predicting peritoneal tuberculosis and peritoneal carcinomatosis based on CT, respectively. Few other rare manifestations of abdominal tuberculosis have been reported.[4],[5],[6] Sharma et al. reported a case of Sister Mary Joseph's nodule secondary to abdominal tuberculosis.[4] Abdominal tuberculosis presenting as abdominal emergency has also been reported.[5],[6]

This case highlights the need to have a high index of suspicion for malignancy even in diagnosed cases of tuberculosis when new findings appear during treatment even before attributing these findings to disease progression due to drug resistance.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organization. Available from: http://www.who.int/mediacentre/factsheets/fs104/en/index.html. [Last accessed on 2017 Oct 05].  Back to cited text no. 1
    
2.
Leder RA, Low VH. Tuberculosis of the abdomen. Radiol Clin North Am 1995;33:691-705.  Back to cited text no. 2
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3.
Ha HK, Jung JI, Lee MS, Choi BG, Lee MG, Kim YH, et al. CT differentiation of tuberculous peritonitis and peritoneal carcinomatosis. AJR Am J Roentgenol 1996;167:743-8.  Back to cited text no. 3
[PUBMED]    
4.
Sharma V, Ahmed SU, Mandavdhare HS. A benign cause of Sister Mary Joseph's nodule: Abdominal tuberculosis. Int J Mycobacteriol 2017;6:321.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Sabooni K, Khosravi MH, Pirmohammad H, Afrasiabian S, Moghbel N, Shahverdi E, et al. Tuberculosis peritonitis with features of acute abdomen in HIV infection. Int J Mycobacteriol 2015;4:151-3.  Back to cited text no. 5
  [Full text]  
6.
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.  Back to cited text no. 6
[PUBMED]  [Full text]  


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