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LETTER TO EDITOR
Year : 2018  |  Volume : 7  |  Issue : 2  |  Page : 200-201

Pneumoperitoneum in treated abdominal tuberculosis: Not always paradoxical worsening


Department of Gastroenterology and Radiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication13-Jun-2018

Correspondence Address:
Vishal Sharma
Department of Gastroenterology, 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_59_18

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How to cite this article:
Mandavdhare HS, Gorsi U, Gupta P, Sharma V. Pneumoperitoneum in treated abdominal tuberculosis: Not always paradoxical worsening. Int J Mycobacteriol 2018;7:200-1

How to cite this URL:
Mandavdhare HS, Gorsi U, Gupta P, Sharma V. Pneumoperitoneum in treated abdominal tuberculosis: Not always paradoxical worsening. Int J Mycobacteriol [serial online] 2018 [cited 2021 Sep 23];7:200-1. Available from: https://www.ijmyco.org/text.asp?2018/7/2/200/234333



Sir,

We read with keen interest the report of pneumoperitoneum during the treatment of abdominal tuberculosis in a non-HIV patient.[1] We had a similar scenario of A 48-year-old male who presented with a 3-year history of recurrent episodes of abdominal pain and subacute intestinal obstruction. He was HIV nonreactive. In 2017, he underwent colonoscopy that revealed multiple ulcers in the cecum and ascending colon with widely open and deformed ileocecal valve. The computed tomography (CT) abdomen showed mural thickening and enhancement of the terminal ileum and ascending colon with gaping ileocecal valve; contracted, pulled, and deformed cecum [Figure 1]. The histopathology showed noncaseating epithelioid granulomas in the submucosa. His Mantoux was positive. He was started on standard four drugs antitubercular therapy (ATT) and had improvement with weight gain. His repeat colon after 2 months showed evidence of early mucosal response. However, 15 days after the end of therapy at 6 months, he had an episode of abdominal pain that subsided on its own. His X-ray abdomen revealed gas under the diaphragm and a repeat CT abdomen revealed pneumoperitoneum with evidence of pneumatosis in ileal loops [Figure 2]a and [Figure 2]b. The patient, however, had no signs of peritonitis and remained well. Pneumoperitoneum disappeared by 3 days, and the patient has remained well after 2 months of this episode.
Figure 1: Initial computed tomography showing pulled up and thickened cecum

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Figure 2: Abdominal X-ray (a) showing pneumoperitoneum and (b) computed tomography showing pneumoperitoneum and pneumatosis

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We suspect that our patient probably had an episode of intestinal obstruction due to persistent tubercular sequelae in the form of stricture resulting in spontaneous pneumoperitoneum. Strangely, the patient did not have any peritonitis and the pain improved by itself. We suggested repeat colonoscopy; however, the patient remained unwilling for the same and had modified his diet to a low-fiber diet and remains well. The patient had no history of any recent procedure. While the paradoxical response to ATT is common and is seen in up to one-third of the patients on ATT in non-HIV-infected patients, however, abdomen as a site of presentation is rare.[2],[3] Further, while the paradoxical worsening while on therapy can cause pneumoperitoneum, our patient had no features of paradoxical worsening and had already completed the therapy. We report the case for two reasons; first, it clearly emphasizes the possibility of posttreatment sequelae in patients with intestinal tuberculosis and need for follow-up in these cases, and second, for the rarity that the patient improved by itself even after the development of spontaneous pneumoperitoneum.

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.
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. 1
[PUBMED]  [Full text]  
2.
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. 2
[PUBMED]    
3.
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. 3
[PUBMED]    


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