Tuberculous peritonitis: Diagnostic value of the ascitic/blood glucose ratio

In a study of 25 consecutive patients presenting with ascites, the use of the ascitic/blood glucose ratio in assisting in the diagnosis of tuberculous peritonitis was investigated. In all 13 patients with histologically confirmed tuberculous peritonitis the ratio was less than 0.96, and in 10 patients with non-tuberculous ascites the ratio was greater than 0.96, this difference being statistically significant (P<0.001). In 2 patients with probable non -tuberculous ascites butwith pulmonarytuberculosis the results were excluded from statistical analysis, as they had received anti-tuberculosis therapy in addition to their other treatment.The conclusion drawn from this study is that the ascitic/blood glucose ratio is a useful test in the differentiation of tuberculous peritonitis from ascites due to other causes.     

56例结核性腹膜炎患者CT影像分析

目的 探讨结核性腹膜炎（TBP）特征性CT影像表现及治疗中影像动态变化的特点。方法 回顾性分析56例临床及病理确诊的TBP患者,观察分析CT影像特征,包括腹腔积液、腹膜（壁腹膜、肝包膜、大网膜及肠系膜）及腹腔淋巴结。56例均行CT平扫+增强扫描。治疗过程中收集动态复查CT影像。结果 腹腔积液45例,大量1例,中少量44例,限制性38例,CT值>20 HU者34例。壁腹膜增厚46例,肝脏边缘部腹膜均有受累,均匀增厚17例,扁丘状凸起或腹膜结核瘤29例,增强扫描结核瘤边缘强化,肝包膜或肝脏受累15例;网膜增厚35例,结节及斑片34例,网膜饼1例,增强扫描网膜饼呈轻度不均匀强化;肠系膜增厚41例,表现为斑片、结节及线状、星芒状条索状高密度影,与肠袢粘连,增强扫描肠系膜血管包埋其内,走形扭曲。腹腔及腹膜后淋巴结增大19例,伴钙化5例,簇集状排列,增强扫描环状或蜂窝状强化。17例完整的动态CT图像,腹腔积液吸收最快,网膜及肠系膜病变吸收稍慢,腹膜结核瘤缩小速度最慢。结论 TBP的CT诊断为多种征象的综合,中少量腹腔积液伴壁腹膜、网膜及肠系膜的增厚粘连是最为常见的影像表现;CT影像动态变化对临床评价疗效具有重要意义。     

54例结核性腹膜炎临床分析

目前医疗条件普遍较好，但结核性腹膜炎的误诊率仍较高。目的：通过分析结核性腹膜炎的临床特点，探讨其实用诊断方法。方法：回顾性分析2002年1月-2007年8月安徽省计划生育学校附属医院确诊的54例结核性腹膜炎患者的临床特点。结果：结核性腹膜炎的误诊率为27．8％，各项辅助检查的阳性率分别为血常规异常37．0％（20／54），血细胞沉降率增快75．9％（41／54），结核菌素试验阳性63．0％（34／54），抗结核抗体阳性48．1％（26／54），血清转铁蛋白下降85．2％（46／54）．腹水腺苷脱氨酶（ADA）活性增高59．1％（13／22），胃镜检查阳性56．2％（9／16），腹腔镜检查阳性87．5％（7／8）。结论：腹腔镜检查和血清转铁蛋白对结核性腹膜炎的诊断阳性率最高，但前者有创伤性，后者缺乏特异性。血清转铁蛋白检测可能为结核性腹膜炎的临床诊断提供了一种新方法。应结合患者的临床表现、各项辅助检查和抗结核治疗的疗效诊断结核性腹膜炎。     

18F-fluorodeoxyglucose-positron emission tomography (FDG-PET) was useful tool for detecting tuberculous peritonitis: report of a case

A 40's-year-old woman who had abdominal pain with fever was referred to our hospital for further examinations. Abdominal computed tomography showed no focal lesion, and no causative lesion was found after a gynecological examination, upper gastrointestinal endoscopy and colonoscopy. Tuberculin test and QuantiFERON-TB were positive, and thus tuberculous peritonitis was suspected. The level of adenosine deaminase (ADA) in ascites was high, and (18)F-fluorodeoxyglucose-positron emission tomography (FDG-PET) showed that FDG accumulated diffusely along the peritoneum. These findings supported the findings of tuberculous peritonitis. Final diagnosis of tuberculous peritonitis was done from laparoscopic biopsy. Combination of QuantiFERON-TB, ADA and FDG-PET was useful in diagnosing tuberculous peritonitis.     

A case of tuberculous peritonitis diagnosed by ultrasonography-guide peritoneal biopsy

The diagnosis of tuberculous peritonitis is quite difficult because the symptoms are not specific for the disease and the incidence of occurrence are relatively rare. We report a case of tuberculous peritonitis diagnosed by ultrasonography-guided peritoneal biopsy. A 64-year-old male was admitted to our hospital because of fever, dyspnea and abdominal pain. Laboratory findings revealed an elevated ESR (53 mm/1 hr.) and positive CRP. The tuberculin skin test was negative. The chest radiograph revealed bilateral pleural effusion. Abdominal ultrasonographic examination and computed tomography showed ascitic fluid, thickening of the mesentery and peritoneum, and inflammatory pseudotumor of the omentum. Ascitic fluid was exudate with a high lymphocyte count and elevated ADA (184 IU/l). Microbiological studies with the fluid were negative. Peritoneal biopsy guided by ultrasonography was performed, and the specimens showed central caseous necrosis surrounded by epitheloid cells and acid-fast bacilli were demonstrated. The size of the pseudotumor, pleural effusion and ascites decreased after antituberculous chemotherapy with corticosteroid was given. Diagnosis of tuberculous peritonitis has often been made by laparotomy or laparoscopy. In a case of this kind, percutaneous peritoneal biopsy guided by ultrasonography is safe and useful.     

Tuberculous lymphadenitis: a clinical study of 23 cases

INTRODUCTION: Tuberculous lymphadenitis is a relatively rare disease in adults. In the absence of pulmonary tuberculosis, tuberculous lymphadenitis is very difficult to differentiate from other diseases. We described our experiences of patients with tuberculous lymphadenitis. RESULTS: We diagnosed 23 patients with tuberculous lymphadenitis out of 207 patients with tuberculosis. Their ages ranged from 18 to 99 years (mean, 45.7 years), and the male-to-female ratio was 7:16. The most common complaints were cervical mass and fever. With the exception of two patients, all diagnosed patients had a strong positive skin test to tuberculin. Observing the site of affected lymph nodes, 16 patients had cervical node involvement, 3 patients had axillary node involvement, 7 patients had mediastinal node involvement, 3 patients had hilar node involvement, 3 patients had abdominal node involvement, and 1 patient had inguinal node involvement. Fifteen patients had neither hilar nor mediastinal node involvement. Eleven patients had no tuberculous lesions other than lymphadenitis. Seven patients underwent biopsy of the lymph nodes. Four of these patients had the evidence of acid-fast bacilli. The remaining three patients were also diagnosed histologically. Five patients underwent fine needle aspiration. Two of them had the evidence of acid-fast bacilli. Acid-fast bacilli were detected in 10 out of 16 sputum samples and in 1 out of 2 pleural effusion samples. Five patients were diagnosed clinically by image (Computed tomography etc.) and by therapeutic effect. Eleven cases underwent contrast-enhanced computed tomography (CT) of the lymph nodes. Seven cases showed central low attenuation with peripheral rim enhancement, whereas the other four cases showed homogeneous attenuation. All patients received chemotherapy for a mean duration of 14.5 months (range, 6-30 years) with apparent improvement, but 1 patient relapsed. CONCLUSION: Tuberculous lymphadenitis remains one of important targets for the differential diagnosis of lymphadenopathy. It is essential that a peripheral lymph node biopsy be performed and examined either histologically and/or microbiologically. A tuberculin skin test and contrast-enhanced CT imaging should also be performed.     

CT平扫对结核性腹膜炎的诊断价值

目的 探讨结核性腹膜炎的CT平扫表现特征。方法 回顾性分析46例有CT扫描资料的结核性腹膜炎患者,其中经手术病理证实6例,腹腔穿刺证实2例,腹腔镜检证实4例,试验性治疗诊断34例。观察内容包括结核性腹膜炎累及壁腹膜、大网膜、肠系膜及腹膜后间隙的CT表现特征。结果 （1）壁腹膜增厚33例,其中均匀、光滑增厚27例,局部不规则增厚6例;（2）腹腔积液31例,其中20例为少量积液;（3）大网膜增厚26例,表现为污迹样增厚22例,饼状增厚2例;（4）肠系膜受累32例,其中9例合并小结节影：（5）淋巴结增大16例;（6）肠壁增厚1例,肠间距增宽2例。结论 结核性腹膜炎CT平扫的主要表现有少量腹腔积液、均匀性腹膜增厚、大网膜污迹样增厚,以及肠系膜、肠管受累与腹腔淋巴结增大,CT平扫能为结核性腹膜炎的诊断提供重要信息。     

Two cases of tuberculous peritonitis with liver cirrhosis complicated by refractory ascites

We present two cases of tuberculous peritonitis with liver cirrhosis complicated by refractory ascites. Case 1 was a 59-year-old female with alcoholic liver cirrhosis. She was admitted to our hospital because of diarrhea, anorexia and inflammatory reactions on a blood test. She had a high fever of 38°C or more and refractory ascites. Tubercle bacilli infection was suspected based on increased levels of serum CA125 and adenosine deaminase (ADA) in ascites. Laparoscopic examination showed white nodules on the peritoneum, and histologic study confirmed tuberculous nodules. The same bacteria were isolated from culture of ascites. Case 2 was a 55-year-old female with hepatitis C virus-infected liver cirrhosis. She was admitted because of high fever and abdominal fullness due to ascites. High levels of serum CA125 and ADA in ascites and ineffectiveness of treatment with antibiotics plus diuretics led us to start anti-tuberculous therapy before definitive diagnosis. Tuberculus bacillus was later isolated from culture of ascites. It is difficult to make early diagnosis of tuberculous peritonitis in cirrhotic patients with ascites due to a lack of specific symptoms. However, determination of serum CA125 and ADA in ascites and the acid-fast bacterial culture of ascites are useful for early diagnosis.     

Pulmonary artery occlusion from tuberculous lymphadenopathy in a child

Occlusion of the pulmonary artery is a rare complication of mediastinal tuberculosis. We report on a 10-year-old girl who presented with a tuberculous pericardial effusion in whom subsequent imaging showed a totally occluded right pulmonary artery from tuberculous lymphadenopathy. Diagnosis was confirmed by polymerase chain reaction from a lymph node biopsy. Failure of medical therapy necessitated surgical reconstruction of her right pulmonary artery. Postoperatively she has normal perfusion of the right lung and normal lung function.     

Tuberculous peritonitis in an endemic area

BACKGROUND: Tuberculous peritonitis is a fatal disease if not diagnosed in time. AIMS: To identify the clinical, laboratory, and diagnostic features of tuberculous peritonitis in Iranian patients. PATIENTS: Included in the study were all cases of tuberculous peritonitis with a definite diagnosis confirmed by pathology in four referral University Hospitals in Tehran between 1989 and 1999. METHODS: All clinical, laboratory, and radiological findings as well as invasive procedures were reviewed. RESULTS: A total of 50 patients (30 female, 20 male), mean age 33.5 years were studied. Main presenting symptoms included abdominal pain (84%), weight loss (72%) and fever (50%). In 24% of patients a positive tuberculin test was found. Erythrocyte sedimentation rate >50 mm/h was detected in 60% of patients and 4.4% had an Erythrocyte sedimentation rate >100 mm/h. Laparoscopy or laparotomy showed peritoneal seeding in 74% of patients. CONCLUSIONS: Exudative ascites should give rise to clinical suspicion of tuberculous peritonitis in endemic areas or in immigrants from endemic areas. Laparoscopy is the most sensitive and specific diagnostic method.     

Ascitic fluid gamma interferon concentrations and adenosine deaminase activity in tuberculous peritonitis.

The gamma interferon (gamma-IFN) concentration and the adenosine deaminase (ADA) activity were evaluated in 30 patients with tuberculous peritonitis, 21 patients with ascites due to a malignant disorder, and 41 patients with cirrhosis. The gamma-IFN concentrations were significantly higher (p < 0.0001) in tuberculous peritonitis patients (mean: 6.70 U/ml) than in the malignant (mean: 3.10 U/ml) and cirrhotic (mean: 3.08 U/ml) groups. Use of a cut off value of > or = 3.2 U/ml gave the assay a sensitivity of 93% (25 of 27), a specificity of 98% (54 of 55), positive (P+) and negative (P-) predictive values of 96% and a test accuracy of 96%. The ADA activity was significantly (p < 0.0001) higher in the tuberculous peritonitis group (mean: 101.84 U/l) than in the control groups (cirrhosis (mean: 13.49 U/l) and malignancy (mean: 19.35 U/l)). A cut off value of > 30 U/l gave the ADA test a sensitivity of 93% (26 of 28) a specificity of 96% (51 of 53), a (P+) value of 93%, a (P-) value of 96%, and a test accuracy of 95%. There was a significant (p < 0.0001) correlation (r = 0.72) between ADA activity and gamma-IFN values in patients with tuberculous peritonitis. These results show that a high concentration of gamma-IFN in ascitic fluid is as valuable as the ADA activity in the diagnosis of tuberculous peritonitis. Both are rapid non-invasive diagnostic tests for tuberculous peritonitis.     

腹内淋巴结结核的影像学诊断

OBJECTIVE: To evaluate the value of X-ray imaging for diagnosing abdominal tuberculous lymphadenopathy. METHODS: 27 cases of tuberculous lymphadenopathy proved by clinical or pathohistological evidence were collected, all of which were examined with radiological imaging methods. RESULTS: The typical CT findings enlarged lymph nodes with peripheral or multilocular enhancement. Enlarged lymph nodes with multiple flecked or massive calcifications were important for diagnosis. Ultrasound examination showed enlarged lymph nodes with uniform echo (less than 2 cm) and with heterogeneous echo (larger than 2 cm). The aim of the barium meal examination of the gastrointestinal tract was to find tuberculous lymphadenopathy encroaching on intestine or merged with intestinal tuberculosis. Abdominal X-ray plain film was helpful to find the calcified tuberculous lymphadenopathy and intestinal obstruction. CONCLUSIONS: Various imaging methods have shown their diagnostic value, but CT was the most important tool for definite diagnosis of tuberculous lymphadenopathy. Ultrasound was more useful for follow-up cases.     

An adult case of mediastinal tuberculous lymphadenitis]

A 40-year-old woman was admitted to the hospital with general fatigue and cough. Chest CT films revealed mediastinal lymphadenopathy with multiple low density areas, but no pulmonary lesions. There were no abnormal findings on neck, abdominal or pelvic CT. A PPD skin test was strongly positive, but M. tuberculosis bacilli were not found in the sputum. Mediastinal tuberculous lymphadenitis was diagnosed histologically and bacteriologically from specimens obtained by mediastinoscopy. Fiberoptic bronchoscopy did not reveal tracheobronchial tuberculosis. Follow-up chest CT three months after the start of antituberculosis chemotherapy with isoniazid, rifampicin and ethambutol hydrochloride showed that the mediastinal lymph nodes were decreased in size. Mediastinal tuberculous lymphadenitis in adults is rare, but the number of reports has increased. Mediastinal tuberculous lymphadenitis in adults must be distinguished from other causes of mediastinal masses. In this case, mediastinoscopy was very useful for differential diagnosis.     

The value of ADA in peritoneal tuberculosis]

The aim of this study was to confirm that ascitic fluid determination of adenosine deaminase activity (ADA) is useful for the diagnosis of tuberculous peritonitis. 109 patients with ascites have been studied; 4 had tuberculous peritonitis and 105 nontuberculous ascites. The mean value of ascitic fluid AQDA was 0.587 +/- 0.2 uKat/l in tuberculous peritonitis and 0.11 +/- 0.1 uKat/l in nontuberculous ascites (p less than 0.001). An ADA value upper than 0.40 uKat/l has a sensitivity of 100% and a specificity of 99% for diagnosing tuberculous peritonitis. Ascitic fluid determination of ADA is simple, cheap and has a good diagnostic accuracy. In countries with high incidence of tuberculosis, measurement of ADA in ascitic fluid should be used as screening test for tuberculosis.     

血清-腹水白蛋白梯度和腹水ADA、CA125在结核性腹膜炎诊治中的临床价值

[目的]探讨血清-腹水白蛋白梯度(SAAG)和腹水腺苷脱氨酶(ADA)、CA125对结核性腹膜炎的临床诊断价值。[方法]选取132例腹水患者进行回顾性分析,并将其分为4组:单纯性结核性腹膜炎组(A组)75例,肝硬化合并结核性腹膜炎组(B组)14例,肝硬化组(C组)17例,其他原因腹水组(D组)26例。对所有患者同一天的血清白蛋白及腹水白蛋白浓度进行检测,计算出SAAG;并测定腹水中的ADA、CA125浓度。[结果]以SAAG11g/L为临界值,诊断结核性腹膜炎的敏感度为96.6%(86/89)、特异性为74.4%(32/43)、准确率为89.4%(118/132),A、B组SAAG浓度显著低于C、D组(P0.05),A、B组间比较差异无统计学意义(P0.05);以ADA40U/L为临界值,诊断结核性腹膜炎的敏感性为92.1%(82/89)、特异性为97.7%(42/43)、准确率为93.9%(124/132),A、B组腹水ADA浓度与C、D组比较,差异有统计学意义(P0.05),A、B组间比较差异无统计学意义(P0.05),A、B组抗结核治疗前后腹水ADA浓度比较差异有统计学意义(P0.05);以CA12535U/ml为临界值,诊断结核性腹膜炎的敏感性为100%(89/89)、特异性为34.9%(15/43)、准确性为78.8%(104/132),各组腹水CA125浓度比较均差异无统计学意义(P0.05),A、B组抗结核治疗前后腹水CA125浓度比较差异有统计学意义(P0.05)。[结论]腹水ADA诊断结核性腹膜炎的敏感性、特异性、准确性均较高,并可作为判断结核性腹膜炎抗结核治疗疗效的观察指标;SAAG诊断结核性腹膜炎的敏感性较高,但特异性较低;腹水CA125对结核性腹膜炎无诊断价值,但可作为治疗疗效追踪的观察指标。     

A case of Vietnamese immigrant with tuberculous mediastinopericarditis

A case of vietnamese immigrant with tuberculous mediastinopericarditis was reported and the literature was reviewed. A 39 year-old man was admitted to our hospital with chief complaints of dyspnea and weakness. Blood chemistry suggested the existence of congestive liver dysfunction. Chest X-ray film revealed marked cardiomegaly and a abnormal mass in the anteriorly superior area which was confirmed as anterior mediastinum on CT scan. Echocardiogram disclosed a large volume of pericardial effusion and thickened pericardium. Tuberculin test was positive. Firstly, this mediastinal mass was believed to be malignant tumor and the pericardial effusion had originated from it. Finally, tuberculous mediastinopericarditis was diagnosed by detecting tuberculous mycobacterium from the cultured pericardial effusion and also the biopsied lymph nodes. Although occurrence of tuberculous mediastinopericarditis is rare at the present time in Japan, this disease has not been exterminated and should be kept in mind.     

T淋巴细胞斑点试验在结核性腹膜炎诊断中的临床应用价值

[目的]研究T淋巴细胞斑点试验(T-SPOT.TB)在结核性腹膜炎临床诊断中的应用价值。[方法]对40例结核性腹膜炎、38例非结核性腹膜炎的患者的腹腔积液实施T-SPOT结核试验。[结果]40例结核性腹膜炎患者中T-SPOT.TB阳性36例(阳性率90.00%),对照组38例非结核性腹膜炎T-SPOT.TB阳性3例(阳性率7.89%)。[结论]T-SPOT.TB是一种鉴别腹腔积液是否为结核性腹膜炎的较好的方法,具有很好的临床应用价值。     

Posterior mediastinal tuberculous lymphadenitis with dysphagia as the main symptom: a case report and literature review

Introduction

Mediastinal tuberculous lymphadenitis (MTL) is mostly seen in primary tuberculosis in children, uncommon observed in adults. It usually presents the toxic symptoms of tuberculosis but rarely with symptoms characteristic of esophageal compression, such as dysphagia. Such patients can easily be misdiagnosed as esophageal neoplasm and get delayed or faulty treatment.

Case report

A 32-year-old man presented with dull chest pain of one month and dysphagia of five days. CRP was elevated, and a skin test was strongly positive. At upper endoscopy, a protruding lesion covered by normal mucosa was seen at 26 cm from the upper incisor. Barium swallow showed visible external compressive stricture on the middle-lower esophagus with normal mucosal pattern. Chest computed tomography (CT) scan showed a subcarinal mass adjacent to the esophageal wall in posterior mediastinum. An endoscopic ultrasonography (EUS) revealed a hypoechoic lesion suspected of esophageal stromal tumor in the fourth layer. A tissue was obtained by ultrasound-guided fine-needle aspiration (EUS-FNA), but cytopathology, bacilliculture and PCR test had no special findings. The patient required experimental antitubercular treatment and the protruding lesion shrank gradually during therapy period.

Conclusions

MTL could not be ignored in the differential diagnosis of posterior mediastinal mass with dysphagia. Analyzing and evaluating test results comprehensively is the key to make correct diagnosis and timely treatment. The experimental antituberculous treatment should be used if MTL is highly suspected.KEYWORDS : Mediastinal, tuberculous lymphadenitis, dysphagia     

Mediastinal tuberculous lymphadenitis presenting as an esophageal intramural tumor： A very rare but important cause for dysphagia

Dysphagia associated with esophageal mechanical obstruction is usually related to malignant esophageal diseases. Benign lesions are rarely a cause for this type of dysphagia, and usually occur either as an intramural tumor or as an extrinsic compression. Mediastinal tuberculous lymphadenitis is rare in adults, and even more rarely causes dysphagia. We report two cases of dysphagia in adult patients caused by mediastinal tuberculous lymphadenitis, presenting radiologicaUy and endoscopically as an esophageal submucosal tumor. Based on the clinical and imaging diagnosis, the patients underwent a right thoracotomy, and excision of the mass attached to and compressing the esophagus. Pathological examination of the specimens showed a chronic granulomatous inflammation with caseous necrosis, which was consistent with tuberculous lymphadenitis.     

Mediastinoscopy in the case of recurrent uveitis

INTRODUCTION: The authors report the case of a patient who presented for 4 years recurrent anterior uveitis accompanied by asymptomatic tuberculous mediastinal lymphadenitis. EXEGESIS: CT scan of the chest showed the existence of mediastinal lymphadenopathy (< 1 cm). Mediastinoscopy with biopsy of the right laterotracheal lymph node was performed. The culture was positive for Mycobacterium tuberculosis, thus permitting the diagnosis of tuberculosis. CONCLUSION: This case report stresses the advantage of extensive etiological assessment when faced with unexplained uveitis; particularly it emphasizes the importance of investigating potential tuberculosis. The existence of granulomatous uveitis, a positive skin test, the ethnic origin, and mostly results of chest CT scan, were the rationale for the use of mediastinoscopy with lymph node biopsy to help guide diagnosis.