A case of Chlamydia trachomatis peritonitis mimicking tuberculous peritonitis

Lymphocytic ascites with low serum-ascites albumin gradient (SAAG) are observed mainly in tuberculous peritonitis, peritoneal carcinomatosis, and pancreatic disease. However, pelvic inflammatory disease (PID) induced generalized peritonitis causing diffuse ascites has been rarely described. We report a 26-year old female patient, who was diagnosed as generalized peritonitis with diffuse ascites due to Chlamydia trachomatis infection. Gynecologic examination did not show the clue of PID and in the analysis of ascites, low SAAG, predominant lymphocyte count and high level of adenosine deaminase were noted. Although the best impression was tuberculous peritonitis on the base of these findings, the laparoscopic finding was consistent with PID and the PCR for C. trachomatis infection in cervical swab was positive. This case suggests that C. trachomatis peritonitis should be considered as a rare cause of low SAAG and lymphocytic ascites in sexually active women and should be intensively evaluated including laparoscopic examination.     

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.     

A case of tuberculous peritonitis developed during chemotherapy for tuberculous pleurisy as paradoxical response

After the start of anti-tuberculous treatment, paradoxical worsening of tuberculous lesions has been described. However, abdominal tuberculosis as paradoxical response is relatively rare. This report describes the 26-year-old female who suffered from peritoneal tuberculosis while treating tuberculous pleurisy with anti-tuberculous medications. It was considered as paradoxical response, rather than treatment failure or else. She was successfully managed with continuing initial anti-tuberculous medications. When a patient on anti-tuberculous medications is presented with abdominal symptoms, the possibility of paradoxical response should be considered to avoid unnecessary tests and treatments, which may result in more suffering of the patient. Herein, we report a case of peritoneal tuberculosis as paradoxical response while treating tuberculous pleurisy.     

食管结核合并结核性腹膜炎1例

食管结核是结核杆菌侵及食管壁导致的一种少见的炎性肉芽肿性病变,其发病率低,易误诊.最容易混淆的疾病是食管癌和食管平滑肌瘤.食管结核常见症状为吞咽困难,胸骨后疼痛,消瘦和发热等,这些症状与食管平滑肌瘤、食管癌比较无特异性,术前诊断较困难.尤其是食管结核合并结合性腹膜炎更是少见.本文报道1例食管结核合并结核性腹膜炎,并结合文献,就诊断及治疗进行复习.     

A case of tuberculous peritonitis showing a rapid increase of bilateral pleural effusion

A 62-year-old man had been treated with INH, RFP, EB, and PZA for pulmonary tuberculosis. Six months after completing the treatment, he was admitted because of low grade fever and abdominal distension. His abdominal radiograph and CT showed ascites, which showed elevated ADA. He was diagnosed as tuberculous peritonitis, and treated with INH, RFP, and EB. Three days after starting treatment, the ascites abruptly disappeared, followed by bilateral pleural effusion and pulmonary edema. He was found to develop ARDS. His pleural fluid was removed and treated with steroid pulse therapy. In spite of improvement of dyspnea, general status gradually deteriorated and he died following two months and a half treatment. Ascites causing a marked increase in abdominal pressure in a patient with tuberculosis peritonitis might move into the thoracic cavity with an unknown mechanism, and the removal of ascites might be needed to prevent this phenomenon.     

结核性腹膜炎的诊断现状

结核性腹膜炎的诊断在结核病较常见的国家仍是一项挑战。该病的临床表现无特异性。以淋巴细胞为主的腹膜炎和低血清-腹水白蛋白梯度(＜11g/L)的患者应考虑结核性腹膜炎可能。腹水培养结核杆菌和经腹腔镜取腹膜活检标本是诊断结核性腹膜炎的重要方法。并讨论多聚酶链反应,腺苷脱氨酶和其他方法诊断结核性腹膜炎的价值。     

结核性腹膜炎的实验室诊断

目的评价聚合酶链反应（ＰＣＲ）结合Ｓｏｕｔｈｅｒｎ杂交技术及酶联免疫吸附试验（ＥＬＩＳＡ）对结核性腹膜炎的诊断价值。方法用ＰＣＲ结合地高辛标记核酸探针Ｓｏｕｔｈｅｒｎ杂交技术检测４２例结核性腹水中结核分支杆菌ＤＮＡ，并与常规细菌学检测及ＥＬＩＳＡ对比。引物来自结核分支杆菌特异重复插入序列ＩＳ６１１０。特异性通过杂交及限制性内切酶ＳａｌⅠ酶切证实。同时比较了Ｓｏｕｔｈｅｒｎ杂交检测与凝胶电泳检测的敏感性。结果ＰＣＲ的敏感性为６９％，ＥＬＩＳＡ为７１％，培养为９％，涂片镜检均为阴性。并发现杂交较凝胶电泳检测更敏感。结论ＰＣＲ和ＥＬＩＳＡ法对结核性腹膜炎有较高的诊断价值，但前者更具有特异性。将Ｓｏｕｔｈｅｒｎ杂交技术与ＰＣＲ技术结合，可进一步提高检测的敏感性和特异性。     

结核性腹膜炎的CT表现

目的探讨结核性腹膜炎(TBP)的CT特点,提高其诊断水平。方法分析32例经临床及病理证实为TBP的CT表现。结果 (1)壁腹膜增厚21例,其中光滑增厚18例、不规则增厚3例;(2)肠系膜改变24例;(3)大网膜改变19例;(4)腹水26例;(5)腹腔淋巴结增大6例。结论 CT能够为临床诊断TBP提供有价值的线索。     

A case of a young woman with tuberculous peritonitis diagnosed owing to high value of ADA

A 26-year-old woman visited the first hospital due to ascites in August 2003, She had continual abdominal pain diagnosed as Irritable bowel disease after a gastrointestinal and colon fiberscopy was performed. Chest-abdominal CT scan revealed normal chest, massive ascites and swollen ovary. To rule out malignancy, surgical biopsy was performed, which brought no significant findings. We focused on the high value of Adenosin deaminase (ADA) in ascites and strongly suspected tuberculotic peritonitis. Consequently, pathologist confirmed the existence of bacterial bodies stained by acid-fast stain after our consultation. Compared with the poor diagnostic accuracy of surgical biopsy, the value of ADA in ascites has a very high sensitivity and specificity. Considering the high risk of being infertile, to begin diagnostic medication of tuberculotic peritonitis is an acceptable choice for young women with a high value of ADA in the ascites.     

The spectrum of tuberculous peritonitis.

From 1966 to 1973, a total of 30 cases of tuberculous peritonitis were seen in Seattle-King County. Abdominal pain, swelling, and constitutional symptoms were the most frequent initial complaints. Radiographic abnormalities consistent with tuberculosis were present in 25 cases, and pulmonary disease was proven in ten. An initial tuberculin test with intermediate-strength purified protein derivative of tuberculin was negative in 19 of 27 patients. Six of 13 initial nonreactors still had negative reactions on repeat testing, and four appeared to be anergic when retested one to four months later. Ascites was present in 67% (20) of the 30 patients, and laparotomy was used most frequently to establish the diagnosis. Diagnosis was particularly difficult in 13 alcoholics, in whom the disease was usually unsuspected, the findings in the ascitic fluid were uncharacteristic, and negative tuberculin reactions were frequent. Peritoneal tuberculosis was a contributory cause of death in five cases. Three of these patients, who were also alcoholics, went undiagnosed and untreated. Two patients died of unrelated causes. Twenty-three have done well, and 19 have completed chemotherapy.