Duodenal tuberculosis: a review of the clinicopathologic features and management of twelve cases

A retrospective analysis of twelve cases of duodenal tuberculosis is presented herein. The average age of the patients was 31.4 years with a male to female ratio of 2:1. The presenting complaints were duodenal obstruction in six patients and subacute intestinal obstruction in three. None of the patients had associated pulmonary tuberculosis. Eight patients had isolated duodenal tuberculosis, two of whom were successfully treated with antitubercular drugs. In four patients, the diagnosis was established at laparotomy by the presence of tubercles over the duodenum. Five patients required a bypass procedure for obstruction caused by the duodenal tuberculosis and one patient was operated on for uncontrollable bleeding from a tubercular duodenal ulcer. All patients remained symptom free after treatment, whether medical or surgical. Thus, in areas where tuberculosis is endemic, even in the absence of pulmonary tuberculosis, duodenal tuberculosis should be suspected in patients with upper gastrointestinal obstruction or in patients with peptic ulcer like symptoms not responding to medical therapy.     

Duodenal tuberculosis: A review of the clinicopathologic features and management of twelve cases

A retrospective analysis of twelve cases of duodenal tuberculosis is presented herein. The average age of the patients was 31.4 years with a male to female ratio of 2:1. The presenting complaints were duodenal obstruction in six patients and subacute intestinal obstruction in three. None of the patients had associated pulmonary tuberculosis. Eight patients had isolated duodenal tuberculosis, two of whom were successfully treated with antitubercular drugs. In four patients, the diagnosis was established at laparotomy by the presence of tubercles over the duodenum. Five patients required a bypass procedure for obstruction caused by the duodenal tuberculosis and one patient was operated on for uncontrollable bleeding from a tubercular duodenal ulcer. All patients remained symptom free after treatment, whether medical or surgical. Thus, in areas where tuberculosis is endemic, even in the absence of pulmonary tuberculosis, duodenal tuberculosis should be suspected in patients with upper gastrointestinal obstruction or in patients with peptic ulcer like symptoms not responding to medical therapy     

Duodenal tuberculosis

Duodenal tuberculosis is an uncommon disease. It may be either extrinsic or intrinsic or both. In the extrinsic type there can either be primary duodenal involvement or compression due to enlarged paraduodenal lymph nodes. The clinical presentation can be dyspeptic or obstructive symptoms. The dyspeptic symptoms include epigastric pain, nausea, and occasional vomiting and obstructive symptoms include bilious vomiting frequently after meals, epigastric pain, and generalized abdominal pain. This report describes a young lady presenting with gastric outlet obstruction symptoms due to tuberculous adhesion involving the proximal duodenum.     

Portal vein thrombosis following laparoscopic surgery in a patient with sickle cell disease

A 28-year-old woman presented with abdominal pain, anorexia, low-grade pyrexia, and a palpable abdominal lump. An abdominal CT scan revealed a mass in the region of the pancreatic head comprised of enlarged lymph nodes interspersed with loculi of pus. Because a fine-needle aspiration failed to establish a diagnosis, the abscess was drained laparoscopically and biopsy specimens were obtained; the specimens confirmed lymph nodal tuberculosis. Postoperatively, the patient received a 9-month course of antitubercular therapy; she remains asymptomatic on follow-up. To the best of our knowledge, this is the first report describing the use of laparoscopy for the drainage of a peripancreatic tuberculous abscess.     

Duodenal perforation in a 14-year-old boy with abdominal tuberculosis despite being on antituberculous treatment

We are presenting a case of a 14-year-old male patient with known history of abdominal tuberculosis on medication for 4 months with frank peritonitis and air under the diaphragm found to have primary perforation of the duodenum due to tuberculosis. Tuberculosis is common in the third world but affects iliocaecal junction commonly. Cases with tuberculous duodenal are rarely reported in the literature.     

Fine needle aspiration biopsy of tuberculous cervical lymphadenopathy

Fine needle aspiration biopsies of 42 histologically confirmed tuberculous cervical lesions were studied. Thirty-four patients had subsequent excision of cervical lymph nodes and eight had incision and drainage of cervical abscesses. All aspirates except two (which were inadequate) were satisfactory for diagnosis and contained inflammatory cells. Twenty-seven smears revealed cells typical of granulomatous lymphadenopathy, that is, epithelioid and multinucleated giant cells. Of all aspirates, 17 smears had bacteriological staining by Ziehl-Nielsen technique, nine of which (53%) were positive for acid-fast bacilli. An aspiration biopsy diagnosis of granulomatous or tuberculous cervical lymphadenopathy was made in 30 patients (71%). In regions where mycobacterial infection is common, the presence of granulomatous changes in lymph node aspirates is highly suggestive of tuberculosis. When the aspirates contain purulent material or when tuberculosis is suspected, staining and culture for mycobacteria should be performed. FNA biopsy is a sensitive, specific and cost-effective way to diagnose tuberculous cervical lymphadenopathy and is recommended.     

Primary Gastric Tuberculosis Mimicking Gastric Tumor That Results in Pyloric Stenosis

Summary BACKGROUND: Primary gastric tuberculosis is rarely seen. It usually produces a diagnostic challenge and may mimic peptic ulcer disease and even a neoplasia. We present a case of primary gastric tuberculosis initially thought to be a neoplasia. METHODS: A 46-year-old female was admitted with one-month history of nausea, vomiting and weight loss. A barium swallow showed a constant filling defect in the antral and prepyloric region. On upper endoscopy, an 8 cm mass was noted in antral and prepyloric regions. The biopsy specimens taken during endoscopy were insufficient for precise diagnosis. An operative diagnosis of gastric carcinoma leading to pyloric stenosis without any distant metastasis was made; a subtotal distal gastrectomy and roux-en-Y gastroenterostomy procedure was therefore applied. RESULTS: Pathologic evaluation revealed necrotic granulomatous inflammation throughout the wall of corpus, necrotizing granulomatous lymphadenitis in the lesser and greater curvature lymph nodes, and also in omentum. There were no findings of carcinoma. Ehrlich-Ziehl-Nielsen staining method revealed numerous acid-fast bacilli. Despite extensive studies, no evidence of extragastric tuberculous involvement was discovered, and she was prescribed an antituberculosis therapy for a period of one year. The patient remains asymptomatic. CONCLUSIONS: Primary gastric tuberculosis usually produces a diagnostic challenge and may mimic peptic ulcer disease and even a neoplasia.     

Gastric outlet obstruction due to duodenal tuberculosis: a case report

A 17-year-old boy was operated on for gastric outlet obstruction; laparotomy revealed a mass with nodules in the first part of the duodenum and multiple mesenteric lymph nodes. The histopathological examination of the duodenal mass and the lymph nodes showed caseating tuberculosis. Because of the rarity of duodenal tuberculosis, the case is reported herewith.     

Tuberculosis of the common bile duct

The intrahepatic biliary tree can occasionally be infected by Mycobacterium tuberculosis, but tuberculosis of the common bile duct has not previously been reported. A 38-year-old man with obstructive jaundice, who was originally thought to have cholangiocarcinoma associated with opisthorchiasis (a common combination in Thailand), was finally proved to have tuberculosis of the common bile duct with adjacent tuberculous lymphadenitis. Following T-tube drainage and antitubercular therapy, he made a complete recovery. The importance of a tissue diagnosis in all cases of obstructive jaundice is emphasized to avoid missing rare but curable diseases.     

Rupture of ascending aorta secondary to tuberculous aortitis

Tuberculous aortitis generally develops at the distal aortic arch and the descending aorta that are close to specific groups of mediastinal lymph nodes, but exceptionally it develops in the ascending aorta. We report a case of rupture of the ascending aorta after tuberculous aortitis in a 53-year-old man without a history of tuberculosis or evidence of a primary foci who underwent cardiopulmonary resuscitation due to severe hemoptysis with subsequent cardiac arrest. The tuberculous aortitis associated with rupture of the ascending aorta was treated with surgical resection and in situ graft placement.     

Six-month combination chemotherapy for cervical tuberculous lymphadenitis

A prospective study was undertaken to determine the effectiveness of a 6-month four-drug regimen in the treatment of 123 patients with cervical tuberculous lymphadenitis. The results showed that the disease was satisfactorily controlled with residual lymph nodes which did not necessitate further chemotherapy in 14.6% of patients at 3 years follow-up. Recurrence requiring further chemotherapy occurred in 3.3% of patients between 9 and 28 months. Wound sinuses occurred in 3.3% of patients and all healed with conservative treatment. The culture results and numbers of lymph nodes at presentation had no effect on outcome at 3 years. An excisional procedure was associated with a lower incidence of residual lymph nodes than an incisional biopsy. Minor gastrointestinal upset from drug treatment was common, but only 2.4% of patients needed a change of regimen. Six months of combination chemotherapy is adequate for the treatment of the disease.     

Congenital spinal tuberculosis associated with asymptomatic endometrial tuberculosis: A rare case report

Spinal tuberculosis constitutes 50% of all musculoskeletal tuberculosis. However, literature regarding congenital spinal tuberculosis is very scanty. Congenital spinal tuberculosis was diagnosed in a two-month-old child on the basis of age at presentation (gibbus since three weeks of age), hepatomegaly, raised ESR, radiological destruction of D10-D11 vertebrae, asymptomatic maternal endometrial tuberculosis and tuberculous histopathology from CT guided biopsy specimen from D10 vertebra. Both child and mother were treated by antitubercular treatment. Child improved symptomatically, gibbus became less prominent and ESR became normal at the end of one year of treatment. Patient had no recurrence during last two years of follow-up. This is the first case of congenital tuberculosis of spine with a documented source of infection from asymptomatic maternal endometrial tuberculosis. CT guided core biopsy from vertebra/aspiration from the paravertebral abscess help in early diagnosis and treatment to reduce neurological morbidity and mortality. Endometrial biopsy help in establishing the diagnosis of congenital tuberculosis and adequate antitubercular treatment in such cases may provide protection to fetus in subsequent pregnancy.     

Tuberculosis as a late complication of total hip replacement

A case of tuberculosis developing in a hip joint which had undergone total prosthetic replacement arthroplasty 7 years previously is described. The patient had no manifestation of active systemic tuberculosis although calcified mesenteric nodes were noted on abdominal X-ray. It is assumed that hip joint infection occurred during a bacteraemia following activation of a latent tuberculous focus in the mesenteric lymph nodes.     

Tuberculosis as a Late Complication of Total Hip Replacement

A case of tuberculosis developing in a hip joint which had undergone total prosthetic replacement arthroplasty 7 years previously is described. The patient had no manifestation of active systemic tuberculosis although calcified mesenteric nodes were noted on abdominal X-ray. It is assumed that hip joint infection occurred during a bacteraemia following activation of a latent tuberculous focus in the mesenteric lymph nodes.     

Membranous nephropathy and granulomatous interstitial nephritis due to tuberculosis

Tuberculous involvement of the genitourinary tract is well reported in the literature. However, reports of glomerular lesions of the kidney due to tuberculosis are rare. Tuberculosis has been identified as the most common infectious cause of granulomatous interstitial nephritis (GIN). We report a 23-year-old female patient with a membranous nephropathy and GIN due to tuberculosis. She presented with renal failure and nephrotic-range proteinuria, both of which resolved with the treatment of tuberculosis. There is only one report, from Japan, of a patient with membranous nephropathy and tuberculous granulomatous nephritis. Our patient is the second with tuberculous GIN and membranous nephropathy. In our patient, the close temporal relationship between the infection and glomerulonephritis, an ulcerated tuberculin skin test, the response to the treatment and the absence of any other systemic disease that might cause the glomerulonephritis suggested an association between tuberculosis and membranous nephropathy. However, a causal association can only be speculation, because membranous nephropathy could remit spontaneously. It is also possible that it might relapse at a later date when the tuberculosis is inactive. Therefore, the association might be either coincidental or causal, and could become clearer as similar patients are reported.     

Peripheral tuberculous lymphadenopathy: a review of 67 cases.

Peripheral tuberculous lymphadenopathy is the commonest form of extrapulmonary tuberculosis. Sixty-seven patients with peripheral tuberculous lymphadenopathy who presented to general surgeons and underwent lymph node biopsy between 1979 and 1989 are reviewed. Fifty-four patients (81 per cent) were of Indian subcontinent ethnic origin and 13 (19 per cent) were of white ethnic origin. The sites most commonly affected were the cervical lymph nodes. Biopsy specimens obtained by open operation were sent for microbiological examination in all but 13 cases, of whom seven were patients of white ethnic origin. Tuberculous lymphadenopathy remains an important differential diagnosis of cervical lymphadenopathy and it is essential that peripheral lymph node biopsies are examined both histologically and microbiologically.     

The coincidence of mediastinal tuberculosis lymphadenitis in lung cancer patients

Mediastinal lymph node enlargement in operable non-small cell lung cancer is of clinical importance since it indicates the high possibility of nodal metastasis. The coincidence of tuberculosis and lung cancer is detected by the mediastinal lymph node staging of lung cancer patients. In our study, we retrospectively re-evaluated the records of patients who had been hospitalized with the diagnosis of lung cancer for the past 10 years. The mean age was 58 +/- 10 years (ranging from 39 to 72). A tuberculous lymphadenitis was detected in 16 of the 315 (5.1%) patients in one and/or multiple stations by either mediastinoscopy or thoracotomy. Inferior paratracheal lymph nodes (4R-4L) were the most frequently affected. None of the patients had a history of primary tuberculosis infection. The cell type was squamous cell carcinoma in ten patients (62.5%) and adenocarcinoma in six patients (37.5%). The tumour was located in the right lung in nine patients (56.2%). The most frequently involved site was the right upper lobe (n = 13, 81.2%). N2 disease was detected in six patients (37.5%). Our study showed that 5.1% of lung patients had tuberculous lymphadenitis coincidentally. The diagnosis and treatment of this latent disease could be considered as important, especially in lung cancer patients who would potentially receive radiotherapy or chemotherapy which alters the immune system. However, the real value of this finding needs further study.     

Primary Duodenal Tuberculosis: a Case Report

Gastroduodenal tuberculosis (TB) is a rare condition and is often associated with pulmonary TB. We report the case of a primary duodenal TB in an immunocompetent patient without evidence of pulmonary TB. Diagnosis of this disease is difficult and is often confused with chronic peptic ulcer disease. Literature data concerning this challenging diagnosis are analysed.     

Pancreatic tuberculosis: a medical disease posing surgical dilemmas

Pancreatic tuberculosis is a rare clinical setting manifesting in various ways. Most often, enlarged peripancreatic lymph nodes or growing tuberculomas compress adjacent organs, leading to biliary tract or gastrointestinal obstruction. Clinical examination, laboratory data, and imaging are all unspecific. Diagnosis is frequently misguided toward neoplasia requiring surgical intervention. However, the role of surgery in pancreatic tuberculosis ends in tissue sampling, abscess drainage, and bypassing obstruction. We present three cases of pancreatic tuberculosis: two caused by obstructive jaundice and the third caused by gastric outlet obstruction. All patients were operated on. Whipple's procedure was performed in one patient, and biliary and duodenal bypassing in the remaining patients. Diagnosis was decided by histopathology in all three cases. Medical treatment was effective in all patients. Although pancreatic tuberculosis is a medical disease, surgery is frequently used. Maintaining a high level of suspicion can assist in avoiding unnecessary laparotomies and solving this medical dilemma.     

The Coincidence of Mediastinal Tuberculosis Lymphadenitis in Lung Cancer Patients

Mediastinal lymph node enlargement in operable non-small cell lung cancer is of clinical importance since it indicates the high possibility of nodal metastasis. The coincidence of tuberculosis and lung cancer is detected by the mediastinal lymph node staging of lung cancer patients.

In our study, we retrospectively re-evaluated the records of patients who had been hospitalized with the diagnosis of lung cancer for the past 10 years. The mean age was 58 ± 10 years (ranging from 39 to 72).

A tuberculous lymphadenitis was detected in 16 of the 315 (5.1%) patients in one and/or multiple stations by either mediastinoscopy or thoracotomy. Inferior paratracheal lymph nodes (4R-4L) were the most frequently affected. None of the patients had a history of primary tuberculosis infection. The cell type was squamous cell carcinoma in ten patients (62.5%) and adenocarcinoma in six patients (37.5%). The tumour was located in the right lung in nine patients (56.2%). The most frequently involved site was the right upper lobe (n = 13, 81.2%). N2 disease was detected in six patients (37.5%).

Our study showed that 5.1% of lung patients had tuberculous lymphadenitis coincidentally. The diagnosis and treatment of this latent disease could be considered as important, especially in lung cancer patients who would potentially receive radiotherapy or chemotherapy which alters the immune system. However, the real value of this finding needs further study.