Tuberculous peritonitis complicating long-term peritoneal dialysis. Report of 5 cases and review of the literature

The characteristics of 5 patients who developed tuberculous peritonitis while receiving long-term peritoneal dialysis (PD) are presented. There were 2 males and 3 females. 3 patients were on intermittent and 2 were on continuous ambulatory peritoneal dialysis when tuberculous peritonitis was first diagnosed. None of the patients had recently received immunosuppression therapy or were diabetics. The clinical presentations were similar to other forms of peritonitis complicating PD except for a more insidious onset. As extraperitoneal involvement and peritoneal lymphocytosis were rarely present, the diagnosis was mainly dependent on the direct demonstration of Mycobacterium tuberculosis with smear (1 patient) and culture (4 patients). In 1 patient with a pleuroperitoneal communication, the diagnosis was made by pleural biopsy and a positive response to antituberculous therapy. All patients responded to treatment with a combination of three antituberculous drugs which included streptomycin, isoniazid, rifampicin and pyrazinamide. Two patients were transferred to hemodialysis. In 3 patients, peritoneal dialysis was continued. Peritoneal clearance and ultrafiltration capacity were unchanged for up to 16 months after treatment in 2 patients who continued peritoneal dialysis but was reduced by 30 and 50%, respectively, in the remaining patient. Only 1 patient died, but her death was not directly related to tuberculous peritonitis. It was concluded that with a high index of suspicion and early institution of treatment, tuberculous peritonitis complicating PD can be successfully treated with low mortality and without compromising the dialysis capacity of the peritoneal membrane.     

Perforation peritonitis in primary intestinal tuberculosis.

Primary intestinal tuberculosis is unusual in European and North American countries today. Its diagnosis is often surprising and differentiation from inflammatory bowel diseases is difficult. The authors present a rare case of severe stercoral peritonitis caused by multiple intestinal perforations in a patient with primary ileocecal tuberculosis. Initial clinical and laboratory investigations led to the suspicion of inflammatory bowel disease. The subsequent diagnostic workup included colonoscopic examination of the cecal and terminal region of the ileum with multiple biopsies. After the pathologist had assessed the specimen as indicating Crohn's disease, appropriate therapy was initiated. Several days later, however, the patient was readmitted to a surgical intensive care unit with clinical signs of peritonitis and immediately operated on. The final diagnosis from a resection specimen confirmed the diagnosis of primary intestinal tuberculosis. The follow-up was complicated by a subhepatic abscess formation with the necessity for surgical drainage. The patient's recovery was uneventful, she underwent intensive antituberculotic therapy and is asymptomatic at present. Surgeons caring for patients with acute abdomen should be aware of tuberculous perforation peritonitis even in non-risk groups of patients.     

Non-tuberculous and tuberculous mycobacterial peritonitis in peritoneal dialysis patients

Introduction: Peritoneal dialysis (pd)-associated mycobacterium peritonitis is an important clinical entity in patients with end stage renal disease. They present a significant diagnostic and therapeutic challenge for clinicians because clinical findings and laboratory investigations can not be differentiated from symptoms caused by non-tuberculous mycobacterium (ntm), Mycobacterium tuberculosis (tb) or other bacteria. The aim of the present article is to know the differences between the clinical manifestations and laboratory investigations, the appropriate diagnosis, treatment strategies and prognosis for tb and ntm disease in patients with pd-associated mycobacterial infections. Methods: This was a retrospective observational study conducted over a period of 25 years. Out of 1737 patients, only 7 were diagnosed with mycobacterial peritonitis. Result: Evaluable data showed that there were three patients diagnosed with ntm peritonitis and four patients with tuberculous peritonitis. The mean age of the patients was 53.9?±?11.8 years. Although all patients developed abdominal pain and cloudy dialysate, only four patients (57.1%) had fever. Two patients (28.6%) suffered severe sepsis and septic shock. Therefore, the patient survival rates for ntm and tuberculous peritonitis were 100.0% and 75.0%, respectively. Two patients were shifted to long-term hemodialysis; therefore, the technical survival rates for ntm and tuberculous peritonitis were 66.7% and 50.0%, respectively. Notably, recurrence of mycobacterial infection was found in one patient with both pulmonary tuberculosis and tuberculous peritonitis. Conclusion: The diagnosis of mycobacterial peritonitis remains a challenge to medical staffs because of its insidious nature, the variability of its presentation and the limitations of available diagnostic test.     

Tuberculous pseudoaneurysm of the femoral artery complicated by cutaneous tuberculosis of the foot: a case report

An infected pseudoaneurysm of the right common femoral artery in a 69-year-old patient receiving methotrexate therapy was confirmed to have been caused by Mycobacterium tuberculosis. After surgical excision of the aneurysm and revascularization using femoral vein, cutaneous manifestations of M tuberculosis infection in the foot complicated the course. We hypothesized that methotrexate may have triggered the reactivation of dormant tuberculosis in this patient. Because extrapulmonary tuberculous pseudoaneurysms are clinically similar to other types of infected pseudoaneurysm, M tuberculosis infection should always be suspected during the initial diagnosis. We propose that mycobacterial cultures should be routine when initial cultures and Gram stain are negative.     

Pulmonary and peritoneal tuberculosis in a CAPD patient

Patients with chronic renal failure have an increased incidence of tuberculosis due to decreased cellular immunity. More than half of the tuberculosis infection in these patients presented with extrapulmonary involvement. Tuberculous peritonitis is an important problem in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). Simultaneous pulmonary and peritoneal tuberculosis is a very rare condition. We describe a 39-year-old man with culture negative CAPD peritonitis. In spite of conventional antimicrobial therapy the patient had persistent fever, weight loss, and night sweats. Approximately after one month from starting treatment, both sputum specimen and peritoneal fluid were positive for mycobacterium. Quadruple therapy for tuberculosis has been started. The response to treatment was promptly. He is still on treatment for six months and receiving CAPD. Tuberculous peritonitis should always be considered when patients on CAPD develop culture negative peritonitis treated with conventional antibiotics without improvement. In addition, the existence of extraperitoneal tuberculosis, especially pulmonary disease must be investigated.     

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.     

Hypercalcemia, inappropriate calcitriol levels, and tuberculosis on hemodialysis

We describe a female patient undergoing hemodialysis who developed tuberculosis, hypercalcemia, and inappropriately elevated calcitriol levels. These findings suggest ectopic production of calcitriol by tuberculous granulomas. Successful treatment of tuberculosis led to a substantial decrease in the levels of calcium and calcitriol.     

Hypercalcemia in a patient with tuberculous adrenal insufficiency

OBJECTIVES: To raise awareness of hypercalcemia as a rare and at times inaugural manifestation of adrenal insufficiency. CASE REPORT: Evaluation of hypercalcemia in a 43-year-old man showed adrenal insufficiency. Biopsies of the testes and adrenal glands revealed epithelioid and giant cell lesions indicating tuberculosis. Although tuberculosis can contribute to hypercalcemia, this possibility was ruled out in our patient by the low serum 1,25-dihydroxy-vitamin D3 levels and return to normal of serum calcium and renal function under hormone replacement therapy. It should be noted, however, that a course of pamidronate was given. CONCLUSION: The mechanism of hypercalcemia associated with adrenal insufficiency is controversial. Hyperparathyroidism was ruled out in our patient. Adrenal insufficiency should be considered in some patients with hypercalcemia.     

Value of gamma interferon enzyme-linked immunospot assay in the diagnosis of peritoneal dialysis-associated tuberculous peritonitis

International Urology and Nephrology - Tuberculous peritonitis is the most common form of extrapulmonary tuberculosis infection in peritoneal dialysis patients. However, diagnosing tuberculous...     

Hypercalcémie associée à une insuffisance surrénalienne d’origine tuberculeuse

Objectives. To raise awareness of hypercalcemia as a rare and at times inaugural manifestation of adrenal insufficiency. Case-report. Evaluation of hypercalcemia in a 43-year-old man showed adrenal insufficiency. Biopsies of the testes and adrenal glands revealed epithelioid and giant cell lesions indicating tuberculosis. Although tuberculosis can contribute to hypercalcemia, this possibility was ruled out in our patient by the low serum 1,25-dihydroxy-vitamin D3 levels and return to normal of serum calcium and renal function under hormone replacement therapy. It should be noted, however, that a course of pamidronate was given. Conclusion. The mechanism of hypercalcemia associated with adrenal insufficiency is controversial. Hyperparathyroidism was ruled out in our patient. Adrenal insufficiency should be considered in some patients with hypercalcemia.     

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.     

Tuberculous peritonitis in a CAPD patient cured without catheter removal: case report, review of the literature, and guidelines for treatment and diagnosis

Tuberculous peritonitis in the chronic peritoneal dialysis patient carries a high mortality, which may reflect the diagnostic delay that is often encountered in these cases. Accordingly, a high index of suspicion and an aggressive diagnostic approach (which may include laparoscopic biopsy) should be applied to the patient with persistent culture negative peritonitis. One of the first continuous ambulatory peritoneal dialysis (CAPD) cases involving tuberculous peritonitis successfully treated without interruption of dialysis or removal of the peritoneal dialysis catheter is reported. The literature is reviewed to provide diagnostic and therapeutic guidelines in dealing with this serious infection.     

A case of tuberculous tenosynovitis in a patient with systemic lupus erythematosus.

A 52-year-old woman with systemic lupus erythematosus (SLE) was infected with tuberculosis (TB) on her forearm and hand, after 16 years of steroid therapy. Debridements and anti-TB therapy were performed successfully. Recently, the risk of significant morbidity from TB has been on the rise; this appears to be a complication of steroid therapy used to treat AIDS and some collagen vascular diseases. It is thought that steroid therapy causes an increased risk of TB. In this paper, we report our experience of this SLE patient who developed tuberculous tenosynovitis. We suggest that TB infection must be considered in the differential diagnosis whenever a patient presents with a chronic wrist or hand inflammation that is non-responsive to steroid treatment. Once TB infection is suspected, both histopathological and bacteriological examinations should be performed. Emergent treatment includes surgical debridement and the institution of early anti-TB therapy immediately after completing histopathological examination.     

腹腔镜技术诊断结核性腹膜炎的应用价值

目的:探讨腹腔镜技术诊断结核性腹膜炎有效性及安全性.方法:回顾分析2006年1月至2011年1月为36例疑为结核性腹膜炎的患者行腹腔镜探查术的临床资料,并收集临床数据、腹水成分、组织病理活检进行临床评估.结果:32例患者经组织学活检及抗酸杆菌培养确诊为结核性腹膜炎,其中19例以腹腔粘连为临床表现,13例表现为腹水,腹腔镜确诊率为88 9％.术后无并发症发生,均经规范抗结核治疗治愈.结论:腹腔镜探查术是诊断结核性腹膜炎安全、准确的方法.     

Tuberculous peritonitis in no risk patients: diagnostic approach

BACKGROUND: Incidence of tubercoulosis is increasing in Western countries particularly in immigrants from endemic areas and in patients with HIV or immunocompromised. The disease is unusual in patients without risk factors. In these conditions the diagnosis of tuberculous peritonitis is often delayed, resulting in high morbidity and mortality. METHODS: We describe a case of tuberculous peritonitis in a man suffering from ascites referred for presumed peritoneal carcinosis. The finding of no malignancies in the peritoneal fluid must rise the suspect of tuberculosis that, if misdiagnosed, is fatal. The patient was submitted to diagnostic videolaparoscopy and multiple biopsies were done. The definitive histological diagnosis was chronic granulomatous flogosis with giant cells, focally necrotizing, caused by peritoneal tubercolosis. RESULTS: The patient was submitted to chemotherapy with isoniazide, rifampicine, piazafoline, ethambutol and streptomycine which determined the resolution of the clinical picture. CONCLUSIONS: We believe the diagnostic procedure of choice is videolaparoscopy when tubercolous peritonitis is suspected. This technique allows to obtain selective biopsies of peritoneal nodules and to collect samples for specific cultural and cytohistological exams. The operation is safe, reliable with few complications and permits a prompt diagnosis necessary to cure the patient.     

Haematogenous tuberculous infection following revision of a loosened total hip replacement

A case of tuberculous arthritis complicating revision of a total hip replacement (THR) is reported. Primary THR was performed for arthrosis of the hip and the patient underwent revision because of aseptic loosening. After this surgical procedure, secondary infection with Mycobacterium tuberculosis occurred. Bacterial contamination due to haematogenous spread probably from a reactivated old quiescent tuberculous pleural focus is proposed as the most likely source of infection in this patient. Tuberculous infections in THR are rare but prophylactic use of antituberculous drugs in patients with a history of tuberculosis may reduce the risk of reactivation of old foci and serve to eliminate contamination of prosthetic replacements. Received: 15 May 1997     

Total hip arthroplasty complicated by tuberculous infection

The case of a 66-year-old woman with tuberculous infection complicating a total hip arthroplasty that had been performed 4 years previously for degenerative arthritis is reported. The patient had no prior history of exposure to tuberculosis and no evidence of skeletal or nonskeletal tuberculous infection. The need for a high index of suspicion when dealing with unexpected arthroplasty failure is emphasized. Tuberculous cultures are recommended in these cases prior to revision surgery.     

Ventriculoperitoneal shunt for hydrocephalus secondary to tuberculous meningitis: a case report

A case of hydrocephalus secondary to tuberculous meningitis is reported. A 6-month-old baby was admitted to our hospital with a 10-day history of high fever. Neurological examination revealed no abnormal findings other than neck stiffness. Cerebrospinal fluid findings suggested tuberculous meningitis, because of pleocytosis (608/mm3, 100% lymphocytes) and reduced sugar content (19 mg/dl). Mycobacterium tuberculosis was found in cerebrospinal fluid culture. Although anti-tuberculous therapy was administered for 2 weeks, deterioration of consciousness and papilledema appeared. CT scan demonstrated enlargement of the entire ventricular system, indicating communicating hydrocephalus. After a ventricular drainage was performed, consciousness disturbance improved, but the high fever persisted. Judging by cerebrospinal fluid findings, the meningitis seemed to be in the active stage. Therefore an Ommaya reservoir was installed instead of a cerebrospinal fluid shunt for fear of disseminating the tuberculous infection through the shunt tube. However, the hydrocephalus was not well controlled. Consequently, a ventriculoperitoneal shunt was placed, despite the fact that the disease was still active. The fever then gradually subsided, and cerebrospinal fluid findings normalized. The patient was discharged without any neurological deficits one month after emplacement of the ventriculoperitoneal shunt. The antituberculous therapy has been continued, and there is no sign of infection propagated through the shunt 13 months following discharge from the hospital. The result suggests that a cerebrospinal fluid shunt can be placed for hydrocephalus even in the active stage of tuberculous meningitis under antituberculous therapy.     

获得性免疫缺陷综合征合并新型隐球菌性脑膜炎及结核性脑膜炎一例并相关文献复习

目的提升对获得性免疫缺陷综合征（AIDS）合并中枢神经系统新型隐球菌及结核分枝杆菌混合感染的认知。 方法分析1例AIDS合并新型隐球菌性脑膜炎及结核性脑膜炎患者的诊疗过程，并结合相关文献进行复习。 结果1例38岁男性患者因AIDS合并新型隐球菌性脑膜炎于2015年3月17日于武汉大学中南医院住院诊治，完善检查后确诊为新型隐球菌及结核分枝杆菌颅内混合感染，给予抗感染及对症综合治疗后，病情缓解，预后较好。 结论AIDS合并隐球菌性脑膜炎及结核性脑膜炎患者应及时诊断，予以抗隐球菌、抗结核综合治疗并适时启动抗逆转录病毒治疗，可改善预后。     

腹腔镜探查术对结核性腹膜炎的诊断分析

目的 分析腹腔镜探查术对结核性腹膜炎的诊断价值.方法 选择从2003年到2009年间治疗的26例疑诊为结核性腹膜炎并行腹腔镜探查术的患者,回顾性分析患者的临床资料,评价腹腔镜探查术的诊断价值.结果 组织学活检确诊了20例患者为结核性腹膜炎,结核的诊断率为76.9%.其余6例患者中,4例患者为腹腔内广泛性的恶性肿瘤,2例...