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Case Presentation

Case Presentation. Ezana M. Azene. HPI – Day 1. 35 y/o immigrant from Guatemala living in U.S. for past 3 years CC: 3 months burning left-sided abdominal pain radiating to epigastrium and back. Physical Exam – Day 1. Febrile

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Case Presentation

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  1. Case Presentation Ezana M. Azene

  2. HPI – Day 1 • 35 y/o immigrant from Guatemala living in U.S. for past 3 years • CC: 3 months burning left-sided abdominal pain radiating to epigastrium and back

  3. Physical Exam – Day 1 • Febrile • Abdomen soft with moderate TTP diffusely, mild guarding without rebound, normal bowel sounds, possible splenomegaly • Remainder of exam normal

  4. Relevant Initial Lab-work – Day 1 • Hct: 26↓, WBCC: 3.3 ↓ (4% ↓ lymphocytes) • Alb: 1.7↓, TP: 7.3 (gamma gap = 5.6↑) • AlkPhos: 727 ↑ (with GGT↑), AST 116 ↑, ALT 81 ↑ • Lipase: normal

  5. Initial CE CT – Day 1 2 cm MIP

  6. Initial CE CT – Day 1

  7. Initial CE CT – Day 1

  8. Initial CE CT – Day 1

  9. CT report – Day 1 • “… very suggestive of mycobacterial … infection. Extensive fat stranding makes lymphoma or other malignancy less likely.”

  10. Admitting Plan • IV fluids • HIV serology • TB w/u (including sputum AFB and sputum/blood culture) • Negative pressure isolation and droplet precautions

  11. Abdominal U/S – Day 2 Increased omental echogenicity Omentum Spleen

  12. U/S Report • “Mass-like thickening of the omentum. Findings worrisome for TB peritonitis”

  13. Hospital Course Sputum AFB negative Culture negative • HIV positive (CD4 ~ 60) – Day 2 • ID consult – Day 2 • DDx: Lymphoma > disseminated histoplasmosis > typhoid fever > TB > septic emboli • “Would continue off antimicrobial therapy” • Recommended tissue biopsy • Hematology consult – Day 4 • DDx: Lymphoma > TB

  14. Hospital Course Sputum AFB negative Culture negative • Abdominal paracentesis – Day 5 • Reactive cells, no malignancy • AFB negative • Cultures pending • Respiratory isolation stopped – Day 5 or 6 • Bone marrow biopsy – Day 6 • Negative • Echocardiogram – Day 10 • Normal

  15. Hospital Course • Unstable, ICU transfer – Day 10 • Non-con CT: calcified perihepatic lymph node (missed on CE CT) • Liver core biopsy – Day 11 • Granuloma with rare filamentous AFB • TB Rx started – Day 11 (I think…) Actinomyces? TB? Nocardia?

  16. Hospital Course • CT guided omental biopsy – Day 12 • Benign fibroadipose tissue with focal granuloma • Patient rapidly improved and discharged home – Day 19

  17. Post-Hospital Course • Initial induced sputum cultures positive for TB 4 days after discharge • Initial blood cultures positive for TB 1 day after discharge • Liver biopsy culture positive for TB 4 days after discharge • Omental biopsy culture positive for TB 6 days after discharge • Ascites was never positive for TB or AFB

  18. Current Patient Status • Not fully compliant with D.O.T.S. and HAART • May need incarceration

  19. Mechanism of Spread to Peritoneum, Omentum, and Mesentery • Infection of GI mucosa by contaminated milk or swallowed sputum followed by transmural spread • Direct hematogenous spread • Lymphatic spread with direct extension • e.g. from ruptured necrotic lymph nodes Through the Laparoscope Tiny peritoneal nodules (appear confluent on CT) Ascites Omental thickening Eur Radiol (2004) 14:E103–E115 The Internet Journal of Infectious Diseases. 2010 Volume 8 Number 2

  20. Frequency of TBP • TB peritonitis occurs in < 4% of TB patients • However, in developing countries, up to … • 30% of non-pulmonary TB involves TB peritonitis • 20% of all ascites is due to TB peritonitis • Increased risk with alcoholism, cirrhosis, renal failure, diabetes mellitus, malignancy, intravenous drug abuse, steroid therapy, and AIDS. Eur Radiol (2004) 14:E103–E115 Singapore Med J 2008; 49(6) : 488

  21. Mortality of TBP • 15-60% in post-antibiotic era • Higher when hepatic cirrhosis present • “The high mortality for tuberculousperitonitis is explained, at least in part, by its highly variable and often nonspecific clinical presentation and the practical difficulties in establishing an early bacteriologic diagnosis.” • EARLY INITIATION OF THERAPY REDUCES MORTALITY Chow et al. Clinical Infectious Diseases 2002; 35:409–13

  22. Classic Types of TBP (basically useless) • Wet type (90%) • Free or loculatedascites • Fibrotic fixed type occurs (60%) • Omental masses and matted loops of bowel and mesentery • Dry or plastic type (10%) • Caseous lymph nodes, fibrous peritoneal reaction, and dense adhesions • Our case was Wet + Dry Journal of Clinical Imaging 28 (2004) 340–343

  23. Biochemical Diagnosis of TBP • Adenosine Deaminase elevated in ascites • In one meta-analysis, ADA levels showed high sensitivity (100%) and specificity (97%) • CA 125 may be elevated (mimicking ovarian CA) J ClinGastroenterolVolume 40, Number 8, September 2006

  24. Microbiological Diagnosis of TBP • Ascites smear, PCR and culture have extremely low sensitivity (<5% in most studies) • Lymphocytic exudate usually present • Tissue biopsy usually needed • Omentum or lymph nodes • Granulomas (usually caseating) • Not always smear positive • High sensitivity with liquid culture J ClinGastroenterol Volume 40, Number 8, September 2006

  25. CT Appearance Suggestive of TBP • Smooth, mild, non-nodular peritoneal thickening with pronounced enhancement • “Smudged” appearance of omentum (extensive stranding) • Presence of mesenteric macronodules (> 5 mm) • Splenic hypodensities and splenomegaly • Low density and/or calcified lymph nodes • Ascites may be higher density than water Journal of Computer Assisted Tomography Volume 20(2), March/April 1996, pp 269-272 Eur Radiol (2004) 14:E103–E115 Singapore Med J 2008; 49(6) : 488

  26. US Appearance of TBP • Increased omental echogenicity • Diffuse, hypoechoic peritoneal thickening (2-6 mm) • Echogenic fibrous strands creating locculations of ascites • Most useful for guiding biopsy

  27. DDx • Omental and peritoneal findings • Malignancy (carcinomatosis (esp. ovaian), mesothelioma, lymphoma) • Non-TB peritonitis • Hypodense lymph nodes • Whipple disease • Typhoid fever • Celiac Disease • Burkitt/Burkitt-type lymphoma • Treated lymphoma and necrotic metastases • Splenic Hypodensities • Lymphoma • Sarcoidosis • Non-TB microabscesses • Lymphatic malformations • Vascular anomalies

  28. Summary • TB peritonitis carries high mortality and requires rapid treatment • Image-guided biopsy (omental, lymph node) is best chance for definitive diagnosis • Usually no need for surgical biopsy • Imaging, especially CT, may be 1st clue to diagnosis • If characteristic findings are present in appropriate epidemiological setting… TREAT, then stop treatment if you’re wrong

  29. Summary • Think of TB Peritonitis if 2 or more… • Extensive omental and mesenteric fat stranding • Hypodense abdominal lymph nodes • Splenic hypodensities • Higher than normal density ascites (not like blood, though) • Smooth peritoneal thickening • Moderate peritoneal enhancement

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