Medizinisches Rätsel - Antwort

Answer: Tuberculous Peritonitis

The intraoperative findings, including multiple diffuse involvement of the visceral and parietal peritoneum, white military nodules, ascites, violin string–like fibrinous strands, and omental thickening, as shown herein, typically signify the diagnosis of tuberculous peritonitis. Granulomatous inflammation of the peritoneum with multinucleated giant cells was also demonstrated microscopically. Acid-fast bacilli were found. Fibrous tuberculous peritonitis was confirmed. The patient recovered by using 4 combined antituberculous medications.

The first reported case of tuberculous peritonitis dates back to 1843. 1 Approximately 3.5% of patients with pulmonary tuberculosis have tuberculous peritonitis. 2 It represents 2% of the causes of ascites. 3 According to a summary of 11 series, 4 25% to 83% of cases of tuberculous peritonitis are associated with pleuropulmonary tuberculosis. Sixty-two percent of patients have alcoholic liver disease. Continuous ambulatory peritoneal dialysis and human immunodeficiency virus are other risk factors.

Although recognized early historically, the diagnosis of tuberculous peritonitis still poses significant challenges. Clinical features, including fever, abdominal pain, and ascites, are not specific. Ascitic fluid analysis might show predominant lymphocytes and a high protein level (>2.5 g/dL [to convert to grams per liter, multiply by 10]), but results of acid-fast staining of fluid are seldom positive for tuberculous peritonitis. Culture of fluid is positive in only 25% of patients. Polymerase chain reaction, with sensitivity up to 95% in smear-positive patients, was disappointingly low in smear-negative patients with tuberculous peritonitis. 5 Adenosine deaminase activity in the ascitic fluid seems to be a promising diagnostic measure. 5

Peritoneal carcinomatosis, sarcoidosis, starch peritonitis, and Crohn disease may mimic the features of tuberculous peritonitis. Peritoneal biopsy, therefore, must be performed to make a diagnosis if no other foci suggest tuberculosis. Currently, to our knowledge, there are no randomized controlled trials comparing image-guided biopsy, laparoscopy, and laparotomy. Laparotomy, however, is reserved for patients with the fibroadhesive type of tuberculous peritonitis, as in the present patient. Most patients with acute symptoms are diagnosed using only laparotomy. 6

If left untreated, the overall mortality of tuberculous peritonitis may be as high as 51%. 7 Epidemiologically speaking, extrapulmonary tuberculosis is rarely infectious. Transmission is likely, nevertheless, in rare cases of contact with discharge (such as from an open wound) that contains tuberculous bacilli. 8 Surgeons should be alert for this possibility when performing similar consulting operations.

REFERENCES

1. Dineeen P, Homan WP, Grafe WR. Tuberculous peritonitis: 43 years' experience in diagnosis and treatment. Ann Surg. 1976;184(6):717–722.

2. Sheldon CD, Probert CS, Cock H, et al. Incidence of abdominal tuberculosis in Bangladeshi migrants in east London. Tuber Lung Dis. 1993;74(1):12–15.

3. Runyon BA. Approach to the patient with ascites. In: Yamada T, Alpers D, Laine L, Kaplowitz N, Owyang C, eds. Textbook of Gastroenterology. Vol 1. 4th ed. New York, NY: Lippincott Williams & Wilkins; 2003:948–972

4. Bastani B, Shariatzadeh MR, Dehdashti F. Tuberculous peritonitis: report of 30 cases and review of the literature. Q J Med. 1985;56(221):549–557.

5. Sanai FM, Bzeizi KI. Systematic review: tuberculous peritonitis: presenting features, diagnostic strategies and treatment. Aliment Pharmacol Ther. 2005;22(8):685–700.

6. Way LW, Doherty GM. Peritoneal Cavity: Current Surgical Diagnosis and Treatment. 12th ed. New York, NY: McGraw-Hill Co; 2006

7. Katigbak MW, Shlasko E, Klein SM, Calaman S. Peritoneal tuberculosis in a 15-month-old male: surgical diagnosis of an insidious disease. Surg Infect (Larchmt). 2005;6(2):255–258.

8. Wilcock K, Hammett TM, Parent DG. Controlling Tuberculosis in Community Corrections. Washington, DC: US Dept of Justice, Office of Justice Programs, National Institute of Justice; 1995. NIJ Research in Action series

Ho, Cheng-Maw ; Lee, Po-Huang
Archives of Surgery. Volume 142(12), December 2007, p 1220