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Infection -
TB
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Written by Dr Sebastian Zeki
MCQs for this page
TB
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Risk Factors:
Cirrhosis.
HIV infection.
Diabetes mellitus
Underlying malignancy.
Following treatment with
anti-tumor necrosis factor
(TNF) agents.
CAPD.
From hematogenous
spread from a
primary lung focus
from latent state or
from active
pulmonary or miliary
TB
Less likely is spread
from infected small
intestine or contigu
-
ously from tubercu
-
lous salpingitis
Visceral peritoneum
Parietal peritoneum
Visceral and parietal peritoneum become increasingly
studded with tubercles.
Visceral peritoneum
Parietal peritoneum
Fibroadhesive Disease
(Dry form)
Ascites develops secondary to "exudation" of proteina
-
ceous fluid from the tubercles, similar to the mechanism
leading to ascites in patients with peritoneal carcinoma
-
tosis.
> 90 % of patients with TB peritonitis have ascites at the
time of presentation,
It develops within 1 year of developing CAPD.
The most common features are ascites (93 %), abdominal
pain (73 %), and fever (58 %).
The diagnosis usually requires a targeted peritoneal biopsy
performed under direct visualization.
If laparoscopy non-diagnostic, should have a
mini-laparotomy
Laparoscopic findings:
1)visceral and parietal peritoneum is studded with multiple
whitish nodules or tubercles.
2) Enlarged lymph nodes,
3)"Violin-string" fibrinous strands
4) Omental thickening.
Targeted biopsies reveal caseating granulomas in up to 100
% of patients and are positive for acid fast bacilli in 74 % of
patients.
Gold-standard= culture growth
Tuberculin skin testing with
purified protein derivative (PPD) -
+ve in 70 % but -ve doesnt exclude.
Patients with a known previous skin reaction to TB maybe anergic
at the time of PPD reading.
Radiologic imaging
Can get: peritoneal thickening, omental caking, and the presence
of ascites with fine mobile septations on ultrasound and CT
imaging.
Peritoneal fluid analysis
Lymphocytic ascites (in CAPD, it may be neutrophilic)
Exudate with (SAAG) is <1.1 g/dL. unless have cirrhosis when
SAAG is >1.1g/ dL
AFB stain sensitivity is 5%
Culture positive in 20% and takes 6w to come back (50% dead in
6 weeks of presentation)- increase sensitivty with larger volume
(>1L) but impractical
Polymerase chain reaction-
may be more useful but sensitivity
not established
Adenosine deaminase(ADA)
ADA is a purine-degrading enzyme involved in maturation and
differentiation of lymphoid cells.
ADA levels had high sensitivity (100 %) and specificity (97 %)
using cut-off values from 36 to 40 IU/L; the optimal cut-off value
was 39 IU/L.
Lower sensitivity in patients with cirrhosis (30 %) due to the
characteristically poor humoral and T cell mediated response of
cirrhotic patients.
As a result, ADA measurement has its greatest utility in settings
where TB peritonitis is suspected in non-cirrhotic patients.
T-cell based testing for
mycobacterium
TB (ELISPOT)
Measures gamma producing T-cell responses to early secreted
antigenic targets of
mycobacterium
TB, has sensitivity and
specificity for extrapulmonary TB as 94 and 88 %, respectively.
Treatment
Fever usually resolves within one week of commencing anti-tuberculous
treatment.
> 90 % of patients have improvement in abdominal ascites within weeks
of initiating treatment.
The role of steroids is still not established but it may help in preventing
adhesions.
TB Peritonitis
Clinical Manifestations
Lab results:
Mild to moderate normochromic normocytic
anaemia in most patients (mean hemoglobin
concentration 9.9 g/dL)- in 50%.
A normal leukocyte count- present in most patients.
CA-125-not helpful.
Old TB- visible on chest x-ray in only 33 %.
Prognosis
There is a mortality of 25%.
Advanced age, delay in initiating therapy, and underlying cirrhosis
have been associated with higher mortality rates.
Some develop complications (such as small bowel obstruction)
related to adhesions.
Diagnosis
20% have no risk factors
Written by Dr Sebastian Zeki
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