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| Case of the Week Tuesday 31/10/2006 |
Presented by Dr. Rasha El-Etrebi.
Click here to download a power point presentation for the case.
Click here to download a power point presentation for GI Tuberculosis by Prof. Shokry Hunter.
TB Peritonitis
Staff round presentation
Prof.Dr.Zakaria Salama Unit
Unit members:
Dr.Ahmad Nabil
Dr.Samar Kamal
Dr. Mohammad Menesy
Dr.Basem Amin
Resident: Rasha El Etrebi
Personal history:
• Female patient N.S.A, 50 years old, born and lives in El Fayoum, married for 30 years, mother of 4, the youngest is18 years old , housewife .
• History of contact with canal water and receiving parenteral antischistosomal treatment.
• No special habits of medical importance.
• Menopausal for 8 years.
Complaint:
Abdominal distention for 1 year
• The condition started one year ago, by gradual onset ,progressive course of abdominal distention, associated with right hypochondrial pain, dull aching in character, with no specific radiation, not related to meals, increases with exertion .
• One month later, she developed lower limb oedema, for which she sought medical advice, where lab. Investigations, and ultrasound were done, and she was told to have liver cirrhosis , ascites and gall bladder stones .
• She was advised to restrict salt intake , and received diuretics without improvement .
• That is why she was admitted in Ahmed Maher hospital, where lab. investigations and ultrasound were repeated, and she was told that the liver appears normal, and was referred to our department to search for the cause of ascites.
• No history of jaundice , change in color of urine or stools, or itching , No bleeding tendency or history of encephalopathy.
• No history of fever , night sweats , anorexia , perception of body masses or significant weight loss.
• No history of other system affection.
• Past history of HTN for 4 years, for which she received antihypertensive treatment and stopped 2 years ago upon medical consultation.
No Past history of operation or blood transfusion.
• Family history : No similar condition in the family.
Examination:
General examination:
• The patient is conscious , well oriented to time , person and place and of average body built.
• Bp: 100/70 pulse:80/min temp: 37.2 c (she was afebrile all through her hospital stay)
Head and neck exam.:
• No jaundice or pallor.
• Angular stomatitis.
• No lymph node swelling.
• No thyroid swelling.
• Neck veins are not congested.
Ascites is not detected by shifting dullness.
Auscultation:
• Normal intestinal sounds
• No venous hum.
Chest, Heart, Neurological and Musculoskeletal exam. :
• Free.
Gynaecological examination:
• Free.
Lab. investigations : • Urine analysis:
Normal except for amorphous urate crystals.
• CBC with differential :
HGB 11.9g/dl (12-18) WBC 7.84 x 1000/ul
MCV 86.8fl (80-99) B 0%
MCH 29.5 pg (27-31) E 6%
MCHC 34.0g/dl (33-37) ST 5%
Seg 44%
L 31%
M 14%
PLT 204x1000 / ul
• ESR 1st hour : 115 2nd hour : 138
Liver Biochemical profile :
• T.BIL 0.42mg/dl (0.1-1.0)
• D.BIL 0.20 mg/dl (0.0-0.25)
• AST 46 u/l (0-37)
• ALT 30 u/l (0-41)
• ALP 101 u/l (35-104)
• GGT 57 u/l (8 – 61)
• Total Ptn 7.7g/dl (6.6-8.7)
• ALB 3.7 g/dl {3.5 – 3.7} (3.4-5.2)
• PT 14.9 sec
• PC 80% (75-120%)
• INR 1.18
Hepatitis markers:
• HBs Ag : negative.
• HBs Ab : negative.
• HBc Ab total : reactive.
• HCV Ab : reactive.
• HCV RNA by PCR : pending.
Abdominal ultrasound Liver: Mildly enlarged ,fibrofatty echopattern, smooth surface and peripherally attenuated hepatic veins . No focal lesions or IHBR dilatation . P.V. is not dilated (10mm ), few variable sized hepatodudenal lymph nodes, the largest measured 12 x 9 mm.
Gall bladder :Average in size and wall thickness , multiple small calculi are seen (4-6 mm in diameter) . CBD is not dilated
Spleen: High normal in size (12.5 cm), homogenous echo- pattern, S.V = 8.7 mm.
Vaginal Ultrasound
Normal , except for free fluid in Douglas pouch from ascites for more confirmation by CT abdomen.
Ascitic fluid analysis : • Physical exam.: Sample is yellow and slightly turbid.
• TLC in ascitic fluid: 65 cells/ ml , mainly neutrophils
• Total proteins: 7.2gm/dl.
• ALB: 2.8 g/dl ( SAAG :3.7 – 2.8 = 0.9)
< 1.1
• LDH: 215 u/l (n:125-243)
• Adenosine Deaminase:
In ascitic fluid : 90.3 u/l
In serum: 53.2 u/l (n: 8.2 – 20.5 u/l)
Ratio: 1.7 ( less than 2.5)
Ascites of local cause :
(SAAG 0.9)
DD of ascites of local cause :
-
Tuberculous peritonitis.
Malignant ascites.
Pancreatic ascites.
Biliary ascites.
Post operative.
Connective tissue disease.
Bowel obstruction/ infarction.
lymphatic leak.
For the possibility of T.B.:
• Tuberculin test :Positive: (25 mm induration).
• ? Chest X- ray PA & LAT. :
.Bilateral basal prominent bronchial markings & peribronchial thickening denoting chronic bronchitis.
. Prominent both hilar shadows , likely vascular in origin.
. Clear both C/P angles.
. Normal cardio-thoracic ratio.
. Dilated unfolded aorta.
• BAC TEC in ascitic fluid :
Negative.
• PCR and MTD in ascitic fluid:
They were not available.
• For the possibility of malignancy:
• Tumor markers revealed:
CEA 2.9 ng/ml ( Up to 5)
CA 19-9 12 u/ml (0.0-37)
CA 125 133.03 u/ml (0.0-35)
B2 microglobulin 900 ug/l (850-1150)
• Gynecological consultation was done with vaginal US:
Normal , except for free fluid in Douglas pouch from ascites for more confirmation by CT abdomen.
• CT abdomen was done and revealed :
Moderate amount of clear ascites.
Gall bladder stones.
Rt renal cortical cyst.
No definite adnexal masses or cysts.
Endoscopy:
• Upper endoscopy revealed :
Antral gastritis.
• Colonoscopy revealed :
Colonscopic examination up to the caecum revealed no abnormality.
• Laparoscopy was arranged and revealed:
• Yellowish clear fluid in Douglas pouch and peritoneal cavity ( Ascites), sampled for cytology.
• Discrete white miliary nodules (tubercles), varying in size from 0.3 cm to 1.5 cm, one of them was biopsied.
• Bands of adhesions are seen surrounding the uterus and adnexa.
• Cytology was repeated from the laparoscopic sample, and revealed:
Ascitic fluid with excess number of lymphocytes, some RBCs, and bland looking mesothelial cells, negative for cytologically malignant cells
• Pathology from the tubercle taken revealed:
Fibrous tissue core showing few epithelioid tuberculoid granulomas with minimal foci of caseation for bacteriological confirmation for tuberculous organisms.
The case was considered as T.B. peritonitis and she started treatment on 3/10/2006 with:
• Rimactazid 300mg : two tab. before breakfast /day
(Isoniazide 150 mg + Rifmpicine 300 mg)
• Streptomycin :1 gm Im injection every other day.
• ETB 500 mg (Ethambutol HCL) two tab. after
breakfast/day
• Hostacortin was recommended by a dose of 30 mg/day
• Follow up after one week of treatment :
Liver functions:
• T-Bil 1.00 mg/dl (0.1 – 1.0)
• D-Bil 0.38 mg/dl (0.0 – 0.25)
• AST 27 u/l (0 – 37)
• ALT 41 u/l (0 – 41)
• ALP 123 u/l (35 – 104)
• GGT 71 u/l (8 – 61)
• Total Ptn 7.7 g/dl (6.6 – 8.7)
• ALB 2.9 g/dl (3.4 – 5. 2)
• Follow up after one month of therapy :
ESR:
1st hour:97
2nd hour:130
Liver biochemical profile:
T-Bill 0.71 mg/dl (0.1 - 1.0)
D-Bil 0.00 mg/dl (0.0 - 0.25)
AST 34 u/l (0.0 - 37)
ALT 16 u/l (0.0 – 41)
ALP 119 u/l (35 – 104)
GGT 98 u/l (8 – 61)
T protein 9.3 g/dl (6.6 – 8.7)
ALB 3.8 g/dl (3.4 – 5.2)
Creatinine 1.3 mg/dl (0.7 -1.2)
Urea 45mg/dl (10 – 50)
Ultrasound:
Moderate amount of free and clear ascites.
Thank you
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