Tuberculous peritonitis in a German patient with primary biliary cirrhosis: a case report
Abstract
Background:
The number of cases of tuberculosis as a complication in people with immunodeficiency, people on immunosuppressive therapy and among the immigrant population is increasing in Germany. However, tuberculous peritonitis rarely occurs without these risks, particularly in Germans. The incidence of tuberculous peritonitis in Germany is very low; tuberculosis of the intestinal tract was found in approximately 0.8 % of tuberculosis cases in 2004. The diagnosis of tuberculous peritonitis is often delayed on account of non-specific clinical symptoms. The absence of specific biological markers, long incubation times for cultures and nonspecific radiographic or ultrasonographic signs increase the morbidity associated with this treatable condition.
Case presentation:
We report a case of tuberculous peritonitis in a 73-year-old female German patient. Her medical history revealed primary biliary cirrhosis (PBC) since 1992. On admission, she complained of abdominal pain, vomiting, ascites and peripheral edema. The patient has been in a seriously reduced general condition and had fever up to 39.6°C. A few weeks earlier, the patient was in another hospital with the same complaint. Inflammatory parameters were elevated, but the procalcitonin level was normal. Blood culture was always negative, as was the tuberculin test. Ultrasonography of the abdomen showed massive ascites with multiple septa. The patient underwent a computed tomography (CT) scan of the abdomen which showed a thickened intestinal wall in the sigmoid colon and a pronounced enhancement of the peritoneum. Computed tomography scans of the lung showed only slight bilateral pleural effusion. Because of the anaesthetic and bleeding risk due to thrombocytopenia, laparoscopy was not immediately undertaken. The culture from ascites was positive for M.tuberculosis after three weeks.
Conclusion:
In primary biliary cirrhosis patients with non-specific clinical symptoms, such as vomiting, abdominal pain, ascites, weight loss, and fever, tuberculous peritonitis must be considered in the initial differential diagnosis, although these symptoms may be attributed to cirrhosis of the liver with spontaneous bacterial peritonitis. Ultrasonographic and CT scab findings are not specific for tuberculous peritonitis, but an awareness of the ultrasonographic features and the features of the CT scan may help in the diagnosis of tuberculous peritonitis and avoid clinical mismanagement.
Background
In industrialised countries, tuberculosis increasingly occurs in the immigrant population and in patients with acquired immune deficiency syndrome (AIDS) and those on immunosuppressive therapy. Tuberculosis of the intestinal tract ranked 8th of all forms of tuberculosis (0.8%) in 2004 in Germany, after pulmonary forms (79.6%), extrathoracic lymph nodes (7%), pleura (3.6%), genitourinary (3.3%), intrathoracic lymph nodes (2.4%),osteoarticular (1%), and spine (0.9%). Tuberculous peritonitis is also rare in Germany. The diagnosis of any extrapulmonary forms of tuberculosis is quite difficult; in the case of peritoneal tuberculosis this is because clinical manifestations are non-specific, such as weight loss, abdominal pain, fever, ascites, vomiting [1-3]. The diagnosis of tuberculous peritonitis is often delayed on account of non-specific clinical signs or symptoms, absence of specific biological markers, long incubation times for cultures and non-specific radiographic or ultrasonographic signs. The prognosis in tuberculous peritonitis was unfavorable before treatment with antituberculous drugs became available and the mortality averaged 50 per cent [4].
Case report
Two months before the patient visited our hospital she had been admitted to the emergency unit of another hospital with vomiting, abdominal pain and weight loss of 10 kg within three months. A diagnosis of spontaneous bacterial peritonitis was ruled out. Her clinical signs were initially attributed to severe gastritis and an ulcer in the pyloric canal. She had suffered from primary biliary cirrhosis (PBC) since 1992 and had been treated with 750 mg of ursodeoxycholic acid daily without immunosuppressive therapy. She had no significant past history of pulmonary or genital tuberculosis. She had given birth to a son and a daughter.
