Introduction
Abdominal tuberculosis is 6° more frequent tuberculosis
localization after lymphatic, urinary, articular, miliary and meningeal
involvement. It could be complicated with tuberculous peritonitis.
Materials and
methods
A 76-year-old Ethiopan man has been in haemodialysis
for 10 months. An unknown nephropathy drove him to end stage renal disease 7
years ago. He is affected by arterial hypertension, ischemic cardiopathy,
asthma. HIV tests are negative. In October 2013 hiccup and dysphagia appeared. US-endoscopy
showed an hypoechoic 3cm-lesion nearby a dishomogeneous pancreatic body. Abdominal CT scan
displayed a 2.6cmX3.5cmX3cm-mass with mixed solid-liquid appearance settled
between head and body of pancreas, with no separation from gastric wall. From
this lesion partially colliquated lymphadenopathies extended to portal vein and
inferior caval vein and liver hypodense foci suspected for metastasis were
observed. Gastroscopic biopsies only showed moderate chronic gastritis. A
needle-biopsy only displayed necrotic tissue. In December 2013 an increasing
abdominal pain appeared. Cancers markers were all negative (alfa-feto, CEA, Ca
19.9, Ca 125). A diagnostic laparoscopy
(suspect of pancreas cancer versus lymphoma) was planned but he was
admitted to hospital for acute colitis: US displayed thickened sigmoid-colon walls,
thin liquid layer and irregular perivisceral fat. Bowel mucosa was normal at
colonscopy and inflammatory bowel diseases were excluded. Acute abdomen arose
and he underwent an urgent surgey for serous corpuscolated peritonitis: there
were widespread micronodules on whole peritoneum and tight bowel adherences
were dissolved. Histological examination showed severe granulomatous flogosis
with multinucleated giant cells and palisading histiocytes. Negative Wright
reaction excluded Brucellosis. A necrotizing sarcoid granulomatosis was
suspected.
Results
Performance status declined towards cachexia. New CT
scan showed periepatic abscesses that were drained, with results of Bacillum
Tuberculosis. Specific long-lasting therapy was started (riphampycin,
isoniazid, ethambutol, pyrazinamide).
Conclusion:
Abdominal tuberculosis has to be
considered in high-risk population as immunedepressed dialysis patients,
moreover if coming from endemic area: its incidence has recently increased. Diagnosis isn’t simple because symptoms are
aspecific and caseous necrosis can’t be always detected. US scan is an
important instrument to monitorize transient lymph node swelling and to suspect
disease if it rapidly evolves into both abscesses or chronic lymphadenitis.
