Laparoskopi, peritoneal tüberküloz tanısında etkili bir yöntem olabilir

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Introduction
Tuberculosis continues to be an
important health problem in both
developing and underdeveloped countries, though it is uncommon in
the Western world (1). There are several case reports pointing out to an
uncertainity in the preoperative differential diagnosis of female genital
tuberculosis and advanced ovarian
cancer, mainly due to the nonspecific
nature of the common presenting
symptoms, signs, and the further
association of elevated CA-125 levels
(2-12). A high index of clinical suspicion is mandatory for definitive diagnosis, since specific antituberculous
therapy can obviate unnecessary laparotomies. This report of our experi-Cilt 49 · Sayý 1 · Gülhane TD Laparascopy in peritoneal tuberculosis · 43
Results
The mean age of the patients was
28.3±4.7 years (median 28; range 22-
37). All patients were referred to the
gynecologic oncology unit with a history of abdominal swelling and
pelvic-abdominal pain. The other
symptoms were swelling in the legs
and menstrual irregularity (in two
patients); weight loss and lack of
appetite (in one patient). Ascites was
present in all patients, but no masses
were palpable either abdominally or
vaginally.
All patients had moderate iron
deficiency anemia with a median
hemoglobin level of 10.5 gr/dl; (range
9.7-11.1 gr/dl ) The white blood cell
counts, platelet counts, erythrocyte
sedimentation rates, liver function
test results, urea concentration, and
electrolyte levels were all within normal reference ranges. Intracutaneous
injection of 5 tuberculin units of
purified protein derivative caused a
median skin induration of 11 mm for
every patient (range 10-14 mm). A
plain x-ray film of the chest showed
normal appearance of the lungs, pleura, and mediastinum in all of the
cases. All patients underwent abdominopelvic computerized tomography (CT), and transabdominal and
transvaginal ultrasound examinations. All patients showed gross
ascites and irregular thickening of the
peritoneum. There were ovarian
masses with heterogeneous textures
of about 5 cm in size in two cases.
Abdominal paracentesis was performed in the diagnostic work-up of all
cases. Ascitic fluid was an exudate
with lymphocytosis and no malignant
cells. No acid-fast bacilli were seen by
direct microscopy. Standard bacteriological and mycological cultures of
ascitic fluids were negative. Results of
tuberculosis polymerase chain reaction analysis of the ascitic fluid were
negative. Sputum and urine cultures
performed for all mycobacteria species were negative. All patients had
elevated serum CA 125 levels with a
median of 162 U/ml, (range 75 to 500
U/ml). All patients had normal cervical smears and endometrial biopsies.
A diagnostic laparoscopy was performed in all cases. Ascites with a
median of 4 liter (range 3 to 5.5 lt),
miliary peritoneal lesions, and filmy
adhesions throughout the peritoneal
cavity were the major intraoperative
findings. These findings were considered highly suggestive of tuberculosis. In two patients with ovarian
masses documented by preoperative
CT and ultrasound scans, exploration
of the adnexae revealed corpus hemorrhagicum. Multiple biopsies were
obtained from various parts of the
peritoneum and the omentum. Frozen section examinations demonstrated granulomatous inflammation
with necrosis, compatible with tuberculosis in all patients. Acid-fast bacilli were detected in the postoperative
histopathological specimen of one
patient. The postoperative courses of
the patients were uneventful.
All the patients received antituberculous therapy with isoniazid,
rifampicin, ethambutol and pyrazinamide. Treatment was started with a
combination of four drugs for the
first 3 months, and continued thereafter with three drugs for nine
months. Preoperative high serum
CA-125 levels were found to be within normal limits two months after the
completion of therapy.
Discussion
Although vaccination against the
disease during early infancy is
mandatory, tuberculosis is not a rare
phenomenon in our country. Since
the clinical pictures of the patients
with peritoneal tuberculosis are similar to those of patients with ovarian
cancer, we are used to consider peritoneal tuberculosis in the differential
diagnosis of ovarian cancer. The most
common signs and symptoms were
abdominal swelling, abdominopelvic
pain, ascites and elevated serum CA-
125 level (2,13) in our cases. Other
infectious agents (e.g., Actinomyces
species and other mycobacteria) may
produce similar clinical pictures.
Recently, a case of Streptococcus milleri
infection mimicking ovarian carcinoma was reported (14). Age may also
be used as a good clinical predictor in
favour of peritoneal tuberculosis. The
age range of our cases contributed to
the findings of previous studies
demonstrating that women with peritoneal tuberculosis were younger
than those with ovarian carcinoma
(2,15).
A strongly positive tuberculin test
(Mantoux) is sometimes indicative of
reactivation of tuberculosis (16). The
10 to 14 mm skin induration (+) of
our cases seems to be related to prior
vaccination. The results of chest Xrays and sputum cultures showed that
these tests were not helpful in the
diagnostic work-up, as reported by
other authors (16,17).
In our cases, cultures of ascitic
fluids failed to demonstrate the infection, in contrast with the cases reported by Irvin et al (15) and Piura et al
(18). Guinea pig inoculation and culturing for tuberculosis have a turnaround time of about six weeks,
which could be a detrimental delay in
treatment in the case of the ovarian
cancer patient. Combined use of guinea pig inoculation and culture also
has a low sensitivity about 37% (19).
Ascitic fluid analysis for mycobacteria generally does not contribute to
more than 25% of the tuberculous
peritonitis diagnoses. Direct preparations of ascitic fluid were not found
to be positive for acid-fast bacilli in
our cases as previously demonstrated
by Bilgin et al (17).
An elevated adenosine deaminase
activity in fluids isolated from the
serousal cavities is considered to be44 · Mart 2007 · Gülhane TD Dede ve ark.
an excellent tuberculosis marker,
though only a few centers use it as an
exclusive measure for tuberculosis
diagnosis (1). On histologic examination, epithelioid granulomatous
lesions with necrosis are typically
seen in cases of peritoneal tuberculosis. In one of our cases Ziehl-Nielsen
stain revealed acid-fast bacilli, however this is not always the case and is not
essential for diagnosis (6,20). Cytopathological evaluation of ultrasonographically guided peritoneal biopsies
may be a diagnostic approach, though
it was never practiced at our institution (21).
Polymerase chain reaction (PCR)
for mycobacteria may be helpful for
obtaining results earlier (22). However, tuberculosis PCR analyses failed
to demonstrate the infection in ascitic
fluid, in contrast to the cases reported
by Irvin et al (15) and Piura et al (18).
In our laboratory, IS6110 fingerprinting was performed using the standard
reference protocol (23). It was an
unexpected finding to see that all the
PCR tests for tuberculosis on ascite
fluids were negative even when one
patient had acid-fast bacilli on
histopathological examination. We
could not find a reasonable explanation for this unusual finding.
Although ovarian carcinoma remains to be the first diagnostic choice
in patients with elevated serum CA-
125 levels, an elevation of CA-125 is
not a guarantee of ovarian carcinoma,
even in those women presenting with
organic abdominal pathologies.
Several reports have showed raised
serum CA-125 levels, pelvic masses,
ascites, or pleural effusions in cases of
tuberculosis (6). In most reported
cases, the CA-125 levels have been
<500 U/mL, and in a study of 11
patients the mean level was 316.6
U/mL (6). In our cases both the
median level, and the range of serum
CA 125 (162 U/ml and 75 to 500
U/ml, respectively) were consistent
with the previous reports. Simsek et
al noted that the association between
elevated serum CA-125 levels, and
peritoneal tuberculosis was not an
incidental finding (24). Monitoring
serum CA-125 levels is helpful to
evaluate the effectiveness of medical
treatment in patients with peritoneal
tuberculosis. Serum CA-125 levels
can be expected to normalize in two
months as in our cases, and other relevant reports.
Sonographic features of tuberculous peritonitis may illustrate adnexal
masses, adhesions and septated or
particulate ascites. Omental and peritoneal thickening can also be seen
(25). However, ultrasonography has
conflicting results in previously
reported cases, revealing ascites and
complex pelvic masses (12,17). We
detected adnexal pathology only in
two cases and the sonographic features were not helpful in diagnosis.
In computerized tomographic
examination, the presence of a
smooth peritoneum with minimal
thickening and pronounced enhancement suggests peritoneal tuberculosis, whereas nodular implants and
irregular peritoneal thickening suggest peritoneal carcinomatosis (26).
In a retrospective study, Ha et al
showed that patients with tuberculosis were more likely to have mesenteric changes, macro-nodules (>5
mm in diameter), splenomegaly, and
splenic calcification visible on CT
imaging. Patients with carcinomatosis were more likely to show a more
irregularly infiltrated omentum and
to have the loss of the thin omental
line covering the infiltrated omentum
(27). They calculated the sensitivities
of CT scan in the prediction of tuberculosis and carcinomatosis as 69%
and 91%, respectively. However, CT
imaging does not appear to be any
more specific than ultrasonography
for diagnosis of this condition, as
consistently shown in our cases and
in other reports (18,28).
The most fruitful algorithm for
the diagnosis of possible peritoneal
tuberculosis remains to be established. In the case of a young patient
with generalized ascites and no suspicious mass, an abdominal paracentesis may be the first step in the diagnostic algorithm. If direct cytologic
examination, culture or PCR analysis
of ascitic fluid are inconclusive, diagnostic laparoscopy should be performed to obtain multiple tissue samples. Paracentesis and laparoscopy are
not only simple, effective and minimally invasive diagnostic tools but
also can be therapeutic tools whenever uncertain conditions of massive
ascites are noted. In one series of 200
patients with undiagnosed ascites,
laparoscopy proved to be a safe method of providing a diagnosis (29). In
another series of 135 patients with
tuberculous peritonitis, 97% of cases
were diagnosed on the basis of biopsy
specimens taken during laparoscopy
(24). Since the gross appearance of
peritoneal tuberculosis may resemble
that of a disseminated ovarian carcinoma, a frozen-section analysis should always be considered during the
laparoscopy. If no carcinoma is detected, and histopathological examination is consistent with diagnosis of
tuberculosis, unnecessary extensive
surgery is avoided and a multi-drug
anti-tuberculosis regimen should be
started. In patients with a suspicious
adnexal mass, performing paracentesis or laparoscopy may lead to recurrences in the needle tracts, and
laparoscopic port sites in case of ovarian malignancy (30). In ovarian cancer patients with abdominal wall
metastases, prognosis is reportedly
worse (31). Therefore laparotomy
seems to be reasonable in cases with
adnexal masses. On the other hand
Volpi et al emphasized the importance of laparascopy for the differential diagnosis of tuberculosis in aCilt 49 · Sayý 1 · Gülhane TD Laparascopy in peritoneal tuberculosis · 45
gynecologic cancer center (32).
In conclusion, our series of ten
patients demonstrated that peritoneal
tuberculosis should be suspected in
young women with ascites with or
without adnexal mass. Chest X-ray,
PPD, sputum culture, direct preparation or PCR studies of ascitic fluid,
CT and ultrasonography may be useful techniques in the diagnosis of
peritoneal tuberculosis. Laparoscopy
is an effective diagnostic tool in
patients with no suspicious mass.
Although elevated serum CA 125 levels are not helpful in the diagnostic
period, it may be useful in the followup of patients.