A Gut Instinct

Posted by • August 8th, 2014

In the latest Clinical Problem-Solving article, a 30-year-old female physician presented to the emergency department in mid-August, with a 4-day history of anorexia, nausea, vomiting, and diarrhea. She had no fever or respiratory symptoms but had mild abdominal discomfort.

Tuberculosis is a well-recognized occupational hazard for those involved in health care. In a systematic review that included 15 studies conducted in high-income countries, health care workers had a median annual risk of pulmonary tuberculosis infection of 1.1% (range, 0.2 to 12), as compared with a risk of 0.1 to 0.2% in the general population.

Clinical Pearls

How has the incidence of extrapulmonary tuberculosis changed in the United States?

There has been a steady decline in cases of tuberculosis in the United States, from 52.6 cases per 100,000 population in 1953 to 3.6 cases per 100,000 population in 2010. However, the proportion of cases of extrapulmonary tuberculosis per total cases of tuberculosis increased from 7.6% in 1962 to 20% or more since the late 1990s. The risk of extrapulmonary tuberculosis is reported to be increased among women, Asian and foreign-born persons, and health care workers.

What are the epidemiology and features of intraabdominal tuberculosis?

Intraabdominal tuberculosis, including peritoneal and mesenteric lymph-node involvement, is the sixth most common type of extrapulmonary tuberculosis reported in the United States. The diagnosis of intraabdominal tuberculosis is challenging, owing to its protean and nonspecific manifestations. In a large case series, up to two thirds of patients had negative tuberculin skin tests, and many did not have respiratory symptoms. Systemic and constitutional symptoms are frequent, as are abdominal pain and distention. The majority of patients with tuberculous peritonitis have ascites, which results from fluid exudation from peritoneal surfaces; only about 10% of patients present with the “dry type” of tuberculous peritonitis, characterized by a doughy abdomen, adhesions, fibrosis, and the absence of ascites. Often there is a long delay between symptom onset and diagnosis.

Morning Report Questions

Q: What is the reported sensitivity of tuberculin skin testing in cases of active tuberculosis?  

A: In the case of active tuberculosis, the reported sensitivity of tuberculin skin testing is highly variable and is generally estimated from culture-confirmed cases; false negative test results are reported in up to 25% of cases. Tuberculin skin tests should not be considered to be reliable tests for the diagnosis of active disease.

Q: What are the guidelines for treatment of extrapulmonary tuberculosis?        

A: Guidelines for the treatment of extrapulmonary tuberculosis closely mirror those for the treatment of pulmonary tuberculosis. Currently, for susceptible tuberculosis, four-drug therapy for 2 months is recommended, followed by two-drug therapy for 4 months or longer, depending on the extrapulmonary site (e.g., the meninges require longer therapy).

5 Responses to “A Gut Instinct”

  1. dr suryakant dhoke md says:

    Nice case presentefd tb abdomen,in indis is common wth vague abdomnal sumptoms of long duration,diagnosed wth high index of suspcion n treated.

  2. mohamed says:

    Thanks for your very valuable information about extra pulmonary tuberculosis

  3. dr nargis says:

    good information….

  4. Nigel Chua says:

    What are the possible clinical outcomes of a successfully treated pulmonary tuberculosis versus non-treatment/noncompliance/non-diagnosis?

  5. higiniomalave says:

    as a 34 years ortho guy i have not stumble across an abdominal tb in mor tan 30 years i practice in ecuador a third world country and my guess is farmer or third world country