Case 2 -

Tuberculous Peritonitis and Placentitis Michael L. Wilson Denver Health and University of Colorado School of Medicine

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Clinical History: A 30-year-oldpregnant female at 15 weeks gestation presented with fevers, chills, and right lower quadrant pain. The clinical diagnosis was pelvic inflammatory diseaseversus acute appendicitis.The patient underwent laparotomy and appendectomy as the appendix wasvisibly inflamed. There was also visible inflammation of the right fallopian tube and ovary. The pathologic diagnosis was acute periappendicitis with a comment that the inflammation was peri-appendiceal only and thus a source of infection elsewhere in the abdomen or pelvis should be considered. Two and one-half weeks later the patient presented with vaginal bleeding and reported a continuation of fevers and chills since the appendectomy. There was no evidence ofa surgical site infection.The patient went into spontaneous labor and delivered a non-viable fetus. Case 2 - Figure 1 Appendix, serosal surface at left, showing marked chronic inflammation and serosal thickening. Case 2 - Figure 2 Appendix, periappendiceal soft tissues show non-necrotizing granuloma. Case 2 - Figure 3 Appendix, periappendiceal soft tissues show non-necrotizing granuloma. Case 2 - Figure 4 Placenta, focal acute intervillositis adjacent to an area of necrosis (not shown in image). Case 2 - Figure 5 Placenta, focal necrosis with acute inflammation. Description: Sections of the appendix show marked chronic inflammation of the serosa and peri-appendiceal soft tissues. Non-necrotizing granulomas were present. Acute inflammation of the appendiceal mucosa and wall was not identified, nor was a purulent exudate identified within the lumen. There was focal minimal acute inflammation of the serosa and peri-appendiceal soft tissues. The placenta showed focal necrosis with acute inflammation in the areas adjacent to foci of necrosis. Diagnosis: Tuberculous Peritonitis and Placentitis Discussion: The clinical presentation of fever, chills, and right lower quadrant pain was suspected to be the result of either acute appendicitis or an infection located in the right adnexa. Exploratory laparotomy revealed inflammation of the serosa of the appendix, right fallopian tube, and ovary. The intra-operative diagnosis was acute appendicitis, with a suspicion of appendiceal rupture and spread of the infection to the right adnexa. Histopathologic examination of the appendix did not show acute appendicitis, however, but rather showed granulomatous and chronic inflammation of the appendiceal serosa and periappendiceal soft tissues. Acid-fast stain (Kinyoun) of the appendix showed rare acid-fast bacilli in the granulomas. The placenta showed foci of necrosis that were associated with acute inflammation of the adjacent intervillous space. No granulomata were observed and there was no evidence of villitis of unknown etiology (VUE). Acid-fast stain (Kinyoun) of the placenta showed rare acid-fast bacilli in necrotic tissue. Cultures were not performed as both specimens were received in 10% neutral-buffered formalin. Tuberculous Peritonitis: Tuberculosis is caused by members of the Mycobacterium tuberculosis complex, which includes M. tuberculosis, Mycobacterium africanum, and Mycobacterium bovis. Infection occurs following inhalation of aerosols; extrapulmonary disease is the result of hematogenous dissemination. Tuberculous peritonitis occurs in 0.1-3.5% of patients with pulmonary disease and accounts for 4-10% of cases of extrapulmonary tuberculosis [1]. Up to one-half of patients with tuberculous peritonitis have evidence of old pulmonary disease, with another one-sixth of patients showing active pulmonary disease [1]. Clinical signs and symptoms alone are not sufficient to make the diagnosis. The most common symptoms are abdominal swelling and anorexia; the most common sign is ascites [1]. Ultrasonographic findings are non-specific. Although abdominal CT findings are better for demonstrating lymph node involvement, as well as for documenting involvement of the mesentery, omentum, and female urogenital tract, in and of themselves they may not be diagnostic [1]. Paracentesis should be the first step in establishing the diagnosis, including routine chemistry tests, cell count and differential, and culture of ascites. The adenosine deaminase level is a useful test [2]. The sensitivity of culture is low (10-20%), as is the sensitivity of acid-fast smears (<5%) [1]. The role of nucleic acid amplification tests performed on ascitic fluid is unclear at this time. Laparoscopy with direct visualization and biopsy of the peritoneum is probably the gold-standard diagnostic test [1, 3]: direct visualization during laparoscopy has a diagnostic sensitivity of 85-90%. Biopsy will show granulomatous inflammation in 85-90% of specimens, with up to 75% of specimens showing acid-fast bacilli [1]. Laparotomy should be reserved for cases where complications occur or the diagnosis cannot be established by less-invasive procedures [3]. There are a number of published observational reports regarding the clinical, radiographic, and diagnostic features of tuberculous peritonitis [3, 4, 5, 6, 7, 8]. Recent reports have highlighted the observation that peritoneal tuberculosis can mimic ovarian cancer, even so far as to cause elevated CA-125 levels [9, 10]. A tuberculosis-like peritonitis caused by a non-tuberculous mycobacterium has been reported but appears to be rare [11]. Tuberculous Placentitis: In contrast to tuberculous peritonitis, for which there are a number of published observational studies, only scant information has been published tuberculous placentitis [12, 13, 14, 15, 16]. As noted by Benirschke "...The placenta has rarely been examined in putative cases of congenital tuberculosis...." [14]. Published d escriptions of the pathologic findings vary. Some papers emphasize the finding of grossly visible and/or microscopic tubercles [12, 14] but overt granulomatous inflammation is not an invariable finding, with some placentas showing acute inflammation, giant cells in stem villi, or necrosis [14]. In summary, extrapulmonary tuberculous is uncommon in the United States , and tuberculous peritonitis is a rare form of extrapulmonary tuberculosis during pregnancy [15]. The clinical, radiographic, and pathologic features of tuberculous peritonitis are well-described, but much less is known about tuberculous placentitis. References: Peritoneum Lewis S, Field S. Intestinal and peritoneal tuberculosis. In: Rom WM, Garay SM, editors. Tuberculosis. Boston: Little Brown, 1996:585:97. Riquelme A, Calvo M, Salech F, et al. Value of adenosine deaminase (ADA ) in ascitic fluid for the diagnosis of tuberculous peritonitis: a meta-analysis. J Clin Gastroenterol 2006;40:705-10. Akgun Y. Intestinal and peritoneal tuberculosis: changing trends over 10 years and a review of 80 patients. Can J Surg 2005;48:131-6. Radhika S, Rajwanshi A, Kochhar R, et al. Tuberculous peritonitis: 43 years' experience in diagnosis and treatment. Ann Surg 1976;184:717-22. Sochocky S. Tuberculous peritonitis: a review of 100 cases. Am Rev Respir Dis 1967;95:398-401. Manohar A, Simjee AE, Haffejee AA, Pettegell KE. Symptoms and investigative findings in 145 patients with tuberculous peritonitis diagnosed by peritoneoscopy and biopsy over a five year period. Gut 1990;10:1130-2. Bastani B, Shariatzadeh MR, Dehdashti F. Tuberculous peritonitis-report of 30 cases and review of the literature. Q J Med 1985;56:549-57. Burack WR, Hollister RM. Tuberculous peritonitis: a study of 47 proved cases encountered by a general medical unity in twenty-five years. Am J Med 1960;29:510-23. Koc S, Beydilli G, Tulunay G, et al. Peritoneal tuberculosis mimicking advanced ovarian cancer: a retrospective review of 22 cases. Gynecol Oncol 2006;103:565-9. Younossian AB , Rochat T, Favre L, Janssens JP. Ascites and highly elevated CA-125 levels in a case of peritoneal tuberculosis. Scand J Infect Dis 2006;38:216-8. Placenta Kimura H, Yoshizumi M, Iijima M, et al. Tuberculosis-like peritonitis due to an atypical Mycobacterium infection in a Japanese woman. Jpn J Infect Dis 2006;59:189-91. Warthin AS. Tuberculosis of the placenta: a histological study with especial reference to the nature of the earliest lesions produced by the tubercle bacillus. J Infect Dis 1907;4:347-98. Nokes JM, Claiborne HA, Thornton WN, Yiu-Tang H. Extrauterine pregnancy associated with tuberculous salpingitis and congenital tuberculosis in the fetus. Obstet Gynecol 1957;9:206-11. Kaplan C, Benirschke K, Tarzy B. Placental tuberculosis in early and late pregnancy. Am J Obstet Gynecol 1980;137:858-60. Lee GS, Kim SJ, Park IY, Shin JC, Kim SP. Tuberculous peritonitis in pregnancy. J Obstet Gynaecol Res 2005;31:436-8; discussion 438.