Abstract
Introduction
Diagnosing peritoneal tuberculosis is challenging due to unspecific clinical manifestations, particularly in immunocompromised patients with HIV/AIDS and tuberculosis infections.
Presentation of case
An Indonesian man, 26-years-old, complained of mid-abdominal colic and constipation. The patient's present state exhibited symptoms of weakness and paleness, oral candidiasis, a bloated abdomen, palpable discomfort, and shifting dullness. The ascitic fluid analysis showed increased ADA (709 U/L), and detected Mycobacterium tuberculosis using GeneXpert MTB/RIF. Radiographic examination from abdominal x-ray and CT scan revealed a small bowel obstruction. He received intestinal decompression, pain control, intravenous fluid resuscitation, and correction of electrolyte imbalance for small bowel obstruction without any indication for surgical intervention. He also receive first-line ATD for 2 months during intensive phase and 4 months for continuous phase. After a period of 2 weeks following the ATD administration, the patient began taking ARV medication on a daily basis. He showed a good prognosis 6 months following.
Discussion
The diagnosis of peritoneal tuberculosis is challenging due to its unspecific manifestation and some cases are identified when complications such as small bowel obstruction appear. The ADA test and GenExpert MTB/RIF are useful instruments for promptly diagnosing tuberculosis. It is suggested to use ARV treatment in individuals with HIV/AIDS who have peritoneal tuberculosis, starting 2 weeks following ATD treatments.
Conclusion
Peritoneal tuberculosis with small bowel obstruction and HIV/AIDS infection is a rare case in which early diagnosis and monitoring play an important role in successful treatment.
Keywords: Ascitic fluid, GenExpert MTB/RIF, HIV/AIDS, Peritoneal tuberculosis, Small bowel obstruction
Highlights
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The challenge of peritoneal tuberculosis diagnosis was unspecific clinical manifestations.
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Peritoneal tuberculosis can be supported by the ADA test in ascitic fluid.
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GeneXpert MTB/RIF testing on ascitic fluid supports in early diagnosis of peritoneal tuberculosis.
1. Introduction
Human immunodeficiency virus (HIV) is an infectious disease that undermines the human immune system by explicitly targeting CD4 cells. This disease causes acquired immunodeficiency syndrome (AIDS) in the last stage [1]. HIV/AIDS patients have an increased risk of being infected with microorganisms such as Mycobacterium tuberculosis due to a decrease in the immune system. This condition is more likely to occur if the patient resides in a region with high prevalence of tuberculosis, such as Indonesia [2].
Peritoneal tuberculosis is a condition characterized by the inflammation of parietal or visceral peritoneum, which caused by Mycobacterium tuberculosis. This case is reported as much as 25–50 % of all abdominal tuberculosis and around 0.7–1 % of all tuberculosis cases [3]. The diagnosis of peritoneal tuberculosis also has its own challenges, which are unspecific clinical manifestations. Therefore, peritoneal tuberculosis is frequently diagnosed following the occurrence of complications such as small bowel obstruction [4]. The study aimed to report an Indonesian adult with small bowel obstruction due to peritoneal tuberculosis and HIV/AIDS infections. The report was based on Surgical Case Report (SCARE) 2023 guidelines [5].
2. Presentation of case
An Indonesian man, 26 years old, complained of mid-abdominal colic pain with characteristics sharp and continuous. Abdominal pain is often caused by vomiting. The patient has experienced constipation since 5 days ago and his last bowel movement was 2 days ago. The patient's abdomen appears enlarged and feels full and tight. For the past month, he has been experiencing an unexplained fever, chills, night sweats, fatigue, reduced appetite, and significant weight loss (about 10 kg). The patient denies using drug abuse and illicit drugs. The patient has a history of engaging in unprotected sexual intercourse with multiple partners without using condoms for a period of three years, although they have never been married. The family has no history of HIV/AIDS, tuberculosis infection, diabetes mellitus, and allergies.
Upon examination, the patient exhibited signs of weakness and pale. The vital signs showed BP of 98/64 mmHg, HR of 102 ×/min, temperature of 37.7 °C, RR of 22 ×/min, and oxygen saturation of 98 %. There was a decrease in the patient's nutritional status, where the patient's weight in the last month was 10 kg (from 60 kg to 50 kg), body height of 170 cm, and BMI of 17.3 kg/m2. Physical examination revealed sunken eyes, anemic conjunctivitis, dry oral mucosa, and thrush. However, we found a distended abdomen, decreased bowel movement, pain on palpable (pain scale of 3–4 with visual analogue scale), and positive shifting dullness.
Blood laboratory examination revealed an increase in leukocytes (14,380/μL), neutrophils (92.8 %), BUN (40.0 mg/dL), creatinine (1.28 mg/dL), and ESR (102 mm/ h); a decrease in hemoglobin (10.2 g/dL) and lymphocytes (2.4 %); a reactive HIV antibody; and a non-reactive HBsAg and HCV antibodies. Meanwhile, the ascitic fluid analysis showed a normal range in SAAG (0.4 g/dL), increased ADA (709 IU/L), and detected Mycobacterium tuberculosis using GeneXpert MTB/RIF. Mycobacterium tuberculosis was also detected in faeces, but rifampicin resistance was not detected in both. Other bacteria, fungi, or parasites are found to grow in mycobacterial culture, save for Mycobacterium tuberculosis. No Mycobacterium tuberculosis was detected in the sputum using GeneXpert MTB/RIF. HIV viral load examination found 1.73 × 103/mL Log 3.24 Log copies/mL, absolute CD4 count of 26 cells/μL, and CD4 cells of 6.9 % (Table 1).
Table 1.
Laboratory examination results during caring in the hospital.
| Test | Results |
|---|---|
| Hb (g/dL) | 10.2 |
| Leukocytes (mm3) | 14,380 |
| Neutrophils (%) | 92.8 |
| Lymphocytes (%) | 2.4 |
| Platelets (/uL) | 250 × 103 |
| ESR (mm/h) | 102 |
| BUN (mg/dL) | 40.0 |
| Creatinine (mg/dL) | 1.28 |
| HIV Antibody | Reactive |
| HBsAg | NR |
| HCV Antibody | NR |
| SAAG (g/L) | 0.4 |
| ADA (IU/L) | 709 |
| HIV viral load (/mL) | 1.73 × 103 |
| CD4 Absolut (/uL) | 26 |
| CD4 (%) | 6.9 |
Note: ADA = adenosine deaminase; BUN = blood urea nitrogen; CD4 = cluster of differentiation; ESR = erythrocyte sedimentation rate; Hb = hemoglobin; HBsAg = hepatitis B surface antigen; HCV = hepatitis C virus; HIV = human immunodeficiency virus; SAAG = serum-ascites albumin gradient.
An abdominal x-ray showed dilatation of the small bowel, forming a coiled spring shape, along with an increased intestinal gas mixed with faecal matter and minimal distribution in the pelvic cavum (Fig. 1). Meanwhile, abdominal CT scan showed dense fluid in the intestines and mesenteric thickening, visible dilatation and adhesion of the small bowel, and multiple scattered mesenteric lymphadenopathies (Fig. 2). Based on the examination, the patient was diagnosed with small bowel obstruction accompanied peritoneal tuberculosis.
Fig. 1.
Abdominal X-ray showed dilatation of the small bowel, forming a coiled spring shape (arrows), along with increased intestinal gas mixed with faecal matter and minimal distribution in the pelvic cavum.
Fig. 2.
CT scan images of the patient's abdomen. (a) CT Scan abdomen with contrast in coronal and sagital view (b) CT Scan abdomen with contrast in axial views. These pictures showed extra luminal hyperdense free fluid (asterisk), thickening of the intestine (white arrows), and mesenteric (black arrow), visible dilatation and adhesions of the small bowel (purple arrow), multiple scattered mesenteric lymphadenopathies (red arrows). The findings suggest adhesive small bowel obstruction with suggestive peritoneal tuberculosis. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
The patient's management includes nasogastric tube (NGT) insertion, intestinal decompression, fasting, rehydration with crystalloid fluids, and parenteral nutrition. We performed open NGT insertion for decompression and monitored the patient for 72 h. If there was no clinical improvement, an exploratory laparotomy was required. The patient was also treated with an anti-tuberculosis drug (ATD). We used the first regimen category of ATD with a calculated dose of medications according to the patient's weight (rifampicin 450 mg, isoniazid 300 mg, pyrazinamide 1250 mg, and ethambutol 750 mg). The ATD was administered once a day through a nasogastric tube. We also gave cotrimoxazole 960 mg and fluconazole 150 mg daily. Two weeks after ATD, we administered anti-retroviral (ARV) with a regimen of tenofovir (TDF) 300 mg, lamivudine (3TC) 150 mg, and efavirenz (EFZ) 600 mg daily. The patient was hospitalised for 20 days and showed improvement every day. On the last day of treatment, the patient felt well and had no complaints of abdominal pain, fever, or constipation. Abdominal X-ray evaluation showed no small bowel obstruction. He had no complaints during the outpatient visit, therefore the ATD category 1 (intensive phase) was continued for up to 2 months. Afterwards, it was replaced by the ATD category 1 continuous phase and continued until the 6th month.
3. Discussion
In tuberculosis-endemic areas, patients who experience ascitic disease with clinical gastrointestinal disease need to be considered for tuberculosis examination [6,7]. An increase in ADA levels in ascitic fluid can be used as a diagnosis of peritoneal tuberculosis. Increased ADA levels are caused by mycobacterial antigens' stimulation of T cells. Previous studies indicates that an ADA level of >40 IU/L in ascitic fluid indicates the occurrence of peritoneal tuberculosis [8]. Furthermore, the utilization of GeneXpert MTB/RIF in ascitic fluid plays a vital role in promptly diagnosing peritoneal tuberculosis, enabling quick initiation of tuberculosis treatment and enhancing treatment efficacy [9,10]. The abdominal CT scan is also crucial for assessing the patient's peritoneal status [11]. Reportedly, the occurrence of small bowel obstruction due to tuberculosis ranges 12–60 % [12].
Non-operative management (NOM) is a recommended treatment for patients with small bowel obstruction who do not show signs of strangulation, peritonitis, or severe bowel distress. This approach involves relieving bowel decompression by inserting a NGT, managing pain, conducting regular physical examinations, providing intravenous fluid, and correction any electrolyte imbalance. The NGT insertion is effective for relieving bowel distension and pain, and it may also reduce the risk of aspiration from frequent vomiting. The World Society of Emergency Surgery Working Group guidelines on small bowel obstruction recommend limiting non-operative management to 72 h from admission. During this period, clinicians observe signs of small bowel obstruction resolutions, such as decreased NGT output, reduced pain, flatus or defecation, and/or improvement in abdominal distension. The clinicians also observe for signs of clinical deterioration, such as fever, tachycardia, and/or worsening of abdominal pain and distension. Patients with clinical and radiological evidence of ischaemia, strangulation and bowel perforation should have immediate surgery. After observing for 72 h, the patient showed resolution of small bowel obstruction, including stable haemodynamics, decreased abdominal pain, cessation of output from the NGT, the ability to flatus and defecate. The patient's treatment also focuses on the cause of small bowel obstruction, i.e., TB and HIV [13].
Based on recent studies, small bowel obstruction treatment protocols must include NGT decompression by considering water-soluble contrast (WSC). In addition, if small bowel obstruction is not resolved, a laparotomy is required. Prompt surgery is believed to have good results, but there is little agreement regarding when to declare non-surgical observation failure [14]. Based on previous studies, it was reported that 39–83 % of small bowel obstruction patients underwent surgery, where reporting regarding post-surgical mortality was very limited and recurrent post-surgery patients were reported at around 1–10 % from the current literature [15].
Treatment of tuberculosis in patients with HIV/AIDS involves initiating a first-line ATD regimen consisting of Rifampicin 10 mg/kgBW/day, Isoniazid 5 mg/kgBW/day, Pyrazinamide 15 mg/kgBW/day, and Ethambutol 15 mg/kgBW/day for 2 months as the intensive phase of treatment, then continued with Rifampicin 10 mg/kgBW/day and Isoniazide 5 mg/KgBW/day for 4 months as the continuation phase of treatment [16]. On the other hand, ARV is administered after 2 weeks of TB treatment regardless of the CD4 count. The ARV in tuberculosis with HIV/AIDS reduce mortality by 50 % [17].
4. Conclusion
Challenges in the management of peritoneal tuberculosis were unspecific clinical manifestations. Often, peritoneal tuberculosis is identified after complications such as small bowel obstruction. Apart from using an abdominal CT scan, the diagnosis of peritoneal tuberculosis can be confirmed using enhanced ADA levels and GeneXpert MTB/RIF in ascitic fluid for early diagnosis. Management of peritoneal tuberculosis with small bowel obstructions and HIV/AIDS infections includes bowel decompression, pain control, intravenous fluid replacement, and electrolyte balance for no indication of surgery, ATD, and ARV. Apart from that, monitoring plays a vital role in treatment success.
Consent
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.
Ethical approval
Ethical approval is exempt/waived at our institution because the report only has one patient.
Funding
Nothing.
Author contribution
Laili Fitri Niamita: Data curation, investigation, funding acquisition, roles/writing - original draft, writing - review & editing; Bramantono: Conceptualization, methodology, project administration; Mochammad Daviq: validation, software, supervision; Musofa Rusli: supervision, validation, visualisation; Muhammad Vitanata Arifijanto: resource, formal analysis.
Guarantor
Laili Fitri Niamita is the person in charge of the publication of our manuscript.
Research registration number
Not applicable.
Conflict of interest statement
Laili Fitri Niamita, Bramantono, Mochammad Daviq, Musofa Rusli, and Muhammad Vitanata Arifijanto declare that they have no conflicts of interest.
Acknowledgement
We would like to thank Fis Citra Ariyanto, our editor.
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