Introduction

Extra-pulmonary tuberculosis can affect almost any organ in the body. Abdominal tuberculosis is one of the most prevalent forms of extra-pulmonary disease and may involve the intestine, peritoneum, lymph nodes, and solid viscera like the liver, spleen, kidney, pancreas and ovaries. Of the 6.1 million cases of tuberculosis notified to the World Health Organisation (WHO) in 2012, 0.8 million cases had extra-pulmonary tuberculosis.1

Case Report

We report the case of a 57-year-old Tunisian woman who presented with a 2 months history of weight loss of 5 kg ( 6.5 %), cough, nausea without vomiting, decreased appetite and pelvic and abdominal pain. Laboratory data showed a normal white cell count, increased erythrocyte sedimentation rate (53 mm/h; normal range 30–125) and a haemoglobin of 14.1 g/dl. Chest radiograph showed moderate right pleural effusion. Abdominal ultrasound revealed large amount of ascites. Computed tomography showed massive pleural effusion without lung parenchyma lesions, peritoneal thickening, presence of peritoneal tiny nodules with pronounced enhancement, jejunum wall thickening and enlarged mesenteric lymph nodes with low-density center ascites. Sputum was negative for Mycobacterium tuberculosis. Pleural fluid analysis and abdominal paracentesis showed exudative ascitic fluid with 70 % of lymphocytes. Ziehl-Neelsen staining was performed and was negative for acid-fast bacilli. No malignant cell was detected. CT-guided biopsy of the lesions and serosal nodules were evaluated too risky, and diagnostic laparoscopy was performed. In the multiple nodular lesions on the peritoneum, serosal surface of the bowel, right and left ovaries, liver and diaphragm (Fig. 1a, b), a solid mass, 4 cm in size in the uterus and ascitic fluid, was observed. Biopsies were taken for tissue diagnosis. Biopsy specimens consisted in fragments of peritoneum, omentum, diaphragm, liver, and lesion of the uterus. Pathological evaluation showed omental epithelioid granulomas with a central caseous necrosis and presence of Langhans-type giant cells and inflammatory cell infiltration (Fig. 1c). The Ziehl staining revealed a negativity for acid-fast bacilli. Cytologic analysis was negative. The masse of the uterus was a leiomyoma. On the basis of the histopathological results, the patient received anti-tubercular treatment consisting of isoniazid, ethambutol, rifampicin and pyrazinamide. After 2 months, she had a clinic improvement without symptoms. CT scan showed a disappearance of jejunum wall thickening, moderate ascites and stability of lymph node size and absence of other new lesions. The second phase of therapy include isoniazid and rifampicine for 4 months.

Fig. 1
figure 1

a, b Laparoscopic image showing multiple nodular lesions on the peritoneum; serosal surface of the bowel, liver and diaphragm; and c omental epithelioid granuloma

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Discussion

Diagnosis of abdominal tuberculosis is difficult because of non-specific clinical features. M. tuberculosis culture of peritoneal fluid may be negative; thus, this test is diagnostically low. Symptoms may be diffuse and mimic other pathologies. Differential diagnoses of disseminated ovarian cancer with ascites, peritoneal carcinosis, colonic cancer and Crohn’s disease should be considered, and the diagnosis is often established at the time of surgery.2

Microbiological and culture isolation of M. tuberculosis of bacilli is rare for patients with abdominal tuberculosis, and Ziehl-Neelsen staining can be negative in most cases. The diagnosis can be established by histopathology. In fact, abdominal tuberculosis can be diagnosed by histological demonstration of granulomas with caseation necrosis or histological evidence of tuberculosis after biopsy of mesenteric nodes or histological evidence of acid-fast bacilli in a lesion. Only one or more of these criteria confirm the diagnosis.3 – 5 In selected cases, a CT-guided biopsy of the lesions is less invasive and less costly than a laparoscopy.

In our case, we choose to perform biopsy by laparoscopy to have a large number of specimens and to avoid a risk of digestive perforation or liver bleeding. CT scan findings of peritoneal tuberculosis include the presence of a smooth peritoneum with minimal thickening and pronounced enhancement, ascites, enlarged lymph nodes and multiple diffuse nodules on the omentum and viscera. Irregular peritoneal thickening and nodular implants suggest peritoneal carcinosis.6

In differential diagnosis of ovarian masses, ascites, elevated CA 125 and abdominal tuberculosis should be considered when bacteriologic and cytologic analysis is negative. In case of difficult diagnosis or clinical suspicion, laparoscopy with biopsies is helpful for appropriate management.

Conclusion

In suspicion of abdominal tuberculosis with negative Ziehl-Neelsen staining, the use of laparoscopy is justified to obtain a correct diagnosis and is a useful, rapid and noninvasive diagnostic tool.7 – 9 Tissue samples for analysis and histologic confirmation are essentials in the abdominal tuberculosis diagnosis and eliminate other pathologies as ovarian or colonic cancer, carcinomatosis or inflammatory bowel disease.10 Laparoscopic approach avoids unnecessary extended surgery in these patients.