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Abdominal tuberculosis: An unusual presentation
c u r r e n t m e d i c i n e r e s e a r c h a n d p r a c t i c e x x x ( 2 0 1 4 ) 1 e3
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/cmrp
Continuing Medical Education
Abdominal tuberculosis: An unusual presentation Rinkesh Kumar Bansal a, Pankaj Tyagi a, Ashish Kumar a, Praveen Sharma a, Bansal Naresh a, Singla Vikas a, Anil Arora a,*, Seema Rao b a b
Department of Gastroenterology & Hepatology, Sir Ganga Ram Hospital, Delhi, India Department of Histopathology, Sir Ganga Ram Hospital, Delhi, India
article info
abstract
Article history:
Tuberculosis is a very common disease in India. It can present in many ways, common as
Received 28 September 2014
well as uncommon. The high level of suspicion is required, especially to diagnose in un-
Accepted 31 October 2014
common presentation, so that morbidity and mortality can be prevented. Erythema
Available online xxx
nodosum (EN) is an inflammatory disease of the skin and subcutaneous tissue that may be found in infectious diseases like tuberculosis, sarcoidosis, Behc¸et disease, inflammatory
Keywords:
bowel diseases, lymphoma and drug therapy. Here we present a case of young male with
Tuberculosis
tubercular protein hypersensitivity reactions as a presenting feature of abdominal
Erythema nodosum
tuberculosis.
Ziehl Neelson
Copyright © 2014, Sir Ganga Ram Hospital. Published by Reed Elsevier India Pvt. Ltd. All rights reserved.
1.
Introduction
Hypersensitivity reaction to tubercular protein can be the first and only presentation of tuberculosis in a patient with or without evidence of active disease. These hypersensitivity reactions can be of various types like erythema nodosum, phlyctenular conjunctivitis, pleural or pericardial effusion and reactive polyarthritis.
2.
Case report
A 45 year old male admitted in our hospital with complaints of multiple non-pruritic painful nodules over both legs without any joint involvement associated with reddish discoloration of left eye since 7 days. No history of fever, weight loss, cough or expectoration. There was no history of any contact of
tuberculosis in the family. There was no history of significant drug ingestion. There was no history of similar episode or any drug rash in the past. On general physical examination, there was no pallor, icterus, cyanosis or lymphadenopathy. On local examination, multiple erythematous, papulo-nodular tender lesions of 1e1.5 cm size over both legs, more on the extensor surface (Fig. 1) and there was congestion of left conjunctiva (Fig. 2). Respiratory, cardiovascular, abdominal and central nervous system examination were within normal limits. On vital examination, his pulse rate was 80/min, blood pressure was 110/80 mm Hg, temperature was 37.6 C and respiratory rate was 20/min. On investigations, Hemoglobin was 16.5 g/dl, TLC e 11100/ ml and platelet count e 2.19 lakh/ml. Renal and liver function test were normal. ESR was 73 and Mantoux was positive. ANA, Anti-ds DNA, c-ANCA and p-ANCA were negative. Chest X-ray was normal.
* Corresponding author. E-mail address: [email protected] (A. Arora). http://dx.doi.org/10.1016/j.cmrp.2014.11.003 2352-0817/Copyright © 2014, Sir Ganga Ram Hospital. Published by Reed Elsevier India Pvt. Ltd. All rights reserved.
Please cite this article in press as: Bansal RK, et al., Abdominal tuberculosis: An unusual presentation, Current Medicine Research and Practice (2014), http://dx.doi.org/10.1016/j.cmrp.2014.11.003
2
c u r r e n t m e d i c i n e r e s e a r c h a n d p r a c t i c e x x x ( 2 0 1 4 ) 1 e3
Fig. 1 e Erythematous, papulo-nodular lesions. Fig. 3 e After treatment. Skin biopsy from lesion was done which revealed septal panniculitis with necrotizing vasculitis suggestive of erythema nodosum. Endoscopic ultrasound (EUS) was done which revealed periportal and pre-caval lymph adenopathy, though no mediastinal involvement, fine needle aspiration (FNA) was taken which on histopathological examination revealed epithelioid cell granuloma with caseous necrosis and Ziehl Neelson (ZN) staining for acid fast bacilli was positive. An anti-TB treatment comprising rifampicin, isoniazid, ethambutol and pyrazinamide was started and patient respondes to treatment, his skin lesion disappeared after 7 days (Fig. 3).
Fig. 2 e Phlyctenular conjunctivitis.
3.
Discussion
Erythema nodosum (EN) is an acute, nodular, erythematous eruption that is usually limited to the extensor surface of the lower legs, with occasional involvement of thighs or arms.1 It is a hypersensitivity reaction found in infectious diseases like tuberculosis, sarcoidosis, Behc¸et disease, inflammatory bowel diseases, lymphoma and drug therapy or it may be idiopathic in 70% of cases.2 However, sometimes the underlying disease may be difficult to detect, causing diagnosis in later stage, which may be dangerous in the most severe forms, as with the Tuberculosis occurring in our patient. As a manifestation of tuberculosis, erythema nodosum has been described in children with primary tuberculosis infection and may be associated with other hypersensivity manifestation. Immune complex deposition within dermal vessels is an important component in the production of the symptom complex. Approximately 95% of individuals exposed to Mycobacterium tuberculosis remain clinically asymptomatic, while the remaining 5% develop primary TB, which is most often localised in the lungs.3 In a minority of subjects, secondary TB occurs when the pulmonary disease spreads to other organ systems through self inoculation via infected sputum, blood, or the lymphatic system. Retroperitoneal manifestation, such as that observed in our patient, is rare and difficult to interpret. Patients usually present with dusky red, tender, papulonodular lesions over the legs. Lesion borders are poorly defined and size vary from 1 to 6 cm. Individual lesions last approximately two weeks, but occasionally, new lesions continue to appear for three to six weeks. When erythema nodosum is diagnosed, it is important to find out the underlying conditions. These need a detailed history, careful physical examination and relevant investigation including chest Xray. The mantoux test is always positive and a negative test rule out tuberculosis as the etiology.
Please cite this article in press as: Bansal RK, et al., Abdominal tuberculosis: An unusual presentation, Current Medicine Research and Practice (2014), http://dx.doi.org/10.1016/j.cmrp.2014.11.003
c u r r e n t m e d i c i n e r e s e a r c h a n d p r a c t i c e x x x ( 2 0 1 4 ) 1 e3
Erythema nodosum has tendency to disappear by itself and often does not require any specific treatment. If the underlying cause is found, it should be treated first. Non steroidal anti-inflammatory drugs (NSAIDS), bed rest and cool wet compresses are advised for relief of pain.4 Corticosteroids are needed in some cases provided that there is no infection or cancer. In conclusion, our case confirms the important role of EN as a presentation feature of systemic disease and underlines the need to consider TB in such circumstances.
Conflicts of interest All authors have none to declare.
3
references
1. Mert A, Kumbasar H, Ozaras R, et al. Erythema nodosum: an evaluation of 100 cases. Clin Exp Rheumatol. 2007;25: 563e570. 2. Handa R, Raman M, Verma KK. Panniculitides: a clinicopathologic study. J Assoc Physicians India. 2002;50:1008e1012. 3. World Health Organization (WHO). World Health Organization Global Tuberculosis Programme: global tuberculosis control, WHO/ GTB/97.225. Geneva: WHO; 1997. 4. Garcia-Rodriguez JF, Monteagudo-Sanchez B, Marino-Callejo A. Cutaneous tuberculosis: a 15 year descriptive study. Enferm Infect Microbiol Clin. 2008;26:205e211.
Please cite this article in press as: Bansal RK, et al., Abdominal tuberculosis: An unusual presentation, Current Medicine Research and Practice (2014), http://dx.doi.org/10.1016/j.cmrp.2014.11.003
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/cmrp
Continuing Medical Education
Abdominal tuberculosis: An unusual presentation Rinkesh Kumar Bansal a, Pankaj Tyagi a, Ashish Kumar a, Praveen Sharma a, Bansal Naresh a, Singla Vikas a, Anil Arora a,*, Seema Rao b a b
Department of Gastroenterology & Hepatology, Sir Ganga Ram Hospital, Delhi, India Department of Histopathology, Sir Ganga Ram Hospital, Delhi, India
article info
abstract
Article history:
Tuberculosis is a very common disease in India. It can present in many ways, common as
Received 28 September 2014
well as uncommon. The high level of suspicion is required, especially to diagnose in un-
Accepted 31 October 2014
common presentation, so that morbidity and mortality can be prevented. Erythema
Available online xxx
nodosum (EN) is an inflammatory disease of the skin and subcutaneous tissue that may be found in infectious diseases like tuberculosis, sarcoidosis, Behc¸et disease, inflammatory
Keywords:
bowel diseases, lymphoma and drug therapy. Here we present a case of young male with
Tuberculosis
tubercular protein hypersensitivity reactions as a presenting feature of abdominal
Erythema nodosum
tuberculosis.
Ziehl Neelson
Copyright © 2014, Sir Ganga Ram Hospital. Published by Reed Elsevier India Pvt. Ltd. All rights reserved.
1.
Introduction
Hypersensitivity reaction to tubercular protein can be the first and only presentation of tuberculosis in a patient with or without evidence of active disease. These hypersensitivity reactions can be of various types like erythema nodosum, phlyctenular conjunctivitis, pleural or pericardial effusion and reactive polyarthritis.
2.
Case report
A 45 year old male admitted in our hospital with complaints of multiple non-pruritic painful nodules over both legs without any joint involvement associated with reddish discoloration of left eye since 7 days. No history of fever, weight loss, cough or expectoration. There was no history of any contact of
tuberculosis in the family. There was no history of significant drug ingestion. There was no history of similar episode or any drug rash in the past. On general physical examination, there was no pallor, icterus, cyanosis or lymphadenopathy. On local examination, multiple erythematous, papulo-nodular tender lesions of 1e1.5 cm size over both legs, more on the extensor surface (Fig. 1) and there was congestion of left conjunctiva (Fig. 2). Respiratory, cardiovascular, abdominal and central nervous system examination were within normal limits. On vital examination, his pulse rate was 80/min, blood pressure was 110/80 mm Hg, temperature was 37.6 C and respiratory rate was 20/min. On investigations, Hemoglobin was 16.5 g/dl, TLC e 11100/ ml and platelet count e 2.19 lakh/ml. Renal and liver function test were normal. ESR was 73 and Mantoux was positive. ANA, Anti-ds DNA, c-ANCA and p-ANCA were negative. Chest X-ray was normal.
* Corresponding author. E-mail address: [email protected] (A. Arora). http://dx.doi.org/10.1016/j.cmrp.2014.11.003 2352-0817/Copyright © 2014, Sir Ganga Ram Hospital. Published by Reed Elsevier India Pvt. Ltd. All rights reserved.
Please cite this article in press as: Bansal RK, et al., Abdominal tuberculosis: An unusual presentation, Current Medicine Research and Practice (2014), http://dx.doi.org/10.1016/j.cmrp.2014.11.003
2
c u r r e n t m e d i c i n e r e s e a r c h a n d p r a c t i c e x x x ( 2 0 1 4 ) 1 e3
Fig. 1 e Erythematous, papulo-nodular lesions. Fig. 3 e After treatment. Skin biopsy from lesion was done which revealed septal panniculitis with necrotizing vasculitis suggestive of erythema nodosum. Endoscopic ultrasound (EUS) was done which revealed periportal and pre-caval lymph adenopathy, though no mediastinal involvement, fine needle aspiration (FNA) was taken which on histopathological examination revealed epithelioid cell granuloma with caseous necrosis and Ziehl Neelson (ZN) staining for acid fast bacilli was positive. An anti-TB treatment comprising rifampicin, isoniazid, ethambutol and pyrazinamide was started and patient respondes to treatment, his skin lesion disappeared after 7 days (Fig. 3).
Fig. 2 e Phlyctenular conjunctivitis.
3.
Discussion
Erythema nodosum (EN) is an acute, nodular, erythematous eruption that is usually limited to the extensor surface of the lower legs, with occasional involvement of thighs or arms.1 It is a hypersensitivity reaction found in infectious diseases like tuberculosis, sarcoidosis, Behc¸et disease, inflammatory bowel diseases, lymphoma and drug therapy or it may be idiopathic in 70% of cases.2 However, sometimes the underlying disease may be difficult to detect, causing diagnosis in later stage, which may be dangerous in the most severe forms, as with the Tuberculosis occurring in our patient. As a manifestation of tuberculosis, erythema nodosum has been described in children with primary tuberculosis infection and may be associated with other hypersensivity manifestation. Immune complex deposition within dermal vessels is an important component in the production of the symptom complex. Approximately 95% of individuals exposed to Mycobacterium tuberculosis remain clinically asymptomatic, while the remaining 5% develop primary TB, which is most often localised in the lungs.3 In a minority of subjects, secondary TB occurs when the pulmonary disease spreads to other organ systems through self inoculation via infected sputum, blood, or the lymphatic system. Retroperitoneal manifestation, such as that observed in our patient, is rare and difficult to interpret. Patients usually present with dusky red, tender, papulonodular lesions over the legs. Lesion borders are poorly defined and size vary from 1 to 6 cm. Individual lesions last approximately two weeks, but occasionally, new lesions continue to appear for three to six weeks. When erythema nodosum is diagnosed, it is important to find out the underlying conditions. These need a detailed history, careful physical examination and relevant investigation including chest Xray. The mantoux test is always positive and a negative test rule out tuberculosis as the etiology.
Please cite this article in press as: Bansal RK, et al., Abdominal tuberculosis: An unusual presentation, Current Medicine Research and Practice (2014), http://dx.doi.org/10.1016/j.cmrp.2014.11.003
c u r r e n t m e d i c i n e r e s e a r c h a n d p r a c t i c e x x x ( 2 0 1 4 ) 1 e3
Erythema nodosum has tendency to disappear by itself and often does not require any specific treatment. If the underlying cause is found, it should be treated first. Non steroidal anti-inflammatory drugs (NSAIDS), bed rest and cool wet compresses are advised for relief of pain.4 Corticosteroids are needed in some cases provided that there is no infection or cancer. In conclusion, our case confirms the important role of EN as a presentation feature of systemic disease and underlines the need to consider TB in such circumstances.
Conflicts of interest All authors have none to declare.
3
references
1. Mert A, Kumbasar H, Ozaras R, et al. Erythema nodosum: an evaluation of 100 cases. Clin Exp Rheumatol. 2007;25: 563e570. 2. Handa R, Raman M, Verma KK. Panniculitides: a clinicopathologic study. J Assoc Physicians India. 2002;50:1008e1012. 3. World Health Organization (WHO). World Health Organization Global Tuberculosis Programme: global tuberculosis control, WHO/ GTB/97.225. Geneva: WHO; 1997. 4. Garcia-Rodriguez JF, Monteagudo-Sanchez B, Marino-Callejo A. Cutaneous tuberculosis: a 15 year descriptive study. Enferm Infect Microbiol Clin. 2008;26:205e211.
Please cite this article in press as: Bansal RK, et al., Abdominal tuberculosis: An unusual presentation, Current Medicine Research and Practice (2014), http://dx.doi.org/10.1016/j.cmrp.2014.11.003