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Tuberculosis 113
Acute abdomen simulate late presentation of Hirschsprung’s disease in young children,
Uncommonly, the presentation may be like an acute abdomen, which Crohn’s disease, amoeboma, or malignancy in adolescents.
may be due to rupture of a caseous lymph node, GI perforation, tuber- Rectal and Anal Tuberculosis
cular peritonitis, ruptured mesenteric abscess, or acute obstruction, Rectal tuberculosis is rare and may present with haematochezia, con-
especially in the presence of stricture. Involvement of the appendix is stitutional symptoms and constipation with anal discharge, multiple
usually a part of ileocaecal involvement, and rarely may present as an fistula with ragged margins, or perianal swelling. Digital examination
isolated case of acute appendicitis.
may reveal an annular stricture, which is usually tight and of variable
Gastrointestinal involvement length with focal areas of deep ulceration.
The patient may present with nonspecific symptoms of vague abdomi- Miscellaneous Presentations
nal pain, mild discomfort, anorexia, malaise, and fever. After a relay An uncommon presentation of abdominal tuberculosis is as pyrexia of
of investigations, if no cause is identified, an exploratory laparotomy unknown origin. Suggestive hepatomegaly may lead to the diagnosis
is done in view of the persisting symptoms (Figure 18.1). The positive of hepatic tuberculosis on liver biopsy. The miliary and local forms
findings may be only congestion and neovascularisation. Symptoms of hepatic tuberculosis have quite similar clinical presentations and
will subside on starting antitubercular treatment. pathological features. Hepatosplenic tuberculosis is common as a part
of disseminated and miliary tuberculosis.
Female patients with abdominal tuberculosis may present with
menstrual disorders or later with infertility as a result of involvement
of the uterus or fallopian tubes.
Investigations
Diagnosis is usually made through a combination of radiologic, endo-
scopic, microbiologic, histologic, and molecular techniques.
Haematological Tests
Anaemia and hypoalbuminaemia may be associated with tuberculosis
due to poor nutrition. Total leucocyte count is raised in half the cases.
There may also be associated leucocytosis due to superadded infection
along with lymphocytosis suggestive of chronic infection.
A raised erythrocyte sedimentation rate (ESR), although nonspecific,
is a very supportive finding and is a good marker to assess the response
to treatment. Serologic tests have a limited role due to their inability to
distinguish between past and present infections.
Mantoux Test
An induration of less than 6 mm in diameter indicates either (1) an
uninfected patient, (2) recent infection, (3) anergy due to malnutrition
Figure 18.1: A 2-year-old child presenting with subacute intestinal or disease states such as measles, or (4) overwhelming tuberculosis
obstruction due to ileocaecal tuberculosis confirmed on laparotomy. infection (50% of autopsies proved cases of severe tuberculosis had
been Mantoux negative). Induration in the range of 6–9 mm indicates
Oesophageo-Gastroduodenal Tuberculosis either past infection or a Calmette-Guérin bacillus (BCG) tuberculosis
Involvement of oesophagus is extremely rare and presents as dys- vaccination. It may also be found in some cases of active infection,
phagia, odynophagia, and a midoesophageal ulcer. Gastroduodenal particularly where atypical mycobacteria are involved. Induration of
tuberculosis may present with dyspepsia and gastric outlet obstruction. 10–14 mm in children <5 years of age strongly indicates active infec-
Surgical bypass has been required in the majority of cases to relieve tion. Patients with an induration >14 mm are four times more likely to
obstruction, but successful endoscopic balloon dilatation of duodenal have an active disease than those with a Mantoux test in the range of
strictures has also been done. 10–14 mm. If the patient has been vaccinated with BCG before, then
an induration of more than 15 mm at 1 year, or 12 mm at 2 years after
Jejunoileal Tuberculosis vaccination is considered positive.
Tubercular involvement of the jejunum and ileum may present with Specimens for bacteriologic examination include sputum, gastric
malabsorption and subacute intestinal obstruction. On exploration, lavage, bronchoalveolar lavage, lung tissue, and lymph node. Gastric
there may be jejunoileitis with nonspecific inflammatory changes aspirates may be used in place of sputum in children <6 years of age
on biopsy. with pulmonary tuberculosis, as they may not be able to cough out
Terminal Ileal and Ileocaecal Tuberculosis sputum. An early-morning sample should be obtained for undiluted
In India, around 3–20% of all cases of bowel obstruction are due to bronchial secretions accumulated during the night. As gastric acidity is
tuberculosis. Tubercular intestinal stricture presents with recurrent poorly tolerated by the tubercle bacilli, neutralisation of the specimen
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subacute intestinal obstruction in the form of obstipation, vomiting, should be done immediately with 10% sodium carbonate or 40%
abdominal distention, and colicky abdominal pain associated with gur- anhydrous sodium phosphate. Even with utmost care, the tubercle
gling, feeling like a ball of wind is moving in the abdomen, and visible bacilli can be detected in only 70% of infants and in only 30–40% of
intestinal loops. Having a chronic inflammatory pathology, tubercular children with disease. Sputum specimens and bronchoalveolar lavage
perforations are rare and usually single and proximal to a stricture. may be used in older children. Nasopharyngeal secretions and saliva
Segmental Colonic Tuberculosis are not acceptable.
This type of tuberculosis commonly involves the sigmoid, ascend- Acid-Fast Bacilli Staining
ing and transverse colon. Manifestations include chronic constipa- Acid-fast bacilli (AFB) Ziehl-Neelsen staining provides preliminary con-
tion, fever, anorexia, weight loss, and change in bowel habits. It may firmation of the diagnosis, although it cannot differentiate M. tuberculosis