Brenninkmeijer, B.J.

Meer, J.W.M. van der

Vreden, S.G.S.

NARCIS 

Peritoneal tuberculosis in two young immigrants with fever of unknown origin

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218 Netherlands Journal o f  Medicine, 41(1992 ) 218-221 
€ 1992 Elsevier Science Publishers B.V. All rights reserved 0300-2977/9 2 /$ 0 5 .0 0
NJM 00607
Brief Report
Peritoneal tuberculosis in two young immigrants with fever 
of unknown origin
S.G.S. Vrcden a, B.J. Brenninkmcijcr b and J.W .M . van der Mccr a
" Department o f Medicine, University Hospital St. Radhoud. Nijmegen, Netherlands; h Department o f Medicine, St. Joseph Hospital.
Veghel, Netherlands
(Received 9 September 1991; revision received 19 February 1992; accepted 25 February 1992)
Two patients with long-standing fever and weight loss underwent extensive diagnostic procedures 
before peritoneal tuberculosis was diagnosed by explorative laparotomy. By that time they had developed 
signs of intestinal obstruction. Both recovered after trea tm ent,  but one developed serious neurological 
complications, which could not be explained. Peritoneal tuberculosis is a manifestation of tuberculosis 
that is often difficult to diagnose. It should be borne in mind when diagnosing patients with fever of 
unknown origin, especially if they are originally from countries with a high prevalence of tuberculosis. 
Neth J Med 1992;41:218-221.
Key words: Tuberculosis; Peritonitis; Paresis; Fever of unknown origin
Introduction
Nowadays, peritoneal tuberculosis (Ptbc) is 
rarely encountered  in western countries. Most 
cases concern immigrants from regions in which 
tuberculosis is endemic. The lack of pa thog­
nomonic symptoms or signs often causes a delay 
in establishing the diagnosis, even if diagnostic 
procedures are aimed at tuberculosis. Here we 
report two patients in whom the diagnosis was 
made 3 and 8 weeks, respectively, after admis-
sion.
Case 1
A 23-yr-old male of Turkish descent, was ad ­
mitted to hospital because of fever and abdom i­
nal discomfort, which had already lasted for about
Correspondence to: S.G.S. Vreden, M.D.. University Hos­
pital St. Radboud. P.O. Box 9100, 6500 MB Nijmegen. Nether­
lands.
5 weeks. There  were frequent bouts of profuse 
sweating, at night as well as during the day. The 
pain was located in the right lower abdominal 
quadran t,  continuous and related to movement 
and coughing. Although not frequent, his stools 
had been loose, with no blood or mucus. He had 
lost more than 12 kg of body weight. The  medical 
history so far had been unremarkable . The p a ­
tient grew up in Turkey, but had lived in The 
N etherlands for several years. His last visit to 
Turkey was 18 months before.
On examination the patient was not very ill. 
The tem pera tu re  was 39.5°C, the pulse rate 100 
bpm, and the blood pressure 108/54  mmHg. 
T here  was no lymphadenopathy. On percussion 
of the thorax we found the lower border of the 
right lung about 3 cm higher com pared to the 
left, but both lungs were clear. A G rade  1 systolic 
m urm ur was heard along the upper left sternal 
border. The bowel sounds were normal. The ab­
domen was tense and somewhat p ro tuberan t,  but 
soft. Liver and spleen were not palpable and 
there was no shifting dullness. Rectal examina-
219
tion revealed no mass or tenderness. Neurologi­
cal examination was negative. The ESR was 126 
m m /h ,  haemoglobin 6.1 m m o l/ l ,  WBC 13.8 x 
10^/1 with 82% neutrophils, 1 1 % lymphocytes 
and 7% monocytes. The urine gave 5 -2 0  
m onom orphic erythrocytes per high power field, 
sporadic leucocytes and no cell casts. The BUN 
was 2.1 m m o l/ l ,  the serum protein 70 g / I  (the 
albumin 30.6 and gamma-globulin 12 g /I) .  The 
A L A T  was 91 U / l ,  AS A T 68 U / I ,  LDH 320 
U / l ,  CK 18 U / l .  A differential diagnosis was 
made, which included tuberculosis, salmonellosis, 
abdominal abscess, leishmaniasis, malignant lym­
phoma and familial m edite rranean  fever. Cul­
tures of blood, urine and stools rem ained nega­
tive. Serological tests for several microbial 
pathogens, including HIV were negative. An X- 
ray of the thorax was normal, except for an e le­
vated right hemidiaphragm, which on fluoroscopy 
proved not to be paralysed. Because a subdi- 
aphragmal mass was suspected, an ultrasound 
study of the abdomen was performed: no subdi- 
aphragmal mass or fluid could be detected; there 
was a trace of ascites in M orrison’s pouch; the 
intestinal wall of ileum and sigmoid and also the 
m esen ter ium  were som ew hat extended. An 
111 In-labelled leucocyte scan did not reveal ab ­
scesses or focal inflammation. The tuberculin skin 
test, perform ed twice, was negative, as was the 
skin test with Candida antigen. Varidase antigen, 
however, elicited an erythema of 15 mm. Micro­
scopic examination of biopsy specimens of the 
bone marrow and the duodenal mucosa was un re ­
markable; in a liver biopsy, aspecific intralobular 
and portal infiltrates containing lymphocytes, his­
tiocytes and polym orphonuclear cells were ob­
served. During the 3-week period in which the 
patient had been observed and all investigations 
had been performed, his condition worsened; he 
lost ano ther  8 kg. W hen he developed signs of 
intestinal obstruction, we decided to perform an 
explorative laparotomy. This revealed massive in­
filtration of the small intestine and numerous 
granulom as on the peritoneal and mesenterial 
surface. In a biopsy, acid-fast bacilli could be 
dem onstra ted , which on culture proved to be 
Mycobacterium tuberculosis, sensitive to all usual 
tuberculostatic drugs. Therapy  was started  with
etham butol 900 mg and rifampicin 600 mg, both 
once daily, administered i.v. Isoniazid 300 mg 
once daily was only started 4 days later, when the 
patient could take oral therapy. Pyridoxine 50 mg
b.i.d. was added to prevent neurotoxicity from 
isoniazid. The patient recovered slowly on this 
regimen and he gained weight. On the day that 
isoniazid was initiated, he complained of pain 
and muscle weakness in both upper legs; this had 
started a few days prior to surgery. On physical 
examination there was marked atrophy of both 
quadriceps and also paresis of the iliopsoas, ad ­
ductor and abductor, gastrocnemius and tibialis 
anterior muscles. Knee and achilles tendon re­
flexes were absent and there was hypaesthesia on 
the medial side of both upper legs. An EM G  
revealed mass denervation of all muscles inner­
vated by the lumbar plexus. CSF examination and 
myelography were negative. A com puted tomog­
raphy of the ab d o m en  revealed no lym- 
phadenopathy  or abscesses in the psoas region; 
the lower thoracic and lumbar vertebrae were not 
affected. Since the paresis developed on the same 
day as the initiation of isoniazid therapy, the drug 
could not be responsible for this complication. 
Although there was some improvement in subse­
quent weeks, the patient rem ained seriously 
handicapped.
A second EM G  performed 5 months later was 
still consistent with bilateral impairment of the 
lumbar plexus. E thambutol was withdrawn after 
three months of trea tm ent and isoniazid, ri­
fampicin and pyridoxine were continued for nine 
months.
Case 2
A 26-yr-old Somalian refugee was adm itted  to 
hospital because of fever and diarrhoea. He also 
had anorexia, nausea, and epigastric pain. He 
had been living in The N etherlands for 11 months. 
T he  medical history so far had been un rem ark ­
able. On examination the patient was found to be 
moderately ill and his nutritional condition was 
poor. The tem pera tu re  was 40°C. The pulse rate 
was 100 bpm and the blood pressure 120/70 
mmHg. The lungs were clear and there were no 
heart murmurs. The abdomen was supple, spleen
220
and liver were not enlarged. Rectal examination 
revealed no mass or tenderness. The urine was 
unremarkable . The ESR was 125 m m /h ,  Hb 7.4 
mmol/1, W BC 7.1 X 10g/K  with 15% rods, 58% 
neutrophils  and 21% lymphocytes. Minerals, 
BUN and transaminases were normal. Albumin 
20.1 g / I .  A differential diagnosis was made, 
which included AIDS, tuberculosis, salmonellosis, 
an abscess, malignant lymphoma and familial 
M edite rranean  fever. Parasitological and bacteri­
ological examination of the stools was negative. 
Serological assays for several microbial pathogens, 
including HIV were negative, as were blood cul­
tures. R epea ted  chest X-rays were normal. A 
tuberculin skin test was positive, with an indura­
tion of 20 mm in diameter. Microscopic exam ina­
tion of biopsy specimens of the skin, the jejunal 
and rectal mucosa and bone marrow showed no 
abnormalities, as was the case with ultrasound 
and com puted tomography of the abdom en. A 
barium -enem a examination revealed a normal ap ­
pearance of the small and large intestines. A total 
body i,l)G a scan did not show areas of focally 
increased uptake. During a period of 8 weeks in 
which the patient had been observed and all 
investigations were perform ed, his condition 
worsened; this was dem onstra ted  by an additional 
weight loss from 44 to 38 kg. A therapeu tic  trial 
with colchicine, as t rea tm en t of suspected familial 
M edite rranean  fever was not effective. Shortly 
the rea f te r  the patient s tarted  complaining of ab ­
dominal pain. Because of progressive signs of 
peritoneal irritation and sub-ileus, it was decided 
to perform an explorative laparotomy, 61 days 
after admission. T here  was a diffuse peritonitis 
with multiple granulom as and adhesions of the 
intestines. Histology showed a necrotizing inflam­
mation with granulomas, indicative of tubercu lo­
sis. Smears did not reveal acid-fast bacilli, but 
later cultures of the g ranulom atous material were 
positive for Mycobacterium tuberculosis, sensitive 
to all usual tuberculostatic  drugs. T herapy  with 
isoniazid 200 mg, rifampicin 450 mg and pyrazi- 
namide 750 mg (all once daily) was started , to­
ge ther  with paren tera l  nutrition. The te m p e ra ­
ture decreased  slowly and the patient recovered 
completely. Pyrazinamide was discontinued 3 
m onths after  initiation of the therapy, the o ther  
drugs after  9 months.
Discussion
In both patients fever and weight loss were the 
most prom inent clinical features on admission. 
Despite these nonspecific signs, an infection was 
suspected in these young people and because of 
their origin from Turkey and Somalia, respec­
tively, tuberculosis ranked high in the differential 
diagnosis. The tuberculin skin test was negative 
in one of the patients, but this may reflect anergy 
and does not exclude active tuberculosis, e spe ­
cially in severely ill patients. Bone marrow cul­
tures and liver biopsy (in case 1) were negative, 
despite the relatively high yield of these m ethods 
in patients with tuberculosis [1,2]. In both pa ­
tients an explorative laparotomy was necessary to 
establish the diagnosis.
It is debatable  w hether  e tham butol or pyrazi­
namide should be the third com ponent in initial 
therapy. E tham buto l is far less active and is mostly 
used to prevent em ergence of isoniazid resistant 
strains. However pyrazinamide is ineffective 
against M. boris , which in developing countries 
may still play an im portant part in tuberculosis, 
especially if the infection may have been a lim en­
tary.
Paraparesis is a well-known complication of 
tuberculous spondylitis or paravertebral abscess 
[3-6]. In patient 1 none of these conditions could 
be dem onstra ted . Lifeso and colleagues described 
a series of 107 patients with spinal tuberculosis
[5]. In 5 of these patients  neurological im pair­
ment was caused by extradural or in tradural in­
volvement of the spinal canal with tuberculom as 
or arachnoiditis. This was not de tec ted  by myel­
ography or com puted  tom ographic scans, but only 
after laminectomy [5]. Thus, in retrospect such a 
complication may have occurred in our patient.
Peritonitis is an uncomm on manifestation of 
tuberculosis. It accounts for 0.1 to 1% of all 
reported  cases [7-9], and its exact incidence in 
The N etherlands  is unknown. In a Dutch series 
of 85 patients  with tuberculosis, collected in a 
university hospital, Smelt et al. reported  one case 
with peritoneal disease [10]. T he  clinical symp­
toms and signs of Ptbc are nonspecific. Most 
patients have abdominal pain, fever and weight 
loss. Especially when there are no extraperitoneal 
localisations of tuberculosis, it takes a long time
221
before the diagnosis is made. In several series of 
patients with Ptbc, ascites could be established on 
physical examination in 16 to 80% [11-17]. Acid 
fast bacilli, however, could only be dem onstra ted  
in 11 to 50% of ascitic fluids. In these series, the 
percentage  of patients  in whom the diagnosis was 
made after laparoscopy or laparotomy varies from 
5 to 40% and 40 to 97%, respectively. Although 
laparoscopy has been perform ed successfully in 
many cases, it bears a certain risk when intestinal 
adhesions are present. Recently, two studies have 
been published concerning the diagnostic value of 
adenosine deam inase activity in ascites and in the 
serum of patients with Ptbc [18,19]. Both articles 
report high specificity and sensitivity of this test 
for Ptbc. Several sérodiagnostic tests for es tab­
lishing active tuberculosis have been developed, 
with varying sensitivity and specificity [20-23]. 
However, these tests are still not available for 
routine use in the diagnosis of tuberculosis.
It is assumed that Ptbc represen ts  a reactiva­
tion of tuberculosis, ra ther  than primary infection 
[13,24]. The finding that Ptbc in Europe is mostly 
seen in patients  from foreign countries, where 
there is a high prevalence of tuberculosis, sup­
ports this theory [12,13,17].
Ptbc remains a condition which is often only 
diagnosed after the elimination of a variety of 
o ther  conditions. T he  diagnosis should be consid­
ered in young adults, with persistent fever and 
wasting, with or without abdominal symptoms, 
especially when they are originally from areas 
where tuberculosis is endemic. Until the value of 
adenosine deam inase  activity or specific antibody 
assays has been established, the diagnosis of Ptbc 
remains highly d ependen t  on invasive diagnostic 
procedures, such as laparoscopy and laparotomy. 
Normal chest X-rays and negative tuberculin skin 
tests are insufficient to exclude tuberculosis in 
patients  with fever of unknown origin.
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Peritoneal tuberculosis in two young immigrants with fever of unknown origin

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