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POLYMERASE CHAIN REACTION IN ABDOMINAL TUBERCULOSIS

Mary Latha William, Paul Korath, K Jagadeesan
KJ Hospital, Chennai - 84.

A case report of a patient who had an abdominal mass and pain for 6 months was detected to be polymerase chain reaction (PCR) positive for DNA of mycobacterium tuberculosis is presented. The diagnosis of intestinal tuberculosis was made and on treatment with antituberculous therapy the patient made a god recovery. The importance of PCR in establishing an aetiologic diagnosis is highlighted.

INTRODUCTION

Tuberculosis is still one of the most widespread infections known to mankind. Although lung is the predominant site of disease, a sizeable population has intestinal disease. Clinical presentation, radiologic and endoscopic examination provides clues to the diagnosis. However, a definite diagnosis requires biopsy material with granulomas and/or caseation complemented by acid fast staining and culture. There are many occasions when biopsy material is scanty and even in some intestinal resection cases histological evaluation fails to confirm or rule out tuberculosis. [2] Therefore an investigation was conducted to assess the efficacy of PCR in the detection of mycobacteria [l] DNA. M tuberculosis DNA was amplified in 8 out of 12 histologically confirmed cases and in 8 cases diagnosed with non specific inflammation. 8 cases were confirmed by PCR. [2] Polymerase chain reaction (PCR) is known to diagnose tuberculosis quickly.1 PCR based on 123 bp fragment of IS6110 is specific for the mycobacterium tuberculosis complex.

CASE REPORT

A 16 year old female came with the complaints of fever with rigor and abdominal pain on and off for 6 months. She had vomiting for 2 days. She had irregular menstrual periods, loss of appetite and loss of weight in 6 months. On examination her vital signs were normal. She had pallor. Her abdomen showed fullness of the right para umbilical and lumbar region. There was a mass palpable in the right para umbilical and lumbar region, firm in consistency, non tender, ill-defined margins, and immobile in the long axis, but mobile transversely and free fluid was present intraperitoneally. Investigation revealed elevated ESR and mantoux was positive. Biochemical profile and liver function tests were normal. Urine showed 2-4 pus cells but culture sterile. Stool examination was normal. ECG showed sinus tachycardia and ST T changes in infero lateral leads. There was no acid fast bacilli seen in urine. Ascitic fluid showed cell count 4000 cells/cmm; all lymphocytes sugar 76 mg%, protein 6 gm%, gramstain of ascitic fluid showed no organisms or AFB seen in the smear examined and PCR for mycobacterium tuberculosis was positive.

A culture of the ascitic fluid was sterile. Blood smear showed hypochromic RBCs anisocytosis, poikilocytosis, mild neutrophilia and toxic granules present in few of them. Platelets were adequate. X-ray chest showed infiltration in the left upper zone and mid zone. Plain X-ray abdomen showed a few fluid levels. Ultrasonogram of abdomen revealed free fluid in the abdomen, mass in the right lumbar region, ?thickened mesentery, repeat ultrasound revealed mass located in the right para umbilical region. CT abdomen showed findings consistent with small bowel koch’s lesion involving the mesentery and peritoneum with ascites. She was diagnosed to have Tuberculous abdomen with localised ascites. She was treated with anti tuberculous drugs rifampicin, isoniazid, ethambutol and streptomycin.

She was reviewed after 3 months. She had gained weight, her appetite was good and she had no abdominal pain, the mass in the right paraumbilical region was not felt. Repeat CT showed minimal free fluid in the pelvis with minimal mesenteric thickening. She is continuing the antituberculous therapy.

RESULTS

Within 3 months of treatment with ATT the mass reducedin size, appetite improved and relieved of abdominal pain. The repeat CT showed minimal free fluid in the pelvis with minimal mesenteric thickening.

DISCUSSION

In this case only PCR for mycobacterium tuberculosis was positive in the ascitic fluid to ascertain an aetiological diagnosis. When treatment was given according to the confirmed aetiology, the patient’s condition improved, abdominal pain subsided and appetite increased. Therefore PCR is major achievement in the diagnosis and treatment of abdominal tuberculosis. CT abdomen showed marked difference between the previous picture and the one taken after treatment with ATT.

CONCLUSION

The importance of PCR in establishing an etiologic diagnosis of abdominal tuberculosis.

REFERENCES

  1. PCR diagnosis on formalin-fixed, paraffin embedded tissues with acid fast stain and culture and negativity in chronic dialysis patients of cervico-mediastinal tuberculous lymphadenitis. Nephrology, dialysis, Transplantation. June 1998; 13 (6) : 1543-6.
  2. Detection of mycobacterium tuberculosis in paraffin embedded intestinal tissue specimens by PCR characterisation of IS6110 element negative strains. Journal of the Pakistan Medical Association June 1998; 48 (6) : 174-8.
  3. Two young somalians with gastric outlet obstruction as a first manifestation of gastroduodenal tuberculosis. European Journal of Gastroenterology and Hepatology.
  4. The detection of mycobacterium tuberculosis in children and adolescents by using the PCR. Problemy tuberculeza.
  5. Prospective evaluation of the utility of molecular techniques for diagnosing nosocomial transmission of multidrug-resistant tuberculosis. Mayo Clinic Proceedings March 1996; 71 (3) : 221-9.
  6. CT and PCR in tuberculosis infection in childhood (Spanish) Archivos de Bronconeumologia December 1996; 32 (10) : 500-4.
  7. Molecular techniques in the diagnosis of drug-resistant tuberculosis. (Review). Annals of the Academy of Medicine Singapore Sept. 1997; 26 (5) : 647-50 Abstract.

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