Appendicular Mass in a Patient of Ileocaecal Tuberculosis

APPENDICULAR MASS IN A PATIENT OF ILEOCAECAL TUBERCULOSIS

JG SALUJA*, MS AJINKYA**, M PADHYE***,SS KHANNA+
*Head and Associate Professor, Department of Pathology; **Associate Professor, Department of Pathology; ***Lecturer, Department of Surgery; Mumbadevi Homoeopathic Hospital, Vileparle (W), Mumbai 400 056. +Consultant Gastroenterologist, Cooper Hospital, Bhatia Hospital, Holy Family Hospital and Guru Nanak Hospital.

Tuberculous appendicitis being rare, with incidence of 0.1% - 0.3% should always be confirmed by histopathology and bacteriology. Reporting a case of chronic appendicitis which was finally diagnosed as tuberculous serositis of appendix producing an appendicular mass.

INTRODUCTION

In recent years tuberculosis has been merged as an important disease in developing as well as developed countries, especially with rising incidence of HIV infection. Abdomen is one of the common sites of extrapulmonary tuberculosis. Majority of patients do not have associated or antecedent pulmonary tuberculosis. Although ileocaecal tuberculosis is the commonest presentation of abdominal tuberculosis. Isolated lesion in the terminal part of ileum spreading via the lymphatics to produce tuberculous serositis of appendix is seldom found. However appendicular involvement has found to be distinctly uncommon even in the set up ileocaecal tuberculosis. [3-5 , 12] We present a case of tuberculous serositis of appendix in presence of ileal tuberculosis.

CASE PRESENTATION

A 36 year male, married technical worker by occupation. Complaint of pain in abdomen since 8 months, with mass in right ileac fossa. Loose stools alternating with constipation.

Past history: pulmonary tuberculosis at the age of 11 years, pulmonary pleural effusion there after treated by AKT. Operated for haemorrhoids a year back, initially treated for mass in right ileac fossa with antibiotics, which resolved but pain persisted.

Patient came to surgical OPD of Mumbadevi Homoeopathic Hospital for pain in right ileac fossa.

On examination patient as a person - average built, no lymphadenopathy, icterus, pallor, clubbing of nail, afebrile.

Per abdomen - soft tenderness of right ileac fossa, liver and spleen are not palable.

Investigation

(1) Basic haematological investigation were normal.

(2) X-ray chest : old fibrotic scar right upper and mid zone.

Surgeon’s opinion was chronic appendicitis, patient was taken up for surgery, on exploring, the terminal part of ileum showed constriction with dilatation of saccular type, resected with end to end anastomosis. Simultaneously appendix was explored and resected. Post operative recovery was eventful.

Tissue send for histopathology.

Grossly : Ileum showed constriction at both ends and with sac like dilatation in the centre.

Cut section : Showed hypertrophy pseudopolyps at the constricted ends.

Grossly : Appendix serosa congested shows fibrinous exudate on surface, 4 cm long.

Cut section : Lumen narrowed, wall thickened oozing of serosanguinous thick fluid. Microscopically : Ileum showed attempting characteristic epitheloid granuloma with tubercular inflammatory cells. Serosa of appendix showing serositis of tubercular origin. Mucosa was normal, no granulomatous lesion seen. Imprint smear, stained by ZNCF (cold method) demonstrated the presence of acid fast bacilli from hypertrophic pseudopolypoidal mass.

Fig 1 : Gross specimen of ileum showing multiple hypertrophied tubercular pseudopolyps and cut part of appendix

DISCUSSION

Tuberculosis is a common disease in our country affecting people of all age groups and different organ system.

Abdominal tuberculosis accounts for 0.8 - 10% of all hospital admission. [1] In adults gastro-intestinal tuberculosis accounts for 2/3rd of abdominal tuberculosis. In children however the involvement of peritoneum and lymphnode is more common than gastro-intestinal tuberculosis. [2] 85-90% patients have tuberculosis affecting caecum.

Secondary involvement of appendix from ileocaecal tuberculosis is also uncommon and varies from 1.5 - 3.0% cases. [5,6 , 11]

Multiple sites [7] in the same patient may be involved and our case is a good example of involvement of GIT may occur in absence of any discernible tuberculous lesion in chest x-ray but in our patient had a past history of pulmonary tuberculosis with pleural effusion, patient also showed evidence of nodular stricturous as well as pseudopolypoidal lesion (hypertrophied tubercular polyps). The patient did give history of appendicular which resolved by antibiotics (macrolide, aminoglycoside, quinolones) which very well explains that initial process of forming an appendicular mass could also be tubercular in origin with secondary infection and because of lack of competent immune system response as well as short course of antibiotic therapy caused a relapse of the disease process. Other possibility could be that there is a minimal contact [8] of appendicular mucosa with intestinal contents. The probable mode of infection could be intraluminal that extending via the lymphatics to the appendix.

There are three clinical types of tuberculous appendicitis which have been described in the literature. [5] The first type present as an acute form, indistinguishable from pyogenic appendicitis, until histopathological proved. The second clinical type is a chronic form, presenting with vague pain, vomiting, diarrhoea, and a mass in right ileac fossa. The third type is a latent one found accidentally on histopathology examination, our case report appears to be in the second clinical setting.

Differential diagnosis from other condition such as Crohn’s disease, lymphoma may at times, however be difficult even with experienced observer. [9-12] In such cases the clinical presentation of the patient and response to treatment is aid final diagnosis assume greater importance

In our case we considered a final diagnosis of tuberculosis in preference over Crohn’s disease [12] because of several points. First of all Crohn’s disease is rare in India. Secondly features such as fissures, fistula and abscesses were never encountered throughout the illness and during follow up.

The presence of granuloma with Langhan’s cells, epitheloid cells and dramatic response of the patient to AKT is also suggestive. Tuberculosis is endemic particularly in India, isolated tuberculous lesion may or may not be associated with specific signs and symptoms, so the diagnosis is often made only after histopathology and by imprint smear [13] bacteriologically. Therefore it is strongly suggested to have multiple sections of all surgically removed appendix and sent for histopathology and imprint smear for acid fast bacilli in order to prevent misdiagnosis.

ACKNOWLEDGEMENT

We thank the dean Dr. SK Goel of Shri Mumbadevi Homoeopathic Hospital to permit us to publish the case and also express our gratitude to Dr. Ashish Nanabhai from physiology Department for the photographs

REFERENCES

1.Chuttani HK. Intestinal tuberculosis in modern trends in gastroenterology eds. Cord WI Creamer B. London Butterworth’s. 1970, 308-27.

2.Gupta DK, Mishra D. Abdominal tuberculosis in children. Guest Editor :Vimlesh Seth, editor RK Puri, HPS Sachdev. Indian Paediatric Delhi. 1991, 188-194.

3.Jakob T. Tuberculosis of appendix. Acta Davosianna. 1949, 8 : 7.

4.Braasted FE, DocKerty MB, Waugh SM. Tuberculosis Appendicitis. Surgery 1950; 27 : 790.

5.Babrow ML, Friedman S. Tubercular Appendicitis. American Journal of Surgery 1956; 91 : 389.

6.Shah RC, Mehta KN, Jullundwala JM. Tuberculosis of Appendix. Journal of Indian Medical Association 1967; 49 : 138-40.

7.Gupta SC, et al Pathology of Tropical Appendicitis. Journal of Clinical Pathology 1989; 42 : 1169-72.

8.Bhasin V, Chopra P, Kapoor BML. Acute tuberculous appendix. International Journal of Surgery 1977; 62 : 563.

9.Abraham P, et al. Tuberculosis of Gastrointestinal Tract. Indian Journal of Tuberculosis 1992; 39 : 251-56.

10.Shah S, et al. Colonoscopic study of 50 patients with colonic tuberculosis. GUT 1992; 33 : 347-51.

11.Singh MK, Arunabh Kapoor VC. Tuberculosis of appendix - A report of 17 cases and suggest aetiopathological classification. Post Graduate Medical Journal 1987; 63 (744) : 855-57.

12.Satry SC, Seethapath, Rao VN, Mukunda Reddy, et al. Tuberculosis of Appendix. Indian Journal of Tuberculosis 1981, 28-29.

13.Saluja JG, Ajinkya MS. Comparative study of fine needle aspiration cytology, Histopathology and Bacteriology of enlarged lymphnode. BHJ 42, 2 373-7.

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