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UNUSUAL PRESENTATIONS OF TUBERCULOSIS IN CHILDREN
MU Shenoy, MS Kulkarni, R Aradada, VK Kapur
Department of Paediatric Surgery, Bai Jerbai Wadia Hospital for Children, Parel, Mumbai - 400 012.
Tuberculosis is a common disease in our country affecting people of all age groups and different organ systems. We present two unusual cases of tuberculosis abdomen. a) loculated ascites in the lesser sac b) plastic type of tuberculous abdomen with caseating nodes presenting as intestinal obstruction in a 9 month old child. The aim of presenting this case is to make one aware of this condition since it is normally not considered in the differential diagnosis of obstruction at this age.CASE REPORTS
CASE 1
An 8 year old girl was referred to us with epigastric pain since 15 days which was dull aching, non radiating and unrelated to meals. A lump was noticed in the epigastrium since 12 days.
There was no history of vomiting, haematemesis or melaena and jaundice in the past. There were no urinary complaints. 8 months prior to this admission a cervical lymph node biopsy was done in a village, however a histopathology report on the same was not asked for.
Clinically there were healed sinuses over the last cervical region. Abdominal examination revealed a soft lump measuring 10x8x7 cm occupying the epigastrium. It was non pulsatile and did not move with respiration.
Investigations showed a WBC count of 15,400/ml with polymorphs - 56% and lymphocytes - 44. Serum amylase was 177 Somogyi units (Normal 80-180). ESR was 108 mm at the end of 1 hour. Mantoux test was negative. X-ray chest showed enlarged paratracheal nodes.
Ultrasonography of the abdomen revealed multiple cysts in relation to the pancreas, the largest measuring 7 cm in diameter. The stomach was pushed inferiorly and there was compression of the lesser curvature of the stomach.
ERCP showed a normal pancreatico biliary system and an extrinsic impression on the stomach and duodenum.
We subjected the patient to laparoscopy and then exploratory laparotomy where we found a cyst in the lesser omentum anterior to the stomach extending into the lesser sac posteriorly. It was filled with straw coloured fluid. No communication with the pancreas was demonstrable. The cyst was completely excised. The fluid showed the following:
Proteins 2.9 gm% Sugar 57 mg% No cells Amylase 175 Somogyi units. LDH 287 IU/L Cholesterol 190 mg% Histopathology : a tuberculous lesion with cystic degeneration and no lining.
CASE 2
A 9 month old male child was referred to us with:
Abdominal distension 2 days Repeated attacks of nonbilious vomiting 2 days Constipation 2 days
There was no history of blood or mucus in stools. The child was born of a full term normal vaginal delivery. There were no episodes of distension of abdomen associated with vomiting and constipation. The child was fully immunized and was weaned at 6 months.
Abdominal examination showed generalized distension and hyperperistalsis. Per rectal examination showed ballooning of rectum. Plain X-ray revealed multiple air fluid levels. There was polymorphonuclear leucocytosis (Total counts -223,700/ml, polymorphs - 72%).
The child was treated conservatively for a period of 24 hours. There was no improvement in the child’s clinical condition. We then subjected the patient to emergency exploratory laparotomy where we found:
Multiple tubercles over the peritoneal surface and bowel loops, caseating lymph nodes and at one site about 3 feet away from the ileocaecal region the bowel was adherent to the parietal wall causing an acute kink and obstruction.
We did an adhesiolysis and postoperatively put the patient on anti-tuberculous chemotherapy with 3 drugs; INH, rifampicin and pyrazinamide. The histopathology report confirmed the tuberculous aetiology. The patient had wound infection in the postoperative period which required secondary suturing.
DISCUSSION
Abdominal tuberculosis accounts for 0.8% of all hospital admissions.[1] In adults, gastrointestinal tuberculosis account for 2/3rd of all abdominal tuberculosis. In children, however the involvement of peritoneum and lymph nodes is more common than gastrointestinal tuberculosis.[2]
Clinically children above 5 years of age are affected more frequently.
The presentation can be as follows:
1. Plastic type : This is due to diffuse peritonitis with thickening and adhesions of omentum, mesentery and peritoneum. It is rarely seen now.[3] It presents with recurrent attacks of subacute intestinal obstruction. Our case had presented with a first attack of intestinal obstruction and in an age group where other causes of intestinal obstruction are more common, namely strangulated inguinal hernias, intussusception, complicated Meckel’s diverticulum and Hirschsprung’s disease[4]
2. Ascitic type
3. Mesenteric adenitis
4. Miscellaneous - Loculated ascites : Our case had presented with an epigastric lump. Investigations failed to reveal the exact cause. Ultrasonography had shown a mass in relation to the pancreas. ERCP showed an extrinsic impression on the stomach. On laparotomy the cyst was seen in the lesser omentum extending posterior to the stomach. We were able to excise the cyst totally. Biochemical examination of the fluid and histopathology revealed a tuberculous aetiology. The patient on follow-up had shown weight gain and repeat ultrasonography had shown no residual collection.
REFERENCES
1. Chuttani HK. Intestinal Tuberculosis. In: Modern Trends in Gastroenterology. Eds Cord WI, Creamer B, London, Butter worths. 1970; 308-27.
2. Gupta DK, Rohatgi M, Mishra D. Abdominal Tuberculosis. Tuberculosis in children. Guest Editor Vimlesh Seth. Editors - RK Puri, HPS Sachdev, Indian Paediatrics, Delhi. 1991; 188-94.
3 Tandon RK, Sarin SK, Bose SL, et al. A clinicoradiological reappraisal of intestinal tuberculosis. Gastroenterology Jpn 1986; 21 : 17-22.
4. Acute Intestinal obstruction : Harold Ellis : Maingot’s Abdominal Operations Schwartz SI and Ellis H. 9th edition, Prantice Hall International Inc. 1990; 886.
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