T UBERCULOSIS is a protean disease which can be readily confused with

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1 FEBRUARY, 1966 DUODENAL TUBERCULOSIS REPORT OF A CASE By LYSALVARO CRUZ FERREIRA* and A. M. SILVANY FILHOf SALVADOR, BAHIA, BRAZIL T UBERCULOSIS is a protean disease which can be readily confused with many other benign and malignant processes. This fact is well worth keeping in mind, especially in regions where other bacterial and parasitic diseases are endemic, such as Salvador (Bahia, Brazil). In the statistics of the Department of Health of the State of Bahia, tuberculosis ranks first among the causes of death.3 Duodenal tuberculosis is extremely rare. Brown and Sampson, in i 84 autopsied cases of pulmonary tuberculosis with intestinal lesions, found lesions restricted to the small intestine in 6 per cent of the cases and to the large intestine in 19 per cent. In the remaining 75 per cent of the cases, there were lesions in the ileum and cecum. They did not refer, however, to lesions in the duodenum. Matthews et al.6 mention 105 cases of generalized intestinal tuberculosis and report i8 cases of localized duodenal tuberculosis with only 6 of these histologically confirmed. Granet,5 in 1935, in 29 autopsied cases of tuberculosis enteritis, found with ulcerations in the duodenum. Buckstein,2 in 1953, cited a case of hyperplastic tuberculosis of the first portion of the duodenum. In 1957, Feldman4 found that duodenal tuberculosis occurred in only 0.5 per cent of the cases of tuberculosis autopsied. Wig et al.7 in 67 cases of abdominal tuberculosis, found 9 of a hyperplastic type. In 6o cases which had small bowel roentgenograms, there was no evidence of duodenal involvement. In the reviewed Brazilian literature, no references to duodenal tuberculosis were found. REPORT OF A CASE M.B.S., a 43 year old female, mulatto domestic from the interior of Bahia came to the Hospital Aristides Maltez Out Patient Department for the first time on February,, 1962, complaining ofpain in the right upper quadrant of 8 months duration. This pain had a sudden onset, radiated to the sternum and disappeared spontaneously. The general state of the patient was poor. The mucous membranes were pale and there were signs of marked weight loss. There was diffuse tenderness of the abdomen. The liver was palpable, had rounded edges and was tender to palpation. The patient did not return to the hospital for the necessary laboratory examinations. On December i I, 1962, the patient was admitted to the Hospital das Clmnicas with similar complaints plus diarrhea of 10 days duration and semiliquid stools without blood or tenesmus. The past history was negative for chest disease, syphilis and rheumatism. There was no history ofprevious hospitalization. The only symptoms were anorexia and asthenia. There were no respiratory complaints. Before the onset of diarrhea, her bowel habits were normal. Her weight was 27 kg. The examination of the chest was negative. The abdomen was diffusely tender. The liver and spleen were not palpable. Laboratory examinations showed iron deficiency anemia, and low serum proteins with a normal A/G ratio. The cephalin flocculation test was negative. Chest roentgenograms showed pleural thickening in the outer region of the inferior half of the right lung. There was no active lung lesion. In the upper gastrointestinal series, the stomach and duodenal cap were normal. The duodenal arch was hypotonic and the mucosal pattern was irregular. The patient received supportive treatment only and was discharged i6 days later. On January 30, 1963, the patient was ad- * Radiologist, Hospital das Clinicas, Faculdade de Medicina, Universidade da Bahia; Chief of X-ray Diagnosis Department, Hospital Aristides Maltez. f Chief of Pathology Department, Hospital Aristides Maltez. 366

2 - - \oi. 91), No. 2 Duodenal Tuberculosis G. 3. In the supine roentgenogram, the extension mitted to the Hospital Aristides Maltez. She was severely ill and complained of the same symptoms as previously. Palpation of the ab- (lomen revealed a tender and hard epigastric mass. The liver was palpable and had a nodular surface. Because of a presumptive diagnosis of a the duodenum and stasis in the second portion. of the lesion, involving the third and fourth portion of the duodenum and reaching the angle of Treitz, is demonstrated. malignant tumor of the stomach, roentgenograms of the chest and an upper gastrointestinal series were made (Fig. i through 4). The latter showed stasis of the barium meal at the third portion of the duodenum which demonstrated irregular filling defects with intraluminar vege- 11G. 2. The lesions are more evident. Note the sharp limits between the diseased segment and the neighboring segments. FIG. 4. Roentgenogram showing the disseminated nodules in the lower two-thirds of both lungs and pleural thickening on the right.

3 368 Lysilvaro Cruz Ferreira and A. M. Silvany Filho FEBRUARY, , :,,. b,, 7 W I.., y % :,, - (1.3,, p-;. I., rr #{149}. #{231}..... S. S ,. 11G.. Photomicrograph of duodenal lesion. Extensive area of caseation necrosis in the submucosa, surrounded by infiltration of lymphocytes and histiocytes (H & EXI7). tations. The first and second portions of the duodenum were dilated. The roentgenograms suggested a malignant tumor or a granulomatous inflammatory process. The chest roentgenograms showed diffuse nodular shadows in the inferior two-thirds of both lungs and pleural thickening in the right base. Her diarrhea became much worse and was unresponsive to treatment with nonabsorbable sulfa drugs. Seven das s after admission she developed severe dyspnea and lapsed into a coma from which she did not recover. Autopsy Report (Fig. and 6). Autopsy revealed a severely emaciated, dehydrated cadaver, with a slightly protruded abdomen, but without noticeable tumors. There was cyanosis of the upper extremities and edema of the begs. There were pleural effusion and adhesions on.. J - P:.; i... S.:. : :..,;,i.,, #{149}. t #{149}5#{149}S #{149}S. r,.. ; --,.:, #{149}., I i:,,, t1s,- _S_ _.5 - Y. #{149}. -.- #{149}#{149}.,... #{149} : S FIG. 6. Photomicrograph of liver. Granubomatous lesion identical to that in the duodenum (H & EX8o).

4 OL. 96, No. 2 Duodenal Tuberculosis 369 the right (240 ml.) There was miliary dissemination of tuberculosis in the pleura, peritoneum and on the loops of the small bowel. The mesenteric lymph nodes were enlarged, with caseation necrosis. The liver was 4 cm. below the costal margin. There was miliary tuberculosis of the lungs, liver, pancreas, spleen and left kidney. The stomach was normal. In the third and fourth portions of the duodenum, near the angle of Treitz, there was an annular ulceration of mucosa, measuring 4 cm. in diameter, with raised and irregular edges and a yellowish granular bottom. On cutting, a thickening of the wall was noticed at this point with patchy yellowish areas of indefinite contours. The rest of the duodenal mucosa was edematous but not ulcerated. In the terminal ileum, 12 cm. above the ileocecal valve, there was a second ubceration, I cm. wide, involving the entire circumference of the organ. Similar ulcerations were also observed in the cecum and descending colon. Microscopic examination of the duodenum, terminal ileum, cecum and descending colon showed extensive areas of caseation necrosis surrounded by epithelioid cells, lymphocytes and giant cells. The lesions were noted mainly in the submucosa, although the precise location in the ulcerated regions could not be ascertained. DISCUSSION Intestinal tuberculosis can be classified as primary or secondary to dissemination of a lung lesion. In view of the pathologic findings, the reported case can be considered as a primary lesion of the intestine with posterior multivisceral miliary dissemination. Usually, the intestinal lesions of tuberculosis are associated with other advanced systemic lesions. Isolated forms of intestinal tuberculosis, particularly of the duodenum, are extremely rare. The ileum and cecum are more vulnerable sites. In the literature, the following clinical forms are described: ulcerative, hyperplastic and infiltrative. Feldman4 added an additional form, enteroperitoneal, where there is involvement of the peritoneum, lymph nodes and mesentery. The most common form is the ulcerative one. SUMMARY A case of duodenal tuberculosis which simulated a malignant tumor is reported. The patient was a 3 year old female mulatto with diffuse abdominal pain, tumor in the epigastric region and nodules on the surface of the liver. The roentgenograms showed an ulcerative and hypoplastic lesion at the third and fourth portion of the duodenum. In the lungs were multiple nodular shadows simulating carcinomatous dissemination. The differential diagnosis is discussed from a roentgenologic point of view. Lys#{225}lvaroCruz Ferreira Hospital Aristides Maltez Av. D. Jos VI, 332-Brotas Salvador, Bahia, Brazil REFERENCES 1. BRoWN, L., and SAMPSON, H. L. Intestinal Tubercubosis: Its Importance, Diagnosis and Treatment. A Study of the Secondary Ulcerative Type. Second edition. Lea & Febiger, Philadelphia, BUCKSTEIN, J. The Digestive Tract in Roentgenology. Volume I. Second edition. J. B. Lippincott Company, Philadelphia, Estatisticas Sanitarias. Pubbica#{231}#{228}o do Departamento de Sai ide da Secret. Sa,de P iblica Assist. Social, No VI, Bahia, FELDMAN, M. Clinical Roentgenology of the Digestive Tract. Fourth edition. Williams & Wilkins Company, Baltimore, GRANET, E. Intestinal tuberculosis: clinical, roentgenological and pathological study of 2086 patients affected with pulmonary tuberculosis. Am. 7. Digest. Dis., 1935,2, MATTHEWS, W. B., DELANEY, P. A., and Dito- STEDT, L. R. Duodenal tuberculosis: review of literature and report of case of hyperpbastic tuberculosis of duodenum. Arch. Surg., 1932, 25, io-io WIG, K. L., CHITKARA, K. L., GUPTA, S. P., KI5H0RE, K., and MANCHANDA, R. L. Ileocecal tuberculosis with particular reference to isolation of Mycobacterium tuberculosis. Am. Rev. Tuberc., 1961,84,

5 This article has been cited by: 1. Khaqan Jehangir Janjua Duodenal Tuberculosis Mimicking Carcinoma, Head of Pancreas. Annals of Saudi Medicine 14:1, [CrossRef] 2. Malini Vijayraghavan, Arunabh, Anil K. Sarda, Ajay K. Sharma, Tushar K. Chatterjee Duodenal tuberculosis: A review of the clinicopathologic features and management of twelve cases. The Japanese Journal of Surgery 20:5, [CrossRef]