1 yr old girl presented with Fever on and off 3 months H/o frequent semisolid bulky stools 3 months Progressive abdominal distension 3 months Failure

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1 Dr Rajasree S Dr Srinivas S, Dr Bagdi RK, Dr Satheesh C Apollo Childrens Hospital, Chennai

2 1 yr old girl presented with Fever on and off 3 months H/o frequent semisolid bulky stools 3 months Progressive abdominal distension 3 months Failure to gain weight - last 3 months No h/o respiratory symptoms

3 USG abdomen: Right ovarian cyst/ SOL Small paraaortic nodes, omentum and mesentery - thickened, ascites Referred for USG or CT guided FNAC of mass

4 Wt 8kg exp 10.5kg No icterus, pallor, pedal edema No stigmata of CLD Abdomen: Distended, AC: 52cm Dilated veins + Free fluid ++ Mild soft palpable liver and spleen Other systems - normal

5 CBC - normal ESR - 12 mm/hr LFT - normal enzymes and synthetic function RFT - normal Child s clinical condition began worsening rapidly with increasing ascitic fluid and fever spikes > 102 F since day 2 of admission

6 Ill defined hypoechoic lesion 2.7cm x 2.3cm in size in the bladder base and to the left probably of bowel etiology. Moderate ascites with internal echoes. Mild hepatosplenomegaly, bilateral marginal nephromegaly..

7 Fluid appeared turbid 200 cells, 97 % LYMPHOCYTES Fluid Proteins - 5 albumin Serum albumin 4.2g SAAG 1.9 Sugar - 98 LDH - 266

8 ? Intrabdominal cyst like mesenteric cyst secondarily infected/? Bowel perforation with peritonitis/? Malignancy/?? Tuberculous peritonitis Ascitic Fluid Grams stain & cultures - no organism, NG Fluid cytology for malignant cells: negative ADA ( N - <30 U/L ) Fluid PCR for Myco TB - negative

9 Etiology Tuberculosis Malignancy Pancreatic Biliary Chylous Nephrotic Cirrhosis Cardiac SAAG Low Low Low Low Low Low High High Other tests TLC>500 (lympho), ADA+ Cytology Amylase >100 (>5 times) Bilirubin >6 (> serum) Triglyceride >200(>serum) Total protein <2.5g/dL Total protein <2.5g/dL Total protein >2.5g/dL

10 Mantoux - 18mm positive CXR-PA: Consolidation L UL and ML RGJ for AFB x 3 days: negative CXR-PA of both parents: Normal No history of contact of tuberculosis We need some histopathological evidence: Diagnostic laparoscopy and biopsies or bronchoscopy and BAL

11 CT chest : Multiple calcified nodes in the mediastinum and left hilum. L UL consolidation with coarse calcification. No pleural effusion CT abdomen: Significant ascites with peritoneal thickening and nodules, omentum thickened, enlarged nodes with necrosis and coarse calcification in mesentery and retroperitoneum. A necrotic nodule 22 mm in fundus of uterus with fallopian tubes - thickened and nodular Impression: CHEST AND ABDOMINAL KOCH'S

12 Ascites increasing and reaccumulating despite albumin infusions and taps Diagnostic lap/ laprotomy was considered. Our concerns: Disseminated tuberculosis was a possibility but involvement of uterus and adnexa as early as 1.2yr??? Are we missing something else? Fever persisting Anxious parents as well as doctors

13 After much debate and discussion, a collective decision taken and child started on empirical ATT and discharged Fever free in 10 days Abdominal distension did not increase; gradually began to decrease Improvement in appetite/ general well being/ weight Child remains on telephonic follow-up Now almost 7 months down the line- child is doing very well

14 How long ATT / what regime?

15 Abdominal tuberculosis is a rare disease, and is defined as an infection of the peritoneum and hollow or solid abdominal organs by Mycobacterium tuberculosis. The peritoneum and the ileocecal region are the most likely sites of infection and are involved in the majority of cases by hematogenous spread or through swallowing of infected sputum from primary pulmonary tuberculosis. 1) Yu-Ming Hung, Ruwen Jou, et al. ; Mother-Infant Transmission of Mycobacterium Tuberculosis Beijing Genotype Detected by Spoligotyping A Case ReportThorac Med 2007; 22:

16 The diagnostic criteria for were established by Beitzke in 1935, but were revised and proposed by Cantwell et al. [5] in The modified criteria include proven tubercular lesions in the infant plus 1 of the following:(1) lesions occurring in the first week of life, (2) a primary hepatic TB complex or caseating hepatic granulomas, (3) tuberculous infection of the placenta or the maternal genital tract; or (4) exclusion of postnatal transmission by a contact investigation. 1) Yu-Ming Hung, Ruwen Jou, et al. ; Mother-Infant Transmission of Mycobacterium Tuberculosis Beijing Genotype Detected by Spoligotyping A Case ReportThorac Med 2007; 22: