511 A Case Report of A 16-Year-Old Girl with Peritoneal Tuberculosis

Peritoneal Tuberculosis (PTB) is a rare extra-pulmonary manifestation of Mycobacterium tuberculosis infection. It usually presents with non-specific symptoms that can mimic other intra-abdominal pathology. Therefore, a high index of suspicion is needed for diagnosis and early treatment of PTB. Some of the intra-abdominal conditions in young patients that may have similar presentations to PTB include Crohns’ disease, ovarian pathology and acute appendicitis. Diagnosing PTB in the paediatric population tends to be even more challenging as an obvious history of exposure may be difficult to obtain. Diagnostic laparoscopic biopsy and histopathology provides definitive diagnosis. Most studies recommend a 6-month course of anti-TB therapy for abdominal tuberculosis with a planned regimen using Isoniazid, Rifampicin, Pyrazinamide and Ethambutol. This case report presents the case of a 16-year-old girl who presented with a history of recurrent abdominal pain, vomiting and pyrexia. Radiological, laparoscopic, and histopathological findings were used for final diagnosis of this condition. The patient was treated using the anti-tuberculosis therapy for 6 months following which, she was able to make a full recovery.

Extensive surgery for peritoneal tuberculosis, an ongoing diagnostic challenge in resource limited setup

Background: Peritoneal Tuberculosis is an abdominal form of Tuberculosis that affects the peritoneal cavity and enclosed organs. Clinical presentation of this rare form of extrapulmonary tuberculosis resembles that of advanced ovarian cancer and may results in unnecessary extensive surgery especially in resource limited setting. Case presentation: A case of a 36 years old prisoner who presented to us with gradual onset of abdominal distension for one-month, mild abdominal pain and noticeable progressive weight loss. Physical examination revealed she was underweight, afebrile and had a healed sub umbilical median incision scar on a glossily distended abdomen with positive fluid thrill and shifting dullness. She was HIV negative, anemic and had marked elevation of Cancer Antigen 125 marker. Abdominal ultrasound scan showed ascites with multiple cysts originating from the left iliac fossa and the abdominal pelvic CT scan showing left ovarian cyst, ascites of 3 litres and diffuse peritoneal carcinomatosis. Advanced ovarian cancer was suspected and intra-operatively 2.5 liters of straw colored ascitic fluid was found, the bowels and the omentum were covered with diffuse intestinal nodules and multiple inclusion cysts occupying the pelvic cavity. Histopathological analysis of sampled tissues revealed Peritoneal Tuberculosis. Conclusion: Peritoneal tuberculosis shares similarities in presentation to advanced ovarian cancer and should be ruled out in a woman suspected of ovarian cancer before proceeding with surgery. For proper differentiation of the two, histopathological analysis of sampled tissue through frozen section biopsy is the preferred approach in resource limited setup where laparoscopic biopsy or ultrasound guided biopsy is not feasible.

Cystic Lymphangioma: A Rare Cause of Haemorrhagic Ascites

Lymphangiomas are congenital malformations of the lymphatic system. Multiple intra-abdominal cystic lymphangiomas are rare in adults. Author present a case of a 39-year-old male, presenting with recurrent episodes of haemorrhagic ascites. Laparoscopic biopsy and imaging investigations revealed multiple intra-abdominal cystic lymphangiomas involving the spleen, the liver and the retro-peritoneum. Surgical excision including splenectomy, excision of retroperitoneal and mesenteric lesions was done. The patient has been asymptomatic for 2 years on follow-up.

Peritoneal dissemination of breast cancer diagnosed by laparoscopy

The accuracy of modern imaging techniques for the diagnosis of peritoneal carcinomatosis is poor. A breast cancer patient with a high serum CA15-3 level did not receive a definitive diagnosis of peritoneal dissemination by imaging examination and then underwent laparoscopy. Pathological examination showed peritoneal dissemination of breast cancer, but the biological markers were different from the primary lesion: ER(−), PgR(−), and Her2:3 +. T-DM1 therapy was very effective, and her systemic symptoms disappeared. Since biomarkers of metastatic lesions may sometimes change, laparoscopic biopsy is very important and useful.

Coexistence of genital tuberculosis and ovarian serous cystadenofibroma in a young female patient: a case report

Most cases of female genital tuberculosis (TB) are asymptomatic and are thus difficult to diagnose. Coexistence of genital TB and ovarian serous cystadenofibroma (OSCAF) is rare and easily ignored or misdiagnosed. We report a 26-year-old woman with coexistence of genital TB and OSCAF, and with an adnexal mass detected by B-ultrasound. Laparoscopic biopsy of diffuse miliary white nodules was performed on the surface of the peritoneum and both fallopian tubes. Right ovarian cystectomy was performed. Postoperative pathology showed that the right ovarian mass was a benign serous cystadenofibroma, and both fallopian tubes and miliary white nodules on the surface of pelvic organs showed chronic granulomatous inflammation. Polymerase chain reaction for Mycobacterium tuberculosis and acid-fast bacilli culture were positive in biopsies of the fallopian tubes, omentum, and peritoneum. The patient received anti-TB treatment after surgery. Six months after the operation, the patient had no abdominal pain and no major changes in menstruation. Our findings suggest that a timely operation is required for patients with an adnexal mass. During surgery, even if the lesion is similar to a malignant tumor, the surgical approach needs to be cautiously chosen for young patients without children. The patient’s postoperative fertility must be taken into consideration.

Characterization of an Unusually Aggressive Ovarian Malignant Sex Cord Stromal Tumor in an Adolescent Female With Peutz-Jeghers Syndrome

Peutz-Jeghers syndrome (PJS) is a rare autosomal dominant disorder with mutations in SKT11 (19p13.3), mucocutaneous hyperpigmentation, gastrointestinal hamartomatous polyposis, and increased cancer predisposition. A PJS-associated distinctive ovarian tumor is sex cord tumor with annular tubules (SCTAT), which is multifocal, microscopic, bilateral, and almost always clinically benign. Non-SCTAT ovarian tumors with malignant behavior are exceptionally rare. We describe a malignant, multiply recurrent, widely metastatic sex cord stromal tumor in PJS. Case Report: A 17-year-old female presented with new complaints of unintentional weight loss, alopecia, and abdominal fullness. She had a PJS diagnosis at age 7 with mucocutaneous pigmentation, gastrointestinal polyposis, and STK11 mutation. CT showed a 23-cm abdominopelvic mass with diffuse peritoneal metastases and malignant pleural effusion. CA-125 was elevated. CEA, CA 19-9, β-hCG, AFP, and LDH were normal. Laparoscopic biopsy pathology revealed a tumor composed of sheets and loose aggregates of mitotic spindled and round heterogenous eosinophilic and basophilic cells within fibromyxoid stroma. Rare tubules with eosinophilic cytoplasm and focal foamy cells were also seen. IHC was significant for inhibin, calretinin, CD56 and WT1 positivity, and cytokeratin and EMA negativity, consistent with poorly differentiated sex cord stromal tumor. Interestingly, EM showed neurosecretory dense core granules and neurite-like processes. After neoadjuvant therapy, the resected left adnexal mass was 25.5 cm, purple-gray/tan-red, heterogeneous, diffusely cystic, diffusely edematous, rubbery to spongy. In the left ovary were also found unassociated microscopic SCTAT foci. During adjuvant chemotherapy, the patient became pregnant. During the pregnancy, the patient developed liver and pelvic peritoneal recurrence and continued altered chemotherapy. She delivered a healthy late-preterm infant but also concurrently had diffuse peritoneal recurrence. She underwent two more cycles of adjuvant chemotherapy. Approximately 2 years after finishing adjuvant chemotherapy, she again developed peritoneal recurrences, which were resected, and partial chemotherapy response was seen on pathology. She is currently undergoing additional chemotherapy cycles 4 years since the initial diagnosis.

Should laparoscopic lymph node biopsy be the preferred diagnostic modality for isolated abdominal lymphadenopathy?

Background Isolated abdominal lymphadenopathy is frequently detected, but often challenging to diagnose. To obtain a tissue diagnosis, percutaneous biopsy (pb) or laparoscopic biopsy (lb) is often undertaken. The safety profiles and diagnostic accuracy of pb and lb within the abdomen are both poorly defined.Methods In this retrospective analysis, we identified all patients who underwent lb or pb for isolated abdominal lymphadenopathy at our institute during 2008–2016.Results Of 62 patients who underwent nodal biopsy for isolated abdominal lymphadenopathy, 33 underwent lb and 29 underwent pb. For the 33 patients who underwent lb, the procedure was diagnostic in 100% of cases; for the 29 who underwent pb, the procedure was diagnostic in 18 cases (62.1%). Both procedures were safe, with similar complication rates (6.0% for lb; 7.0% for pb).Conclusions Our results establish that lb and pb are both safe and reliable in the setting of isolated abdominal lymphadenopathy. We also demonstrate that each procedure has situational advantages. A pb should be considered to be the upfront diagnostic modality, particularly when anatomic or disease factors favour its success. In situations in which it is felt that pb cannot safely access the lymphadenopathy or in disease states in which the yield of a core biopsy will be insufficient, lb should be strongly considered. Examples include extra-retroperitoneal lymphadenopathy and cases of suspected lymphoma.

Acute Kidney Failure in a Young African American Male

Retroperitoneal fibrosis (RPF) is a condition characterized by chronic inflammatory and fibrotic changes in the retroperitoneum that can lead to serious complications including kidney failure, mesenteric and limb ischemia, and deep venous thrombosis among others. Affected individuals may present with nonspecific symptomology that would require a high clinical index of suspicion for prompt diagnosis. We herein discuss a case of a young African-American man with recurrent deep venous thrombosis who presents with a 4-week history of constant aching pain of abdomen and back and kidney failure. Initial noncontrast computed tomogram (CT) only revealed mild bilateral hydroureteronephrosis with inflammatory changes but without obvious mass or lymphadenopathy. At the insistence of the renal consulting team to rule out RPF, a CT-urogram was performed which revealed an infiltrative mass encasing the aorta, inferior vena cava, and common iliac vessels. Laparoscopic biopsy revealed dense fibroadipose tissue, lymphocytic aggregates, focal scattered IgG4-positive plasma cells, and fibrin deposition. Patient underwent bilateral nephrostomy placement and empirical corticosteroid therapy with resolution of kidney failure. Our case illustrates a classic presentation of RPF with relatively benign findings on noncontrast CT that could have been missed if clinicians did not keep a high index of suspicion for the condition.