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Omental Tuberculosis: A rare presentation of abdominal TB

Technical Report · December 2019

DOI: 10.13140/RG.2.2.31573.58086

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 CASE REPORT

Omental Tubercluosis: A rare presentation of

Abdomial TB
Daniyal Nagi1, Maryam Abid2, Syed Asim Ifthikar3, Fazal Akbar1, Tahir Abdullaha1
Aaron Mckevitt1, Sofia Ruth Nazir1

1
Department of Pulmonology, Abstract
Portincula University Hospital,
Ballinasloe Ireland Tuberculosis is a common disease worldwide nearly 10.4 million people fall
2
Mayo Hospital Lahore- Pakistan
prey to this disease annually. It is a curable infectious disease but emerged as
the major health problem in both developing &under developed countries due
3
Waterford Reginal Hospital to poor socioeconomic status, development of multi drug resistance and poor
Ireland nutritional status of inhabitants.
Address for correspondence
Daniyal Nagi
Department of Pulmonology,
Portincula University Hospital,
Ballinasloe Ireland
E mail:drnagi68@gmail.com

Date Received: Aug 30, 2019

Date Accepted: Oct 20, 2019
Declaration of conflicting
interests

The Author declares that there is

no conflict of interest.

This case report may be cited as: Nagi D, Abid M, Ifthikar SA, Akbar F, Abdullaha T, Mckevitt A, Nazir SR.
Omental Tubercluosis: A rare presentation of Abdomial TB. Pak J Chest Med 2019; 25 (4):186-188

Introduction CASE REPORT

T
uberculosis is a common disease worldwide A 15 years old school girl presented in emergency
nearly 10.4 million people fall prey to this room with severe abdominal pain she was diagnosed
disease annually.1 It is a curable infectious as having acute appendicitis and appendectomy was
disease but emerged as the major health problem in done was discharged home on antibiotics. She again
both developing &under developed countries due to presented after four weeks with jaundice for which an
poor socioeconomic status, development of multi extensive workup was done only LFTSs were
drug resistance and poor nutritional status of deranged rest of the labs were unremarkable. A
inhabitants.2 Pakistan is among the countries with diagnosis of drug induced liver injury was made, was
high incidence of TB and ranks 5th worldwide for managed conservatively and discharged as her LFTs
number of tuberculosis patients diagnosed annually. returned to normal. Seven months later she again
In drug resistant tuberculosis Pakistan ranks 4th presented with abdominal pain, her ultrasound,
worldwide. Statistics show that 500,000 new cases of clinical examination and labs were normal.
TB are diagnosed every year & 15000 of them Considering her history of alternating constipation
developing drug resistant TB.3 The most common and diarrhea with history of stress a provisional
form of TB is pulmonary TB, however abdominal TB is diagnosis of Irritable bowel syndrome was made.
the 6th most common type of TB and it can involve any After three months the patient developed low grade
part of gastrointestinal TB. 4 A very unusual case of temperature with evening rise associated with
abdominal tuberculosis in a young female is abdominal pain and weight loss of 9 Kgs. Patient
presented in this case report. We expect that this underwent thorough investigations which showed
case report will add to the existing literature on this hemoglobin level of 10.9, white cell counts 10.45,
topic. platelet count of 450, CRP 29.8, LFTs normal, TB
Mycodot negative, ultrasound abdomen showed

PJCM 2019; 25 (4) 186

 Omental Tubercluosis: A rare presentation of Abdomial TB

minimal fluid in the right and left iliac fossa, tumor (c) Dry Plastic Type
markers CA19-9 and CA125 normal and urine
Peritoneal tuberculosis can present in any of the
complete was also normal. Patient underwent a CT
above described forms6.
thorax abdomen pelvis with contrast which showed
nodular peritoneal disease with Omental-mesenteric Our case was of DRY PLASTIC TYPE characterized by
thickening besides mesenteric lymphadenopathy. nodular peritoneal disease with Omental-mesenteric
Lymph nodes measuring 11 mm in short axis, the thickening and mesenteric lymphadenopathy12.
changes were supportive of an infective peritonitis Pelvic peritoneal tuberculosis is not an uncommon
most probably granulomatous disease which required extrapulmonary site in young females and the
histological confirmation. The patient was referred to symptoms mimic an advanced ovarian malignancy, it
the surgical team for laparoscopic biopsy (Pic 1, 2, 3). makes it challenging for the treating physician to
Biopsy report shows granulomatous inflammation, come to definite diagnosis5.
positive for acid fast bacilli. She was diagnosed as
case of Omental Tuberculosis. Anti-tuberculous Abdominal Tuberculosis may present as enteric
therapy consisting of isoniazid rifampicin tuberculosis in which the intestine is involved, nodal in
pyrazinamide ethambutol along with pyridoxine was which lymph nodes are involved, peritoneal, solid
started and she was put on regular follow up. Patient visceral in which the viscera like liver, spleen, kidney
began to improve symptomatically and she gained 4 get involved. Abdominal tuberculosis may present as
kgs. After the initial phase of therapy with 4 drugs combination of these varieties as well4.
regimen, she was continued on a 3 drug regimen The most common symptoms with which it Omental
(Rifampicin, Isoniazid, Ethambutol) for further 7 Tuberculosis presents are abdominal pain (92%) and
months. A CT Abdomen was done after 3 months ascites (96%).7 Besides these symptoms they may
which showed regression of the disease. Patient's have weakness (81%), anorexia (45%), night sweats
symptoms settled down and she continued to gain (36%) some of the patients may have elevated CA125
weight with improvement in her appetite. Her levels which can misguide the treating physicians.8 In
inflammatory markers also returned to normal. most cases the Tuberculin skin test and Mycodot may
A further CT abdomen with contrast done at the end of be negative as in above mentioned case so it makes it
the 9 months therapy showed a normal omentam and very challenging to pick up a case of peritoneal
complete resolution of mesenteric lymphadenopathy tuberculosis. Omental tuberculosis is a rare presenta-
with complete resolution of the disease. Patient tion and is challenging to diagnose for a physician.
gained 12 kgs of weight and was completely symptom Invasive procedures like laparoscopy and omental
free. biopsies are needed to get to a final diagnosis.7
Abdominal tuberculosis (especially peritoneal and
Discussion omental) should be considered in differential
Though TB can affect any part of body ,but TB diagnosis if the patient presents with vague gastroin-
affecting the Omentum is a rare occurrence. It can testinal symptoms, since it presents with nonspecific
present as part of Abdominal & Peritonium TB and is symptoms the diagnostic criterions are very few and
usually classified as a Fibrotic-Fixed Type, but we have to get help from additional tests in making a
isolated cases have also been seen11. final diagnosis.9 The histopathological studies have
been proven to be most beneficial in cases of
Tubercular Peritonium can however occur as peritoneal tuberculosis and should be combined with
(a) Wet- Ascitic Type molecular analysis to diagnose difficult cases of
peritoneal tuberculosis10. In developing countries like
(b) Fibrotic Fixed Type and

PJCM 2019; 25 (4) 187

 Omental Tubercluosis: A rare presentation of Abdomial TB

Pakistan. 2012 Feb 1;22(2):113-5.

6. Khan R, Abid S, Jafri W, Abbas Z, Hameed K,
Ahmad Z. Diagnostic dilemma of abdominal
tuberculosis in non-HIV patients: an ongoing
challenge for physicians. World journal of
gastroenterology: WJG. 2006 Oct 21;12(39):6371.
7. Demir K, Okten A, Kaymakoglu S, Dincer D, Besisik
F, Cevikbas U, Ozdil S, Bostas G, Mungan Z,
Cakaloglu Y. Tuberculous peritonitis–reports of 26
cases, detailing diagnostic and therapeutic
problems. European journal of gastroenterology &
Pakistan it becomes challenging to reach a definite hepatology. 2001 May 1;13(5):581-5.
diagnosis due to the poor socioeconomic conditions 8. Uzunkoy A, Harma M, Harma M. Diagnosis of
and lack of insight as most patients refuse the abdominal tuberculosis: experience from 11 cases
invasive tests like laparoscopy. Its still a diagnostic and review of the literature. World journal of
dilemma which needs to be addressed and people gastroenterology: WJG. 2004 Dec 15;10(24):3
should be educated about benefits of such invasive
tests and prompt treatment in these difficult cases. 9. Awasthi S 647., Saxena M, Ahmad F, Kumar A,
Dutta S. Abdominal tuberculosis: a diagnostic
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PJCM 2019; 25 (4) 188

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