Today, tuberculosis still affects millions of people and causes mortality. According to WHO, in 2017, 10 million people developed TB worldwide and around twelve thousand new cases in our country
4,5. Turkey is one of the successful countries in the battle with TB. While the prevalance and mortality caused by the diseases diminished, the treatment success increased over years
6.
Childhood TB differs from adulthood with lower rates of microbiologic proof and higher incidence of developing the disease after primary infection. Before the age of 5, risk of developing hematogenous spread of TB is greater than other age groups. Between 5 and 10 years the risk decreases and rises again during puberty 7.
Our results were in concordance with this data; 7 patients were younger than 5 years old and the remaining patients were older than 12 years old.
Extrapulmonary TB can affect various organs and systems but lymphadenitis is the most common form. Together with meningeal and pleural involvement, they constitute most of the cases 8. Cervical, mediastinal, and axillary lymph nodes are frequently involved sites in all age groups 1. Another study involving only childhood cases of tuberculosis lymphadenitis found that frequency of lymph node regions were similar with adults cases 9. All of our cases had axillary lympha-denopathy. Absence of other sites of lymph nodes can be explained by the fact that pediatricians more frequently refer cervical lymphadenopathy cases to otorhinolaryngology department in our hospital. Although history and physical examination are non-specific, presence of fistulization, hypervascularity in hilar region on Doppler USG can be differentiating from lymphoma or other infectious etiologies 10. BCG vaccine induced lymphadenitis is resistant to medical therapy and usually lead to suppuration, skin fistulization and long healing period with severe scar formation 11. For these reasons and to reduce the time of treatment, abscess drainage or lymph node excision are recommended 12. A recent cochrane systemic review report that the only proven method of treatment for fluctuant/abscessed lymphadenopathy is needle aspiration 13.
Intestinal TB mimics inflammatory bowel disease and presents with similar clinical picture. Definite diagnosis is confirmed by pathologic and microbiologic studies. The study investigating differentiating characteristics of gastrointestinal TB from inflammatory bowel disease found that palpation of abdominal mass, presence of ascites and intestinal obstruction strongly suggest TB. Bowel wall thickening had 70% accuracy for diagnosing TB and 50% for lymphadenopathy regarding abdominal CT findings 14. Presentation and imaging findings of our patients with intestinal TB were in concordance with the literature.
Tubercular psoas abscess usually accompany Pott’s disease and rarely colonic TB however can also occur as an isolated focus. Classic treatment of abscess drainage should be employed by either percutaneous or open approach and must be followed by anti-TB medical treatment 15,16. Both of our patients present with a cold abscess clinic and without vertebral or colonic TB infection. Dramatic clinical improvement achieved after drainage and medical treatment in both cases without recurrence.
Ovarian involvement of TB is important in two aspects: one is the resemblance to malignancy and second is the risk of future infertility. The most commonly affected age group is young women including adolescents. Abdominal pain and distention as presenting symptom, peritoneal implantations, ascites, septations, heterogeneous mass in radiologic studies and elevated CA-125 level can be seen in both malignancy and TB 17. In this age group, benign tumors predominate and malignancy is rare. For these reasons, before aggressive surgical interventions ending with organ loss, biopsies can be taken by minimally invasive techniques for pathologic and microbiologic examination in patients with diagnostic dilemma. This conservative approach can be beneficial for future fertility and avoid peritoneal adhesions 18. Such conservative approach was preferred in our patient and she received anti-TB therapy in the postoperative period resulting in full recovery. However she experienced intestinal obstruction attacks caused by pelvic adhesions.
Microbiologic proof of TB can not be established in many cases because of two reasons: paucibacillary nature of bacteria and neglecting TB-specific tests on tissues gathered by invasive methods. Microscopic and nucleic acid amplification techniques have been developed but culture remains as the gold standard in diagnosis 19. However it is not an ideal test with significant amount of false negative results. For these reasons, the diagnosis is usually made by a combination of clinical picture, laboratory and imaging studies 1,19. A study by Gupta et al found that microbiological confirmation could be made in 17% of extrapulmonary tuberculosis patients 14. In another study by Sevgi et al, 65% of patients were started on anti-TB medical treatment without laboratory confirmation based on clinical findings 20. Low rate of microbiologic proof was also the case in our study. Tissues were spared for TB-specific tests in patients with a preoperative suspicion but all tissues were reserved for pathology or aerobic culture in remaining cases. Tuberculosis should still be kept in mind in the differential diagnosis list of lymphadenopathy, abscess or constitutional symptoms of unknown origin.
In conclusion, extrapulmonary TB can present with a wide range of clinical spectrum. The signs and symptoms are nonspecific in most of the cases and can be confused with malignancy or other infectious diseases. Although the mainstay of treatment is medical, surgery plays an important role both in diagnosis by yielding tissue for culture and pathologic examination and treatment of sequel caused by destructive effects of TB infection.
Conflict of Interest: Authors declare that there is no conflict of interest.
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