Tubercle (1989) 70, 142-145 0 Longman Group UK Ltd 1989

0041-3879/89/0070-0143/$10.00

ABDOMINAL TUBERCULOSIS IN PREGNANCY

0. Freeman

Depatiment of Medicine, University of Benin Teaching Hospital, Benin, Nigeria

Summary T..,r. .~~t;zx..+c -v- .-Jar.-Aher . ..hn nraenntarl \.rith c,hAnminsl +,,hart.,,ln,,c acr.itac earnA I YY” pJarlril,rJ c3l.z UIzJb,,“~U ““ll” ~,~azllr~” ““1,11 ClYUVllllllLll IUYTI~UIVUP CIabIIGa cl,,” hepatomegaly, one in the 2nd trimester of pregnancy who aborted and the other in the post partum period following a normal delivery. Both patients responded to anti-tuberculosis chemotherapy.

L’auteur presente le cas de deux malades atteintes d’une tuberculose abdominale entrainant une ascite et une hepatomegalie; dans le premier cas, il s’agissait d’une femme au tours du deuxieme trimestre de la grossesse, qui a avorte’ et, dans le deuxieme cas, d’une femme en periode de post-par-turn apres un accouchement normal. Les deux malades ont bien repondu a la chimiotherapie antituberculeuse.

Resumen Se describen dos pacientes que presentaban una tuberculosis abdominal con ascitis y hepatomegalia; una estaba en el Segundo trimestre de embarazo y habia abortado y la otra estaba en el period0 de post-part0 despues de un parto normal. Ambas pacientes respondieron bien a una terapia antituberculosa.

Report of cases

Case 7

A 23-year-old female was admitted at 22 weeks of gestation with a 2 weeks history of fever, headache, anorexia, abdominal discomfort and malaise. On examination she was febrile (38.8 “C), pale, anicteric, with no peripheral oedema. The liver was 3 cm enlarged, soft, smooth, and not tender; there was no splenomegaly, and the chest was clinically clear. She was commenced on antimalarial drugs while the cause of her pyrexia was being investigated. However on the 3rd day of admission she aborted a macerated fetus. Her pyrexia persisted and further abdominal examination revealed ascites. The results of investigations showed-Hb 9.7 g/dl, three blood cultures were negative; urine culture was negative; abdominal ultrasound scan showedascitesand hepatomegaly; serum protein was 7.1 g/dl-albumin 3.0 g/dl; the ascitic fluid protein was 4.5 g/dl; ascitic fluid microscopy showed acid-fast bacilli, and the culture yielded Mycobacterium tuberculosis. The Mantoux test was 12 mm positive.

A diagnosis of abdominal tuberculosis was made and she was commenced on streptomycin 0.75 g daily, and Diateben (isoniazid 300 mg+thiacetazone 150 mg) daily. Her temperature settled, her abdominal girth decreased from 95 cm to 80 cm within 4 weeks of therapy. She continued the streptomycin for 3 months and the Diateben for 18 months.

144 Freeman

Case 2

A 30-year-old lady presented with abdominal pain and swelling, fever, cough productive of yellow sputum and diarrhoea 1 week postpartum. On examination, she was pale, febrile, and mildly icteric, but there was no peripheral oedema. The pulse was 1 lO/min, regular, and good volume, blood pressure 110/80, the abdomen was distended and generally tender with mild ascites, 8 cm hepatomegaly, 3 cm splenomegaly and she had crepitations and bronchial breathing over the right lower lobe. A diagnosis of puerperal sepsis with peritonitis and lobar pneumonia was made.

Results of investigations showed Hb of 5 g/dl, bilirubin of 76.9 pmol/l, four blood cultures were negative. Abdominal ultrasound scan showed hepatomegaly and mild ascites. Chest X-ray showed cavitation and consolidation in the right lower zone and the sputum grew Klebsiella and Pseudomonas which were sensitive to gentamycin. Serum protein was 6.8 g/d1 with albumin of 2.7 g/dl, ascitic fluid protein was 5 g/dl; ascitic microscopy showed lymphocytosis but it was negative for mycobacteria. The Mantoux test was 14 mm positive.

Her initial treatment consisted of gentamicin, ampicillin and cloxicillin and 6 units of blood transfusion. After 2 weeks of therapy her chest became clinically clear but she remained febrile. A repeat ascitic fluid microscopy showed acid-fast bacilli. She was then commenced on streptomycin 0.75 g daily and Diateben 450 mg daily. Within 4 days her temperature settled and she continued to improve over the next 18 months.

Discussion Tuberculosis is still a major health problem for young adults in developing countries. Abdominal tuberculosis accounted for 24 % of all patients presenting with ascites in Nigeria [II, but for only 2 % in Houston, Texas [2]. It was found in 10.6 % of 1563 autopsies carried out in lbadan [3]. The route of infection is often a reactivation of a long latent tuberculous focus in the peritoneum, of infected mesenteric glands, or a genitourinary focus which had arisen from an earlier lung lesion [4, 5, 6, 71.

Our two patients were in their 3rd decade, were multiparous, and presented before rl^,:..^-. . . ..*I_ z ̂ ..^_ ..l_rl__:__, __.:_ ^_ ..J:_-,-r-& ^_^_ -..:- -_-1 --I-:-- . ..L.-L I -.-_ “wl”txy vvllll Itwe,, a”““llllllal pa,,, “I “151;“rllI”rL, alluraxla allu Irlalalsa, WIIIL;II Ialar

became more manifest in the puerperium with weight loss and ascites. Case 1 demonstrated the glandular type in the abdominal tuberculosis spectrum. This is the commonest type seen in the tropics [4, 51, often presenting as painless ascites, lymphadenopathy, and hepatosplenomegaly. Case 2 falls in the tuberculous peritonitis group. The cavitating consolidation in the right lobe could be a reactivation of an old tuberculous pulmonary lesion that became secondarily infected by Klebsiella.

The development of tuberculous disease in these patients could be due to pregnancy- associated depressed cellular immunity, and since tuberculous infection is controlled by cellular immunity 181, this might predispose them to a primary infection or a recrudescence of an old focus. Secondly, malnutrition lowers both cellular and humoral immunity [9] and this could act as a trigger mechanism [IO] in these patients, as both of them had low serum albumin levels of 2.8 g/dl and 3.0 g/dl.

The diagnosis of abdominal tuberculosis is proven when mycobacteria are seen on staining or culture of ascitic fluid, but this occurs in only 30-50 % of cases [Ill.

Other factors which point to the diagnosis are a positive Mantoux test, ascitic fluid protein greater than 4.5 g/dl, ascitic fluid lymphocytosis, and a good response to antituberculosis chemotherapy. The outcome of pregnancy was accompanied by foetal death in case 1, whilst the second patient went to term. A high index of suspicion, particularly the detection of ascites during pregnancy, might have salvaged the baby.

Tuberculosis in pregnancy 145

In conclusion, abdominal tuberculosis should be suspected in ascites during pregnancy, or in puerperal sepsis that does not respond to the usual antibiotic treatment.

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diagnostic procedures, and therapeutic measures. N Engl J Med 1969; 281: 1091. 7 Sochochy S. Tuberculous peritonitis. Amer Rev Resp Dis 1967; 95: 398. 8 Lloyd AVC. Tuberculin test in children with malnutrition. Brit Med J 1968; 3: 529. 9 Mcfarlane H. lmmunoglbbulins in population of subtropical and tropical countries. AdvClin Chern 1973; 16: 153.

10 Burack W, Hollister R. Tuberculous peritonitis. Amer J Med 1960; 28: 510. 11 Khoury GA, Payne CR, Harvey DR. Tuberculosis of the peritoneal cavity. hit J Surg 1978; 65: 11, 805.