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Ileocecal tuberculosis simulating as intussusception on abdominal ultrasonography: A case report and review of literature

Bilal Mirza, Lubna Ijaz, Afzal Sheikh

Department of Pediatric Surgery The Children’s Hospital and the Institute of Child Health, Lahore, Pakistan


Correspondence

Bilal Mirza
Department of Pediatric Surgery
The Children’s Hospital and the Institute of Child Health
No. 428 Nishter Block Allama Iqbal Town
Lahore, Pakistan
Mobile: 923454772583
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Abstract

Intestinal tuberculosis (TB) has a spectrum of clinical presentations. A 7-year-old male child presented with abdominal distension and pain, vomiting, and constipation for a week. Abdominal radiograph detected free air under diaphragm; ultrasound of the abdomen gave a suspicion of intussusception on the basis of positive donut sign. A diagnosis of intestinal perforation secondary to bowel ischemia due to intussusception was made. At exploration, ileocecal TB was found along with three distal ileal strictures and a perforation at about 10cm proximal to ileocecal valve. The perforation was primarily repaired. The patient gave a good response to post operative antituberculosis therapy (ATT).

Key words: Ileocecal tuberculosis, donut sign, intussusception

 

Introduction

Tuberculosis (TB) is a chronic granulomatous inflammatory disease and intestine is the sixth most prevalent organ of its involvement. Intestinal TB can have diverse clinical presentations. A number of cases have been reported in English literature where intestinal TB proved to be lead point for intussusceptions. However, only one case report is described in Pubmed where ileocecal TB was mistaken for ileocecal intussusception in an infant [1-4]. We are reporting world’s second case of ileocecal TB simulating as intussusception on abdominal ultrasonography.

Case report

A 7-year-old male child presented to Surgery Emergency Department of our hospital with complaints of abdominal distension and pain, vomiting, and constipation for a week. There had been a history of infrequent episodes of pain abdomen and mild fever for more than a month for which he remained under treatment of the medical department of the same hospital. There was no history of contact with TB patient and he had received BCG vaccine.

The previous medical work up for abdominal pain revealed a right sided pelvic kidney on abdominal ultrasonography. The hemoglobin was 9g/dl and WBC’s count was 7000. The ESR of the patient was 45mm. His urinalysis revealed pus cells more than 5 per high field. The pelvic kidney and urinary tract infection (UTI) were thought of as the cause of abdominal pain and fever. A renal scan was performed that revealed fairly functioning both kidneys (fig. 1).

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Figure 1. Renal scan of the patient showing a right pelvic kidney with fair functions

During the index admission the general physical examination revealed a mildly febrile child with temperature 100F, pulse of 90/min and respiratory rate 30/min. The systemic examination was unremarkable except for abdominal distension, and tenderness especially in right lower quadrant. The bowel sounds were absent and digital rectal examination yielded an empty rectum. Abdominal radiograph revealed free air under diaphragm. Ultrasound of the abdomen delineated a donut sign in the right iliac fossa along with mild free debrinous fluid in the pelvis (fig. 2).

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Figure 2. Ultrasound of the abdomen showing a positive donut sign

The patient was optimized for exploratory laparotomy. At operation no intussusception found instead the ileocecal region was found to be inflammed, thickened, edematous and covered with tubercles (fig.3). There were three distal ileal strictures with a perforation at about 10cm proximal to ileocecal junction. The strictures and the thickened ileocecal junction were not causing intestinal obstruction, thus, the perforation repaired primarily with interrupted sutures in two layers. The biopsy was taken from the adherent omentum and regional lymph nodes to document intestinal TB.

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Figure 3. Ileocecal mass (TB)

Postoperative course remained uneventful and patient was discharged on 10th postoperative day on oral ATT. The histology of the submitted specimens revealed typical histopathological features consistent with TB. The patient is on our follow up and doing well.

Discussion

Intestine is the 6th most frequently involved organ of body by mycobacterium. Hyperplastic TB usually involves the ileocecal region and few inches of distal ileum. The clinical features of intestinal TB are variable and range from mild abdominal pain to severe such as intestinal obstruction and perforation with peritonitis [1].

Ileocecal TB usually presents with abdominal pain and occasionally with sub acute intestinal obstruction. In a few cases, intestinal TB was identified as a pathological lead point (PLP) of intussusception and in other few cases intestinal TB was concurrently found with intussusceptions without being the PLP[1,4]. A history of prolonged low grade fever associated with other constitutional symptoms of TB, alternating episodes of diarrhea and constipation, a history of contact with a TB patient, malnutrition, poverty, overcrowding, raised ESR, positive mantoux test, and concurrent pulmonary lesion on chest radiograph are helpful in preoperative diagnosis of intestinal TB [1,3]. In our case the patient had an ectopic kidney and pus cells in the urinalysis; moreover, the history was of a month with vague symptoms. Physicians were concentrating more on ectopic kidney with UTI as cause of his symptoms, especially in absence of a history of contact and also the patient had been vaccinated.

Ultrasound of the abdomen delineated a donut sign in our patient which was a diagnostic feature of intussusception. We were suspecting an intussusception resulting in ischemia and perforation of the intestine as evident by generalized peritonism and free intraperitoneal air. At operation neither intussusception, nor any signs of auto-reduced intussusception were found. In our opinion, the ileal strictures were present very near to inflamed and edematous cecum that may provoke a donut sign when observed with ultrasonography.

De Steenwinkel et al, in 2008, reported the first case of ileocecal TB in a 5 month old infant, presented with signs of intestinal obstruction. In their case ultrasound of the abdomen revealed a donut sign in the right lower quadrant. They initially tried to reduce the intussusception hydrostatically followed by laparotomy that revealed ileocecal TB [3]. Similarly in our patient the preoperative diagnosis was intussusception causing bowel ischemia and perforation.

In conclusion, positive donut sign on abdominal ultrasonogram is not necessarily indicative of intussusception. A history of prolonged symptoms in presence of positive donut sign may provide an insight to other diagnoses. However a high suspicion is required to diagnose the condition preoperatively.

 

 

 

References

1. Mirza MB. Abdominal tuberculosis: An overview. [Online]. 2009 Mar 16 [cited 10-08-2010]; Available from: URL:http://www.babysurgeon.com/documents/ abdominal-tuberculosis.html

2. Abbasi A, Javaherzadeh M, Arab M, Keshoofy M, Pojhan S, Daneshvar G. Surgical treatment for complications of abdominal tuberculosis. Arch Iranian Med 2004; 7: 57-60.

3. De Steenwinkel JEM, Driessen GJA, Kamphorst-Roemer MH, Zeegers AGM, Ott A, van Westreenen M. Tuberculosis mimicking ileocecal intussusception in a 5-month-old girl. Pediatr 2008; 121: e1434-6.

4. Mahajan D, Nigam S, Kohli K. Abdominal tuberculosis presenting as ileocolic intussusception in an infant. Pediatr Dev Pathol 2007;10: 477-80.