Abdominal pain and weight loss are two of the most common symptoms of abdominal TB worldwide with ascites being one of the most common findings on both examination and abdominal ultrasound.3
Our patient manifested all these signs and symptoms. However, one has to bear in mind that these are very non-specific findings and by no means pathognomonic of abdominal TB.
One of the most important findings in our patient was her respiratory symptoms, with an abnormal chest x-ray, which had been missed previously. This is in contrast to other reported cases of abdominal TB,3 4
in which the majority of patients have been found to be free of pulmonary manifestations with normal chest x-ray and AFB-free sputum.
Focusing on the initial chest x-ray, all attempts to identify who had requested the x-ray had failed as there was no electronic record of the request indicating that it had been requested either at an outpatient clinic or by the patient's general practitioner. It is highly unlikely that the patient would have developed such florid disseminated TB.
The most common recurring theme in the literature is that of the difficulty in diagnosis and several sources conclude that a high index of clinical suspicion is vital to achieve this. Given the lack of a ‘diagnostic gold standard’, there is an increasing need for surgical intervention in diagnostic confirmation.5
The most recent data available from the Health Protection Agency (HPA)2
suggests that TB rates are stable; however, these most recent data were published late 2009 using 2008 figures. A very recent study, which looked at TB rates in Europe, disagrees with this HPA data. It suggests that TB rates in the UK, Sweden and Norway are again on the increase most likely due the immigration of people from countries of high incidence.6
Looking again at the HPA's annual report on TB surveillance in the UK, there has been a 2.2% increase in reported cases compared to the previous years with the majority of cases occurring in non-UK born population (77%). However, although incidence of TB is declining, the rate is stable in the UK-born population. Over half of TB cases reported in 2008 had pulmonary disease with or without any extra-pulmonary disease. However, this varied by place of birth: 71% of UK-born cases had pulmonary TB compared to 48% of non-UK-born cases. Ten per cent of TB cases involved both a pulmonary and at least one extra-pulmonary site. Of the extra-pulmonary sites of disease, the most commonly reported in 2008 were extra-thoracic lymph nodes (21%), intra-thoracic lymph nodes (9%) and the pleura (7%), with gastrointestinal tract accounting for 4.7% of cases only.2
These figures highlight the fact that although pulmonary TB is not an uncommon disease, particularly in the non-UK born population, extra-pulmonary disease is rare and a high index of clinical suspicion is essential for timely diagnosis.
- This case highlights the importance of following up young patients with abnormal chest x-ray findings.
- It illustrates the symptoms, signs and extra-pulmonary manifestations of TB infection.
- A high degree of suspicion is required for timely diagnosis of TB in patients in whom the main symptoms are extra-pulmonary.