TUBERCULOUS PURIFIED PROTEIN DERIVATIVES AND SURGERY

   I read with interest, the article titled “Peripancreatic Tuberculous Lymphadenitis misdiagnosed as Pancreatic Tumor: A case report” in the journal.⁽¹⁾ It is well known that Mycobacterium tuberculosis (MTB) infections may present with diverse presentation in the clinical scenarios. It was reported to infect almost all organs, including those of the peritoneal cavity, not exclusively lymph nodes around the pancreas⁽¹⁾ but also female pelvic tract which may mimic pelvic tumors with false positive CA125.^(2,3) It also causes omental lymphadenitis, omental tuberculosis, and tuberculous peritonitis.⁽⁴⁾ In this interesting article, S. Mahafza and his group reported an uncommon presentation of enlarged peripancreatic lymph nodes. Work up short of the final definitive procedure (laparotomy) was not diagnostic, however chest roentegenography may have had given a clue towards this possibility. In abdominal tuberculosis, chest X-rays show evidence of concomitant pulmonary lesions in less than 25% of cases;⁽⁴⁾ however I do not recommend just to bring to a close there, and to accept this finding as the sole main point towards the diagnosis. An exploratory laparotomy was needed and pursued as a diagnostic procedure; it gave the definitive diagnosis of MTB infection proved by histopathology as shown.

 As part of the work up, a PPD test was administered, and was strongly positive. It has been the practice not to utilize the PPD as a test to diagnose or to disprove the presence of tuberculosis as a disease; PPD means mostly that infection with MTB took place i.e. not disease.⁽⁵⁾ In this patient, I guess it was done as a procedure that many of us unnecessarily would do “routinely” in similar situation. In this patient with her chest X-ray findings, the PPD test is not helpful; on the contrary it is contraindicated. PPD positivity would not have added to the concerned diagnosis, its negativity would not exclude it.⁽⁶⁾

A second statement in “discussion” is of interest to me “If medical therapy had failed, then the surgical treatment would have been an option”.  Decades agosurgical approach was a common option to deal with Tuberculosis in both extensive and non-responding localized disease. Unfortunately, with the spread of MDR-MTB (Multi Drug Resistant Tuberculosis) infection, and its worse successor the XDR-MTB (extensively Drug Resistant Mycobacterium tuberculosis) though to a much less extent, both strains narrowed severely the therapeutic options, and gave a way for the surgical option again. Short of having tests done on Mycobacteria like sensitivity and specificity, we may encounter mycobacterial cases that are non-tuberculous⁽⁷⁾ or drug resistant, leaving us without a sharp judgment.  Nowadays, a big concern that we may have worldwide is the MDR-MTB. This highlights the need to utilize more culture techniques, polymerase chain reactions (PCR) to detect resistant genes, and sensitivity patterns, by making them available. Meanwhile, we have to exercise caution in dealing with MTB apparently non-responding to treatment.

Jamal Wadi MD

Office 9, Third Floor, Jordan Hospital Medical Center, Queen Noor Street

Jordan Hospital and Medical Center. Amman-Jordan

Tele/fax +962 6 568 6551

E-mail:jamalwadimd@yahoo.com

JRMS April 2008; 15(1):5

References

1.   Mahafza S, Ghazzawi I, Al-Ajarmeh K. Peripancreatic tuberculous lymphadenitis misdiagnosed as pancreatic tumour:a case report. JRMS 2007; 14(3): 54-56

2.    I˙lhan, Durmus og˘lu. Case report of a pelvic-peritoneal tuberculosis presenting as an adnexial mass and mimicking ovarian cancer, and a review of the literature. Infect Dis Obstet Gynecol 2004; 12:87-89

3.  Mehrangiz Hatami. Tuberculosis of the Female Genital Tract in Iran. Archives of Iranian Medicine; 2005; 8(1): 32-35.

4.    Sharma MP, Bhatia V. Abdominal tuberculosis, Review Article. Indian J Med Res 2004; 120: 305-315.

5.       Diagnostic Standards and Classification of Tuberculosis in Adults and Children. Am J Respir Crit Care Med 2000; 16(4): 1376-1395.

6.    Mandell GL, Bennett JE, Dolin R. Mycobacterium tuberculosis. Principles and practice of infectious disease. 6^th edition. Churchill Livingston, USA; 2006.

7.  Hatherill M, et al. Isolation of non-tuberculous mycobacteria in children investigated for pulmonary tuberculosis. 2006 December 20; doi: 10.1371 /journal.pone.0000021.