Mesenteric vasculitis in a patient of tuberculosis

Abstract

Vasculitis plays an important part in the natural history of abdominal tuberculosis. Here we report an unusual case of mesenteric vasculitis secondary to tuberculosis in ten year old girl who presented with pain abdomen and weight loss. The case was confirmed by highly positive tuberculin test and Doppler study showing altered flow in mesenteric vessels. The flow pattern and patient condition improved after anti-tuberculosis treatment.

Keywords: Tuberculosis, vasculitis, doppler study

How to cite this article:
Guha S, Baboo S, Guha G, Hashmi MA. Mesenteric vasculitis in a patient of tuberculosis. Ann Trop Med Public Health 2012;5:365-6
How to cite this URL:
Guha S, Baboo S, Guha G, Hashmi MA. Mesenteric vasculitis in a patient of tuberculosis. Ann Trop Med Public Health [serial online] 2012 [cited 2020 Aug 4];5:365-6. Available from: https://www.atmph.org/text.asp?2012/5/4/365/102061
Introduction

Tuberculosis is an important cause of mortality and morbidity in developing counties. Along with increase in population, incidence of pulmonary and extra pulmonary tuberculosis has also increased. Abdominal tuberculosis represents the sixth most frequent form of extra pulmonary tuberculosis. [1],[2] Here, we report an unusual case of mesenteric vasculitis secondary to tuberculosis.

Case Report

A ten-year old female child was admitted with history of anorexia weight loss and pain abdomen for 3 weeks. Pain was colicky in nature periumbilical without any definite relation to food. It occurred 4 to 5 times / week with gradually increasing frequency. It was not associated with vomiting diarrhea alteration of bowel habits, melena, joint pains, or skin rash. No history of contact with tuberculosis. On examination, the child was afebrile, anicteric, and weighed 28 kgs. There was no edema or significant lymphadenopathy. Blood pressure was 100/60 mm hg. All the peripheral pulses were equally palpable with normal volume and rhythm. Examination of the abdomen revealed tenderness in the periumbilical region without any muscle guard rigidity or rebound tenderness. There was no organomegaly or palpable mass. Examination of other system was unremarkable. Investigation showed hemoglobin 11 gm %, total count 7900/cu mm [poly 52%, lympho 43%, baso 3%, eosino 2%, mono 0% ], ESR 78 mm, serum amylase, lipase, liver function test, urea creatinine were within normal limits. Anti-nuclear factor and urine for porphyrins were negative. Mantoux test with 5 TU showed an induration of 35 mm. Blood and urine culture were sterile. Chest X-ray was within normal limits. Ultrasonogaphy [USG] of the abdomen revealed intimal thickening of the superior mesenteric artery with luminal narrowing. There was no evidence intraluminal thrombus or clot [Figure 1]. Doppler findings showed raised diastolic component [Figure 2] and [Figure 3]. Barium studies of the gastrointestinal tract did not show any ulceration or perforation. Angiogram of abdominal vessels was suggested but could not be done due to financial constraints.

Figure 1: Showing circumferential intimal wall thickening with luminal narrowing

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Figure 2: Color flow showing loss of laminar flow.

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Figure 3: High end diastolic flow in superior mesenteric artery in doppler study

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Considering pain abdomen, USG findings, and a strongly positive Mantoux test, the child was put on four drugs anti-tubercular drug therapy and short term steroids [8 weeks]. Subsequently, the patient showed symptomatic improvement, pain abdomen subsided, and there was general well-being with weight gain. After six months follow-up, USG showed resolution of flow defects originally observed [Figure 4].

Figure 4: Spectral waveform of superior mesenteric artery showing absent diastolic flow suggesting normalization of the hemodynamics in comparision to the previous Doppler study

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Discussion

Abdominal tuberculosis is an infrequent form of extra pulmonary tuberculosis. Tubercular bacteria reach the gastrointestinal tract via the hematogenous route, ingestion of infected sputum, or contagious spread from adjacent organs. Vasculitis is a well-established feature of neuro / pulmonary / genitourinary tuberculosis but infrequently described in intestinal tuberculosis. Few studies have evaluated the role of mesenteric vasculitis in intestinal tuberculosis. [3],[4] Although involvement of mesenteric vasculature is commonly associated with intestinal ischemia, resulting in ulcerative type of lesions with perforations, our case did not show any evidence of such.

Difficulty of an early diagnosis is the most important cause of morbidity and mortality in mesenteric vasculitis. Diagnosis requires a high index of suspicion because of paucity of confirmatory investigations, which involves logistic and financial constraints in developing countries. Mesenteric vascular involvement is an unusual manifestation of abdominal tuberculosis and should be suspected early to prevent potentially fatal complications.

References
1. Marshall JB. Tuberculosis of the gastrointestinal tract and peritoneum. Am J gastroenterol 1993;88:989-99.
2. Kapoor VK. Abdominal tuberculosis: The Indian contribution. Indian J Gastroenterol 1998;17:141-7.
3. Shah P, Ramakantan R. role of vasculitis in the natural history of abdominal tuberculosis: Evaluation by mesenteric angiography. Indian J Gastroenterol 1991;10:127-30.
4. Bhusnurmath SR, Nagi B. Significance of vasculitis in gut tuberculosis. Indian J Gastroenterol 1991;10:125-6.

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/1755-6783.102061

Figures

[Figure 1], [Figure 2], [Figure 3], [Figure 4]

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