Herausforderungen in der Diagnostik der Darmtuberkulose – Pitfalls einer vergessenen infektiösen Erkrankung: Eine Fallserie und Literaturübersicht

Zusammenfassung

Die Darmtuberkulose ist eine extrapulmonale Manifestation einer Infektion mit Mykobakterien des Tuberkulosekomplexes. Sie ist in den Industrieländern äußerst selten geworden, präsentiert sich mit einer sehr heterogenen, unspezifischen Klinik und ist schwer zu diagnostizieren. Anders als bei der pulmonalen Tuberkulose besitzen die wichtigsten diagnostischen Methoden wie der Nachweis säurefester Stäbchen in der Ziehl-Neelsen-Färbung, der Genomnachweis mittels PCR-Untersuchung und die kulturelle Anzüchtung der Bakterien eine geringe Sensitivität. Wir präsentieren hier die Fälle von drei Patienten/-innen, bei denen wir eine Darmtuberkulose diagnostizierten und erfolgreich behandelten. An die Fallberichte anschließend stellen wir eine Literaturübersicht vor, die die Fallstricke der Darmtuberkulosediagnostik und -therapie beleuchtet.

Abstract

Intestinal tuberculosis is an infectious disease of the extrapulmonary manifestation with the Mycobacteria tuberculosis complex. In developed countries, this disease is rarely seen. The clinical features are heterogeneous and unspecific. Furthermore, intestinal tuberculosis poses diagnostic challenges. Regarding intestinal tuberculosis the Ziehl-Neelsen staining for acid-fast bacillus, PCR examination and culture methods show only poor sensitivity and specificity. In this case series, we present three patients suffering from intestinal tuberculosis, who were diagnosed and treated successfully. Furthermore, we review the literature about the pitfalls of the diagnostic approaches and the treatment options of intestinal tuberculosis.

Schlüsselwörter

Intestinale Tuberkulose (TB) - Abdominelle Tuberkulose - Interferon γ releasing assay (IGRA) - Gastrointestinaltrakt

Key words

intestinal tuberculosis (tb) - abdominal tuberculosis - interferon gamma releasing assay IGRA - gastrointestinal tract

• References

• 1 Bloom BR, Atun R, Cohen T. et al. Major Infectious Diseases: Tuberculosis. 3rd.. Washington (DC): 2017
• 2 Houben RMGJ, Dodd PJ. The Global Burden of Latent Tuberculosis Infection: A Re-estimation Using Mathematical Modelling. PLoS Med 2016; 13: e1002152 . doi:10.1371/journal.pmed.1002152
• 3 Desai U, Joshi JM. Extrapulmonary drug-resistant tuberculosis at a drug-resistant tuberculosis center, Mumbai: Our experience – Hope in the midst of despair!. Lung India 2019; 36: 3-7 . doi:10.4103/lungindia.lungindia_192_18
• 4 van Rijn SP, Zuur MA, Anthony R. et al. Evaluation of Carbapenems for Treatment of Multi- and Extensively Drug-Resistant Mycobacterium tuberculosis. Antimicrob Agents Chemother 2019; 63
• 5 Dhiman RK, Saraswat VA, Rajekar H. et al. A Guide to the Management of Tuberculosis in Patients with Chronic Liver Disease. J Clin Exp Hepatol 2012; 2: 260-270 . doi:10.1016/j.jceh.2012.07.007
• 6 Schaberg T, Bauer T, Brinkmann F. et al. S2k-Leitlinie: Tuberkulose im Erwachsenenalter. Pneumologie 2017; 71: 325-397 . doi:10.1055/s-0043-105954
• 7 Stine JG, Lewis JH. Current and future directions in the treatment and prevention of drug-induced liver injury: a systematic review. Expert Rev Gastroenterol Hepatol 2016; 10: 517-536 . doi:10.1586/17474124.2016.1127756
• 8 Abbara A, Chitty S, Roe JK. et al. Drug-induced liver injury from antituberculous treatment: a retrospective study from a large TB centre in the UK. BMC Infect Dis 2017; 17: 231 . doi:10.1186/s12879-017-2330-z
• 9 Segar M. Global tuberculosis report 2018. Geneva: World Health Organization; 2018 Licence: CCBY-NC-SA3.0IGO
• 10 WHO Regional Office for Europe/European Centre for Disease Prevention and Control. Tuberculosis surveillance and monitoring in Europe 2019–2017 data. Copenhagen: WHO Regional Office for Europe; 2019
• 11 Ramesh J, Banait GS, Ormerod LP. Abdominal tuberculosis in a district general hospital: a retrospective review of 86 cases. QJM 2008; 101: 189-195 . doi:10.1093/qjmed/hcm125
• 12 Kentley J, Ooi JL, Potter J. et al. Intestinal tuberculosis: a diagnostic challenge. Trop Med Int Health 2017; 22: 994-999 . doi:10.1111/tmi.12908
• 13 von Hahn T, Bange FC, Westhaus S. et al. Ultrasound presentation of abdominal tuberculosis in a German tertiary care center. Scand J Gastroenterol 2014; 49: 184-190 . doi:10.3109/00365521.2013.865258
• 14 Sevgi DY, Derin O, Alpay AS. et al. Extrapulmonary tuberculosis: 7 year-experience of a tertiary center in Istanbul. Eur J Intern Med 2013; 24: 864-867 . doi:10.1016/j.ejim.2013.08.704
• 15 Qian X, Nguyen DT, Lyu J. et al. Risk factors for extrapulmonary dissemination of tuberculosis and associated mortality during treatment for extrapulmonary tuberculosis. Emerg Microbes Infect 2018; 7: 102 . doi:10.1038/s41426-018-0106-1
• 16 Cho JK, Choi YM, Lee SS. et al. Clinical features and outcomes of abdominal tuberculosis in southeastern Korea: 12 years of experience. BMC Infect Dis 2018; 18: 699 . doi:10.1186/s12879-018-3635-2
• 17 Debi U, Ravisankar V, Prasad KK. et al. Abdominal tuberculosis of the gastrointestinal tract: revisited. World J Gastroenterol 2014; 20: 14831-14840 . doi:10.3748/wjg.v20.i40.14831
• 18 Cheng W, Zhang S, Li Y. et al. Intestinal tuberculosis: clinico-pathological profile and the importance of a high degree of suspicion. Trop Med Int Health 2019; 24: 81-90 . doi:10.1111/tmi.13169
• 19 Shi XC, Zhang LF, Zhang YQ. et al. Clinical and Laboratory Diagnosis of Intestinal Tuberculosis. Chin Med J 2016; 129: 1330-1333 . doi:10.4103/0366-6999.182840
• 20 Leung VKS, Law ST, Lam CW. et al. Intestinal tuberculosis in a regional hospital in Hong Kong: a 10-year experience. Hong Kong Med J 2006; 12: 264-271
• 21 Limsrivilai J, Shreiner AB, Pongpaibul A. et al. Meta-Analytic Bayesian Model For Differentiating Intestinal Tuberculosis from Crohn’s Disease. Am J Gastroenterol 2017; 112: 415-427 . doi:10.1038/ajg.2016.529
• 22 Patel B, Yagnik VD. Clinical and laboratory features of intestinal tuberculosis. Clin Exp Gastroenterol 2018; 11: 97-103 . doi:10.2147/CEG.S154235
• 23 Gan H, Mely M, Zhao J. et al. An Analysis of the Clinical, Endoscopic, and Pathologic Features of Intestinal Tuberculosis. J Clin Gastroenterol 2016; 50: 470-475 . doi:10.1097/MCG.0000000000000514
• 24 Donoghue HD, Holton J. Intestinal tuberculosis. Curr Opin Infect Dis 2009; 22: 490-496 . doi:10.1097/QCO.0b013e3283306712
• 25 Polat KY, Aydinli B, Yilmaz O. et al. Intestinal tuberculosis and secondary liver abscess. Mt Sinai J Med 2006; 73: 887-890
• 26 Miura T, Shimizu T, Nakamura J. et al. A case of intestinal tuberculosis associated with ileo-ileal fistula. Nihon Shokakibyo Gakkai Zasshi 2010; 107: 416-426
• 27 Toosi TD, Shahi F, Afshari A. et al. Neuropathy caused by B12 deficiency in a patient with ileal tuberculosis: a case report. J Med Case Rep 2008; 2: 90 . doi:10.1186/1752-1947-2-90
• 28 Chong VH, Joseph TP, Telisinghe PU. et al. Chronic inflammatory demyelinating polyneuropathy associated with intestinal tuberculosis. J Microbiol Immunol Infect 2007; 40: 377-380
• 29 Singh BK, Negi S, Meena K. et al. Primary enterolithiasis with intestinal tuberculosis: rare presentation of a common disease. BMJ Case Rep 2018; 11
• 30 Chong VH, Telisinghe PU, Yapp SKS. et al. Tuberculous appendix: a review of clinical presentations and outcomes. Singapore Med J 2011; 52: 90-93
• 31 Mehta V, Desai D, Abraham P. et al. Do additional colonoscopic biopsies increase the yield of Mycobacterium tuberculosis culture in suspected ileo-colonic tuberculosis?. Indian J Gastroenterol 2018; 37: 226-230 . doi:10.1007/s12664-018-0863-8
• 32 Nakamura M, Niwa Y, Ohmiya N. et al. Small bowel tuberculosis diagnosed by the combination of video capsule endoscopy and double balloon enteroscopy. Eur J Gastroenterol Hepatol 2007; 19: 595-598 . doi:10.1097/MEG.0b013e3280ec544c
• 33 Dahale AS, Kumar A, Srivastava S. et al. Esophageal tuberculosis: Uncommon of common. JGH Open 2018; 2: 34-38 . doi:10.1002/jgh3.12043
• 34 Jin XJ, Kim JM, Kim HK. et al. Histopathology and TB-PCR kit analysis in differentiating the diagnosis of intestinal tuberculosis and Crohn’s disease. World J Gastroenterol 2010; 16: 2496-2503
• 35 Ahmad R, Changeez M, Khan JS. et al. Diagnostic Accuracy of Peritoneal Fluid GeneXpert in the Diagnosis of Intestinal Tuberculosis, Keeping Histopathology as the Gold Standard. Cureus 2018; 10: e3451 . doi:10.7759/cureus.3451
• 36 Alvares JF, Devarbhavi H, Makhija P. et al. Clinical, colonoscopic, and histological profile of colonic tuberculosis in a tertiary hospital. Endoscopy 2005; 37: 351-356 . doi:10.1055/s-2005-861116
• 37 Hallur V, Sharma M, Sethi S. et al. Development and evaluation of multiplex PCR in rapid diagnosis of abdominal tuberculosis. Diagn Microbiol Infect Dis 2013; 76: 51-55 . doi:10.1016/j.diagmicrobio.2013.02.022
• 38 Ye BD, Yang SK, Kim D. et al. Diagnostic sensitivity of culture and drug resistance patterns in Korean patients with intestinal tuberculosis. Int J Tuberc Lung Dis 2012; 16: 799-804 . doi:10.5588/ijtld.11.0252
• 39 Chambers HF, Moreau D, Yajko D. et al. Can penicillins and other beta-lactam antibiotics be used to treat tuberculosis?. Antimicrob Agents Chemother 1995; 39: 2620-2624
• 40 Lee M, Lee J, Carroll MW. et al. Linezolid for treatment of chronic extensively drug-resistant tuberculosis. N Engl J Med 2012; 367: 1508-1518 . doi:10.1056/NEJMoa1201964
• 41 Ng SC, Hirai HW, Tsoi KKF. et al. Systematic review with meta-analysis: accuracy of interferon-gamma releasing assay and anti-Saccharomyces cerevisiae antibody in differentiating intestinal tuberculosis from Crohn’s disease in Asians. J Gastroenterol Hepatol 2014; 29: 1664-1670 . doi:10.1111/jgh.12645
• 42 Jung HJ, Kim YH, Kim YS. et al. Differences in Clinical Manifestations according to the Positivity of Interferon-γ Assay in Patients with Intestinal Tuberculosis. Gut Liver 2016; 10: 649-652 . doi:10.5009/gnl15439
• 43 Kalra N, Agrawal P, Mittal V. et al. Spectrum of imaging findings on MDCT enterography in patients with small bowel tuberculosis. Clin Radiol 2014; 69: 315-322 . doi:10.1016/j.crad.2013.10.009
• 44 Engin G, Balk E. Imaging findings of intestinal tuberculosis. J Comput Assist Tomogr 2005; 29: 37-41
• 45 Zhang T, Fan R, Wang Z. et al. Differential diagnosis between Crohn’s disease and intestinal tuberculosis using integrated parameters including clinical manifestations, T-SPOT, endoscopy and CT enterography. Int J Clin Exp Med 2015; 8: 17578-17589
• 46 Krishna S, Kalra N, Singh P. et al. Small-Bowel Tuberculosis: A Comparative Study of MR Enterography and Small-Bowel Follow-Through. Am J Roentgenol 2016; 207: 571-577 . doi:10.2214/Am J Roentgenol.15.15580
• 47 Gurzu S, Molnar C, Contac AO. et al. Tuberculosis terminal ileitis: A forgotten entity mimicking Crohn's disease. World J Clin Cases 2016; 4: 273-280 . doi:10.12998/wjcc.v4.i9.273
• 48 Jullien S, Jain S, Ryan H. et al. Six-month therapy for abdominal tuberculosis. Cochrane Database Syst Rev 2016; 11: CD012163 . doi:10.1002/14651858.CD012163.pub2
• 49 Cheng VCC, Ho PL, Lee RA. et al. Clinical spectrum of paradoxical deterioration during antituberculosis therapy in non-HIV-infected patients. Eur J Clin Microbiol Infect Dis 2002; 21: 803-809 . doi:10.1007/s10096-002-0821-2
• 50 Geri G, Passeron A, Heym B. et al. Paradoxical reactions during treatment of tuberculosis with extrapulmonary manifestations in HIV-negative patients. Infection 2013; 41: 537-543 . doi:10.1007/s15010-012-0376-9
• 51 Hawkey CR, Yap T, Pereira J. et al. Characterization and management of paradoxical upgrading reactions in HIV-uninfected patients with lymph node tuberculosis. Clin Infect Dis 2005; 40: 1368-1371 . doi:10.1086/429317
• 52 Yu SN, Cho OH, Park KH. et al. Late paradoxical lymph node enlargement during and after anti-tuberculosis treatment in non-HIV-infected patients. Int J Tuberc Lung Dis 2015; 19: 1388-1394 . doi:10.5588/ijtld.15.0257
• 53 Akarsu M, Akpinar H. Endoscopic balloon dilatation applied for the treatment of ileocecal valve stricture caused by tuberculosis. Dig Liver Dis 2007; 39: 597-598 . doi:10.1016/j.dld.2007.02.008
• 54 Park JK, Lee SH, Kim SG. et al. A case of intestinal tuberculosis presenting massive hematochezia controlled by endoscopic coagulation therapy. Korean J Gastroenterol 2005; 45: 60-63
• 55 Lee MJ, Cresswell FV, John L. et al. Diagnosis and treatment strategies of tuberculous intestinal perforations: a case series. Eur J Gastroenterol Hepatol 2012; 24: 594-599 . doi:10.1097/MEG.0b013e328350fd4a