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Tuberculous Peritonitis

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141. Ascites (Treatment)

(>1.1 g/dL) (see the calculator). Spontaneous bacterial peritonitis may complicate the course of the disease. Cardiac abnormalities (eg, congestive failure, physiologic right-side heart obstruction, severe valvular regurgitation) may result in ascites. Infection may lead to excess peritoneal fluid. Appendicitis is common in patients in developed countries, whereas tuberculous fluid collections and Salmonella organisms are observed in patients in the developing world. Pancreatic ascites (either from (...) cholecystectomy. Urinary ascites in neonates is usually due to intraperitoneal bladder or ureteric or upper-tract perforation as a result of distal obstruction. Posterior urethral valves are the most common cause; [ ] for this reason, males are affected much more often than females are. Complex urinary anomalies (eg, persistent cloaca) may allow reflux of urine through the genital tract into the peritoneal cavity, without the presence of a perforation. [ ] Chylous ascites may occur in neonates

2014 eMedicine Pediatrics

142. Ascites (Overview)

(>1.1 g/dL) (see the calculator). Spontaneous bacterial peritonitis may complicate the course of the disease. Cardiac abnormalities (eg, congestive failure, physiologic right-side heart obstruction, severe valvular regurgitation) may result in ascites. Infection may lead to excess peritoneal fluid. Appendicitis is common in patients in developed countries, whereas tuberculous fluid collections and Salmonella organisms are observed in patients in the developing world. Pancreatic ascites (either from (...) cholecystectomy. Urinary ascites in neonates is usually due to intraperitoneal bladder or ureteric or upper-tract perforation as a result of distal obstruction. Posterior urethral valves are the most common cause; [ ] for this reason, males are affected much more often than females are. Complex urinary anomalies (eg, persistent cloaca) may allow reflux of urine through the genital tract into the peritoneal cavity, without the presence of a perforation. [ ] Chylous ascites may occur in neonates

2014 eMedicine Pediatrics

143. Epididymal Tuberculosis (Diagnosis)

of infection , whereas adults seem to develop tuberculous epididymoorchitis caused by direct spread from the urinary tract. [ ] The formation of a draining sinus is uncommon in developed countries, but epididymal induration and beading of the vas are common. Involvement of the testis is usually due to direct extension. Infertility may result from bilateral vasal obstruction. Nodular beading of the vas is a characteristic physical finding, and orchitis and the resulting testicular swelling can be difficult (...) . Patients with genital and urethral TB present with a superficial tuberculous ulcer on the penis or in the female genital tract secondary to mycobacteria exposure during intercourse. The penile ulcer may cause cavernositis that extends to the urethra. This form of TB may involve the uterus and fallopian tubes, causing strictures. Consider malignancy if genital ulcers are present. Acute urethritis manifests as mycobacterial discharge and often results in chronic stricture formation. Next: Causative

2014 eMedicine.com

144. Chronic Pain Syndrome (Diagnosis)

Ovarian dystrophy or ovulatory pain Pelvic congestion syndrome Postoperative peritoneal cysts Residual accessory ovary Subacute salpingo-oophoritis Tuberculous salpingitis Reproductive disorders (uterine) Uterine reproductive disorders associated with chronic pain include the following: Adenomyosis Chronic endometritis Atypical dysmenorrhea or ovulatory pain Cervical stenosis Endometrial or cervical polyps Leiomyomata Symptomatic pelvic relaxation (genital prolapse) An intrauterine contraceptive

2014 eMedicine.com

145. Cirrhosis (Diagnosis)

America and Europe are cirrhosis, neoplasm, congestive heart failure, and tuberculous peritonitis. In the past, ascites was classified as being a transudate or an exudate. In transudative ascites, fluid was said to cross the liver capsule because of an imbalance in Starling forces. In general, ascites protein would be less than 2.5 g/dL in this form of ascites. A classic cause of transudative ascites would be portal hypertension secondary to cirrhosis and congestive heart failure. In exudative ascites (...) , fluid was said to weep from an inflamed or tumor-laden peritoneum. In general, ascites protein in exudative ascites would be greater than 2.5 g/dL. Causes of the condition would include peritoneal carcinomatosis and tuberculous peritonitis. Nonperitoneal causes Attributing ascites to diseases of nonperitoneal or peritoneal origin is more useful. Thanks to the work of Bruce Runyon, the serum-ascites albumin gradient (SAAG) has come into common clinical use for differentiating these conditions

2014 eMedicine.com

146. Atypical Mycobacterial Diseases (Diagnosis)

, Rengasamy G, Madasamy B, Kulanthaivelu A, Subramanian G. Subcutaneous aspergillosis with coexisting atypical mycobacterial infection. Indian J Pathol Microbiol . 2010 Apr-Jun. 53(2):359-60. . Seidl A, Lindeque B. Large joint osteoarticular infection caused by Mycobacterium arupense. Orthopedics . 2014 Sep. 37(9):e848-50. . Hauch A, Ory B, Paramesh A. Atypical mycobacterial infections of peritoneal dialysis catheter exit sites - a louisiana issue. J La State Med Soc . 2014 Sep-Oct. 166(5):213-6 (...) . Sporotrichoid dermatosis caused by Mycobacterium abscessus from a public bath. J Dermatol . 2000 Apr. 27(4):264-8. . Edeer Karaca N, Boisson-Dupuis S, et al. Granulomatous skin lesions, severe scrotal and lower limb edema due to mycobacterial infections in a child with complete IFN-? receptor-1 deficiency. Immunotherapy . 2012 Nov. 4(11):1121-7. . Pai HH, Chen WC, Peng CF. Isolation of non-tuberculous mycobacteria from hospital cockroaches (Periplaneta americana). J Hosp Infect . 2003 Mar. 53(3):224-8

2014 eMedicine.com

147. Pleural Effusion (Follow-up)

of conditions, including empyema; rheumatoid, tuberculous, or lupus pleuritis; malignancy; urinothorax; or esophageal rupture. [ ] Cytologic analysis ­- Especially if malignancy is suspected. In the appropriate clinical setting, Gram staining, acid­-fast bacilli staining, and culture and sensitivity for aerobic and anaerobic organisms and fungi. Additional studies should be requested on the basis of the gross appearance of the pleural fluid or when a specific condition is suspected. Procalcitonin and C (...) , and an absence of air bronchograms. A massive effusion is often attributable to an underlying malignancy. Other conditions that must be considered include the following: Congestive heart failure Tuberculosis (TB) Cirrhosis with ascites Transdiaphragmatic rupture of a liver abscess into the pleural space (>90% right-sided) Paragonimiasis (usually unilateral) Peritoneal dialysis (90% right sided) Cryptococcosis Pancreatic pseudocyst Chronic pancreatitis Meigs syndrome Uremic pleuritis Yellow nail syndrome

2014 eMedicine Emergency Medicine

148. Pericarditis and Cardiac Tamponade (Follow-up)

(all level C evidence) [ ] Pericardiectomy is the treatment mainstay of chronic permanent constriction (class I). To prevent progression of constriction, administer medical therapy for specific pericarditis conditions (ie, tuberculous pericarditis) (class I). Consider empiric anti-inflammatory therapy in the setting of transient or new diagnosis of constriction with concomitant evidence of pericardial inflammation (ie, elevated CRP or pericardial enhancement on computed tomography scan/cardiac (...) pericardiectomy. Tubercular infection is managed with the usual antituberculous chemotherapy. The 2015 updated ESC guidelines recommend consideration of intrapericardial urokinase to reduce the risk of constriction in tuberculous effusive pericarditis (class IIb, level C evidence). [ ] Controversy exists regarding the use of steroids in the treatment of tuberculous pericarditis. The ESC 2004 guideline advises using corticosteroid therapy only in patients with secondary tuberculous pericarditis, and only

2014 eMedicine Emergency Medicine

149. Pleural Effusion (Diagnosis)

of conditions, including empyema; rheumatoid, tuberculous, or lupus pleuritis; malignancy; urinothorax; or esophageal rupture. [ ] Cytologic analysis ­- Especially if malignancy is suspected. In the appropriate clinical setting, Gram staining, acid­-fast bacilli staining, and culture and sensitivity for aerobic and anaerobic organisms and fungi. Additional studies should be requested on the basis of the gross appearance of the pleural fluid or when a specific condition is suspected. Procalcitonin and C (...) , and an absence of air bronchograms. A massive effusion is often attributable to an underlying malignancy. Other conditions that must be considered include the following: Congestive heart failure Tuberculosis (TB) Cirrhosis with ascites Transdiaphragmatic rupture of a liver abscess into the pleural space (>90% right-sided) Paragonimiasis (usually unilateral) Peritoneal dialysis (90% right sided) Cryptococcosis Pancreatic pseudocyst Chronic pancreatitis Meigs syndrome Uremic pleuritis Yellow nail syndrome

2014 eMedicine Emergency Medicine

150. Mycobacterium Chelonae (Overview)

intervention involving injectable foreign materials, artificial prostheses, and implantable devices (eg, pacemakers, prosthetic valves) are at risk. [ ] Surgical site infections have ranged from sternal wound infections associated with the bone wax to plastic and reconstructive surgical infections linked to contaminated water or marking solution. [ , ] These infections have been associated with acupuncture and mesotherapy in South America. [ ] M chelonae has caused peritonitis and dialysis catheter (...) infections in peritoneal dialysis patients. [ ] It causes intravascular catheter infections of all types and is particularly common in the immunocompromised patient. The eye is the second most common site of M chelonae infection. The organism is known to cause , canaliculitis, conjunctivitis, , , and keratitis. [ ] Risk factors for infection include both accidental and surgical trauma, (LASIK), penetrating keratoplasty (PK), and all procedures involving retained biomaterial. [ ] Additional risk factors

2014 eMedicine.com

151. Atypical Mycobacterial Diseases (Treatment)

caused by Mycobacterium arupense. Orthopedics . 2014 Sep. 37(9):e848-50. . Hauch A, Ory B, Paramesh A. Atypical mycobacterial infections of peritoneal dialysis catheter exit sites - a louisiana issue. J La State Med Soc . 2014 Sep-Oct. 166(5):213-6. . Atallah D, El Kassis N, Araj G, Nasr M, Nasnas R, Veziris N, et al. Mycobacterial infection of breast prosthesis--a conservative treatment: a case report. BMC Infect Dis . 2014 May 5. 14:238. . Frisk P, Boman G, Pauksen K, Petrini B, Lonnerholm G. Skin (...) in a child with complete IFN-? receptor-1 deficiency. Immunotherapy . 2012 Nov. 4(11):1121-7. . Pai HH, Chen WC, Peng CF. Isolation of non-tuberculous mycobacteria from hospital cockroaches (Periplaneta americana). J Hosp Infect . 2003 Mar. 53(3):224-8. . Perrin C. A patient with acquired immunodeficiency syndrome (AIDS) and a cutaneous Mycobacterium avium intracellulare infection mimicking histoid leprosy. Am J Dermatopathol . 2007 Aug. 29(4):422. . Ali S, Sivak-Callcott JA, Khakoo R, Williams HJ

2014 eMedicine.com

152. Mycobacterium Chelonae (Treatment)

-Frébault V, Grimont F, Grimont PAD, et al. Deoxyribonucleic acid relatedness study of the Mycobacterium fortuitum-Mycobacterium chelonae complex. Int J System Bacteriol . 1986 Jul. 36:458-60. . Adékambi T, Berger P, Raoult D, Drancourt M. rpoB gene sequence-based characterization of emerging non-tuberculous mycobacteria with descriptions of Mycobacterium bolletii sp. nov., Mycobacterium phocaicum sp. nov. and Mycobacterium aubagnense sp. nov. Int J Syst Evol Microbiol . 2006 Jan. 56(Pt 1):133-43 (...) Jersey, 2002-2003. MMWR Morb Mortal Wkly Rep . 2004 Mar 12. 53(9):192-4. . Correa NE, Cataño JC, Mejía GI, Realpe T, Orozco B, Estrada S, et al. Outbreak of mesotherapy-associated cutaneous infections caused by Mycobacterium chelonae in Colombia. Jpn J Infect Dis . 2010 Mar. 63(2):143-5. . Song Y, Wu J, Yan H, Chen J. Peritoneal dialysis-associated nontuberculous mycobacterium peritonitis: a systematic review of reported cases. Nephrol Dial Transplant . 2012 Apr. 27(4):1639-44. . Moorthy RS, Valluri

2014 eMedicine.com

153. Cirrhosis (Treatment)

America and Europe are cirrhosis, neoplasm, congestive heart failure, and tuberculous peritonitis. In the past, ascites was classified as being a transudate or an exudate. In transudative ascites, fluid was said to cross the liver capsule because of an imbalance in Starling forces. In general, ascites protein would be less than 2.5 g/dL in this form of ascites. A classic cause of transudative ascites would be portal hypertension secondary to cirrhosis and congestive heart failure. In exudative ascites (...) , fluid was said to weep from an inflamed or tumor-laden peritoneum. In general, ascites protein in exudative ascites would be greater than 2.5 g/dL. Causes of the condition would include peritoneal carcinomatosis and tuberculous peritonitis. Nonperitoneal causes Attributing ascites to diseases of nonperitoneal or peritoneal origin is more useful. Thanks to the work of Bruce Runyon, the serum-ascites albumin gradient (SAAG) has come into common clinical use for differentiating these conditions

2014 eMedicine.com

154. Epididymal Tuberculosis (Treatment)

of infection , whereas adults seem to develop tuberculous epididymoorchitis caused by direct spread from the urinary tract. [ ] The formation of a draining sinus is uncommon in developed countries, but epididymal induration and beading of the vas are common. Involvement of the testis is usually due to direct extension. Infertility may result from bilateral vasal obstruction. Nodular beading of the vas is a characteristic physical finding, and orchitis and the resulting testicular swelling can be difficult (...) . Patients with genital and urethral TB present with a superficial tuberculous ulcer on the penis or in the female genital tract secondary to mycobacteria exposure during intercourse. The penile ulcer may cause cavernositis that extends to the urethra. This form of TB may involve the uterus and fallopian tubes, causing strictures. Consider malignancy if genital ulcers are present. Acute urethritis manifests as mycobacterial discharge and often results in chronic stricture formation. Next: Causative

2014 eMedicine.com

155. Tuberculosis of the Genitourinary System (Treatment)

of hematologic spread of infection , whereas adults seem to develop tuberculous epididymoorchitis caused by direct spread from the urinary tract. [ ] The formation of a draining sinus is uncommon in developed countries, but epididymal induration and beading of the vas are common. Involvement of the testis is usually due to direct extension. Infertility may result from bilateral vasal obstruction. Nodular beading of the vas is a characteristic physical finding, and orchitis and the resulting testicular (...) is secondary to genital TB. Patients with genital and urethral TB present with a superficial tuberculous ulcer on the penis or in the female genital tract secondary to mycobacteria exposure during intercourse. The penile ulcer may cause cavernositis that extends to the urethra. This form of TB may involve the uterus and fallopian tubes, causing strictures. Consider malignancy if genital ulcers are present. Acute urethritis manifests as mycobacterial discharge and often results in chronic stricture

2014 eMedicine.com

156. Trematode Infection (Treatment)

). Human infection with Paragonimus westermani occurs by eating inadequately cooked or pickled crab or crayfish that harbor metacercariae of the parasite (6). The metacercariae excyst in the duodenum (7), penetrate through the intestinal wall into the peritoneal cavity, and then through the abdominal wall and diaphragm into the lungs, where they become encapsulated and develop into adults (8) (7.5-12 mm X 4-6 mm). The worms can also reach other organs and tissues, such as the brain and striated muscles (...) , water bamboo, water hyacinth, and lotus Ingestion of freshwater aquatic plants that harbor metacercariae Table 3. Comparative Features of Major Human Schistosoma Species S haematobium S mansoni S japonicum Adult Body surface of male Finely tuberculate Grossly tuberculate Nontuberculate (smooth) Testes 4-6, in a cluster 6-9, in a cluster 7, in a linear series Position of ovary Posterior to middle of body Anterior to middle of body Posterior to middle of body Number of eggs in uterus 20-30 1-4 50-300

2014 eMedicine.com

157. Pericarditis, Constrictive-Effusive (Overview)

that in patients with tuberculous pericardial effusion, right atrial pressure and interleukin-10 (IL-10) levels were higher in those with effusive-constrictive pericarditis. The study included 68 patients with tuberculous pericardial effusion, 36 of whom had effusive-constrictive pericarditis. The investigators determined that the latter group had a right atrial pressure of 17.0 mmHg, versus 10.0 mmHg in the other patients, prior to pericardiocentesis. In addition, the serum and pericardial concentrations (...) of IL-10 were 38.5 and 84.7 pg/mL, respectively, in the patients with effusive-constrictive pericarditis, compared with 0.2 and 20.4 pg/mL, respectively, for the patients with nonconstrictive tuberculous pericardial effusion. [ ] Effusive-constrictive pericarditis may be part of a clinical continuum. Stages of infective pericarditis have been observed that range from acute pericarditis and tamponade with effusion to constrictive pericarditis without effusion. Effusive-constrictive pericarditis

2014 eMedicine.com

158. Pericardial Effusion (Overview)

). (See , , , and .) This image is from a patient with malignant pericardial effusion. Note the "water-bottle" appearance of the cardiac silhouette in the anteroposterior (AP) chest film. Embryology In the human embryo, the pericardial cavity develops from the intraembryonic celom during the fourth week. The pericardial cavity initially communicates with the pleural and peritoneal cavities, but during normal development these are separated by the eighth week. The visceral and parietal pericardium (...) , which is associated with effusions in other body cavities The most common cause of and myocarditis is viral. Common etiologic organisms include coxsackievirus A and B, and hepatitis viruses. Other forms of infectious pericarditis include the following: Pyogenic - Pneumococci, streptococci, staphylococci, Neisseria , Legionella species Tuberculous Fungal - Histoplasmosis, coccidioidomycosis, Candida Syphilitic Protozoal Parasitic Neoplastic Neoplastic disease can involve the pericardium through

2014 eMedicine.com

159. Pleural Effusion (Overview)

); this is known as "trapped lung" (eg, extensive atelectasis due to an obstructed bronchus or contraction from fibrosis leading to restrictive pulmonary physiology) Decreased lymphatic drainage or complete lymphatic vessel blockage, including thoracic duct obstruction or rupture (eg, malignancy, trauma) Increased peritoneal fluid with microperforated extravasation across the diaphragm via lymphatics or microstructural diaphragmatic defects (eg, , cirrhosis, peritoneal dialysis) Movement of fluid from (...) squeezed out of the pleura as a result of an imbalance in hydrostatic and oncotic forces in the chest. However, other mechanisms of injury may include upward movement of fluid from the peritoneal cavity or, in iatrogenic cases, direct infusion into the pleural space from misplaced (or even migrated) central venous catheters or nasogastric feeding tubes. Transudates are caused by a small, defined group of etiologies, including the following: Congestive heart failure Cirrhosis (hepatic hydrothorax

2014 eMedicine.com

160. Abdominal Hernias (Follow-up)

hernia is generally safe, failure to reduce is not infrequent and mandates prompt exploration. Signs of inflammation or obstruction should rule out attempts at reduction. Difficult reduction should promptly be followed by repair. Unintentional reduction of the intestine with vascular compromise leads to perforation and peritonitis with high morbidity and mortality. En masse reduction after vigorous attempts at reducing a hernia with a small fibrous neck results in ongoing compromise of the entrapped (...) (particularly the fallopian tube and ovary) may not be reducible into the peritoneum. The walls must then be inspected for a sliding component. To repair a sliding hernia, the sac is ligated distal to the fallopian tube and divided. The proximal sac is ligated and then invaginated into the peritoneal cavity. A purse-string suture inside the opened hernia sac may be used to aid in visualization during sac closure. The internal ring is closed with sutures from the transversalis fascia to the iliopubic tract

2014 eMedicine Surgery

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