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Tuberculous Peritonitis

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141. Virtual Reality Biofeedback in Chronic Pain and Psychiatry (Overview)

remnant syndrome 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

2014 eMedicine.com

142. 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

143. 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

144. 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

145. 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

146. 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

147. 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

148. Pericarditis, Constrictive-Effusive (Follow-up)

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

149. Pericarditis, Acute (Follow-up)

) [ ] 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 magnetic resonance imaging) (class IIb (...) 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 as an adjunct

2014 eMedicine.com

150. Pericarditis, Uremic (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.com

151. Pleural Effusion (Follow-up)

of effusion, and more rapid improvement in quality of life, compared with 31 patients choosing talc pleurodesis. [ ] Tuberculous pleuritis Tuberculous pleuritis is typically self-limited. However, because 65% of patients with primary tuberculous pleuritis reactivate their disease within five years, empiric anti-TB treatment is usually begun pending culture results when sufficient clinical suspicion is present, such as an unexplained exudative or lymphocytic effusion in a patient with a positive PPD (...) analysis of pleural, peritoneal and pericardial effusions. Clin Chim Acta . 2004 May. 343(1-2):61-84. . Kolditz M, Halank M, Schiemanck CS, Schmeisser A, Hoffken G. High diagnostic accuracy of NT-proBNP for cardiac origin of pleural effusions. Eur Respir J . 2006 Jul. 28(1):144-50. . Porcel JM, Martinez-Alonso M, Cao G, Bielsa S, Sopena A, Esquerda A. Biomarkers of heart failure in pleural fluid. Chest . 2009 Sep. 136(3):671-7. . Wilcox ME, Chong CA, Stanbrook MB, Tricco AC, Wong C, Straus SE. Does

2014 eMedicine.com

152. Mycobacterium Chelonae (Follow-up)

-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. Epididymal Tuberculosis (Follow-up)

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

154. Trematode Infection (Follow-up)

metacercariae. This is the infective stage for the mammalian host (5). 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 (...) , and Polypylis Freshwater plants such as water caltrops, water chestnut, 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

2014 eMedicine.com

155. 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

156. Tuberculosis (Follow-up)

, or axillary lymph nodes. Typically, infected lymph nodes are firm and nontender with nonerythematous overlying skin. The nodes are initially nonfluctuant. Suppuration and spontaneous drainage of the lymph nodes may occur with caseation and the development of necrosis. A study reported on the accuracy and safety of endobronchial ultrasound (EBUS) transbronchial needle aspiration (TBNA) for the diagnosis of tuberculous mediastinal lymphadenitis. The study concluded that EBUS-TBNA is a safe and well (...) node tissue, bone marrow, blood, liver, cerebrospinal fluid (CSF), urine, and stool may be useful, depending on the location of the disease. Decontamination of other microorganisms in the specimens obtained may be performed by the addition of sodium hydroxide, usually in combination with N -acetyl- L -cysteine. Other body fluids (eg, CSF, pleural fluid, peritoneal fluid) can also be centrifuged; the sediment can be stained and evaluated for presence of acid-fast bacilli (AFB). CSF smear results

2014 eMedicine Pediatrics

157. 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

158. Tuberculosis (Treatment)

, or axillary lymph nodes. Typically, infected lymph nodes are firm and nontender with nonerythematous overlying skin. The nodes are initially nonfluctuant. Suppuration and spontaneous drainage of the lymph nodes may occur with caseation and the development of necrosis. A study reported on the accuracy and safety of endobronchial ultrasound (EBUS) transbronchial needle aspiration (TBNA) for the diagnosis of tuberculous mediastinal lymphadenitis. The study concluded that EBUS-TBNA is a safe and well (...) node tissue, bone marrow, blood, liver, cerebrospinal fluid (CSF), urine, and stool may be useful, depending on the location of the disease. Decontamination of other microorganisms in the specimens obtained may be performed by the addition of sodium hydroxide, usually in combination with N -acetyl- L -cysteine. Other body fluids (eg, CSF, pleural fluid, peritoneal fluid) can also be centrifuged; the sediment can be stained and evaluated for presence of acid-fast bacilli (AFB). CSF smear results

2014 eMedicine Pediatrics

159. Mesenteric Adenitis

28. 12(24):3933-5. . Patlas MN, Alabousi A, Scaglione M, Romano L, Soto JA. Cross-sectional imaging of nontraumatic peritoneal and mesenteric emergencies. Can Assoc Radiol J . 2013 May. 64(2):148-53. . Benetti C, Conficconi E, Hamitaga F, Wyttenbach M, Lava SAG, Milani GP, et al. Course of acute nonspecific mesenteric lymphadenitis: single-center experience. Eur J Pediatr . 2018 Feb. 177 (2):243-246. . Gross I, Siedner-Weintraub Y, Stibbe S, Rekhtman D, Weiss D, Simanovsky N, et al (...) RG. Incidentally detected misty mesentery on CT: risk of malignancy correlates with mesenteric lymph node size. J Comput Assist Tomogr . 2012 Jan-Feb. 36(1):26-9. . Koning JL, Naheedy JH, Kruk PG. Diagnostic performance of contrast-enhanced MR for acute appendicitis and alternative causes of abdominal pain in children. Pediatr Radiol . 2014 Aug. 44 (8):948-55. . Borgia G, Ciampi R, Nappa S, et al. Tuberculous mesenteric lymphadenitis clinically presenting as abdominal mass: CT and sonographic

2014 eMedicine Radiology

160. 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

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