1. SALHI.K 1 ; AYAT.A 1 ;HELLARA.A 1 ;JERBI.S 2 ;MAHJOUB.B 1 ;BOUSSOFFARA.R 1 ; HAMZA.AH 2 ; SOUA.H; MT.SFAR 1. 1 Service de Pediatrie CHU Taher Sfar Mahdia 2 Service de Radiologie CHU Taher Sfar Mahdia GI7

2. INTRODUCTION:  The peritoneum is one of the locations outside the most common pulmonary tuberculosis.  Peritoneal tuberculosis poses a public health problem in endemic regions of the world.  The diagnosis is difficult and still remains a challenge : insidious nature, variability of presentation and limitations of available diagnostic tests.  We report a case of an adolescent girl who was diagnostic with this disease.

3. Patients and Methods:  A 14 years old girl admitted with a chronic diarrhea since 4 months,weakness,decreased appetie and weight loss.  Physical examination showed : A pale girl. Fever (38.7°). Painful abdomen. No organomegaly or lymphomegaly.  We completed with a biologic and radiologic investigation.

4. Results:  Laboratory investigation revealed: elevated erythrocyte sedimentation rate(110/130) anemia (Hb=8.7g/dl), high CRP (97mg/l). All other routine biochemical tests, celiac serology,anti Dnatif, antinuclear anticorps were within the normal range in the serum. The BK search was negative.

5. Results:  The chest X ray was normal.  Abdominal ultrasonographie showed a little ascite.  TDM showed: ascite. small bowel thichening. Multiples necrotic lymphadenopathy. liver nodule (22 mm in the segment IV)

6. Results:  laparotomy  multiple smalls nodules and fibrotic adhesive bands covering peritoneal surfaces compatible with peritoneal tuberculosis later confirmed histologically (caseating granulomas)  The girl was treated with quadritherapie : Rifampicine, Izoniasid, Pyrazinamide and Ethambutol during 4 months.  There were no clinical amelioration, and a cutaneous fistulas appeared.

7. Results:  Myelogramme  was normal.  A second abdominal TDM: showed the persistence of the same pathologie and appearing of cutaneous fistulas.  we suspected a multidrug resistant tuberculosis so we added ofloxacine, Amikacine and corticotherapie.  After 1 month the patient became more better.

8. Results: Small bowel thikhening Ascite Abdominal TDM of our patient

9. DISCUSSION :  Peritoneal tuberculosis is predominantly a disease of young adults between 21-40 years old with an equal sex incidence.  Tuberculosis bacteria reachs the gastrointestinal tract via: Haematogenous spread Ingestion of infected sputum Direct spread from infected contiguous lymph nodes or fallopian tubes

10. DISCUSSION :  Peritoneal tuberculosis occurs in three forms :  Wet type with ascitis+++  Dry type with adhesions.  Fibrotic type with omental thickening and loculated ascites.  It is commonly manifested by : abdominal pain, diarrhea, fever, weight loss, and anemia.  Laboratory Findings are:  Anemia, elevated sedimentation rate, high CRP.  Elevated CA-125

11. DISCUSSION :  Chest X ray  search a pulmonary tuberculosis.  Ultrasonographie  ascites, lymphadenopathy, omental thickening and caking.  TDM  Three main types :  Wet Type Peritonitis : Is the most common type of peritonitis (90% ). Free or loculated ascites, Usually slightly hyperattenuating (20–45 HU) relative to water due to its (high protein and cellular content).

12. DISCUSSION : Wet type tuberculous peritonitis. Contrast-enhanced CT scan shows ascites (arrows) that is hyperattenuating relative to urine within the bladder (arrowheads)

13. DISCUSSION :  Fibrotic Type Peritonitis: It accounts for 60% of cases of peritonitis. It manifests as mottled low-attenuation masses with nodular soft-tissue thickening.  Dry Type Peritonitis : Is seen in 10% of cases. Characterized by mesenteric thickening, fibrous adhesions, and caseous nodules. Its imaging manifestations are highly suggestive of, but not specific for, tuberculosis.

14. DISCUSSION : Fibrotic type tuberculous peritonitis. CT scan obtained with oral and intravenous contrast material shows omental caking (arrowheads) with thickening of the underlying small bowel (*).

15. DISCUSSION :  Peritoneal Biopsy : 85-95% Sensitive Performed by: - laparoscopic guidance or minilaparotomy - exploratory laparotomy.  Caseating Granulomas Langerhans Type Giant Cells.  Microbiology  Ziehl-Neelsen Stain

16. Treatment  Same treatment as pulmonary TB Four drug regimen: – Isoniazid – Rifampicin – Ethambutol – Pyrazinamide  Quadritherapie during 2mounths than bitheraphie during 4moutns(Isoniazide+Rifampicin)

17. Conclusion :  The diagnostic of peritoneal tuberculosis is difficult.  It presents with nonspecific symptoms. laboratory investigations may not be helpful.  Radiologic investigation and laparotomy help to get the diagnostic and to treat early affected patients.