Since the recognition of the disease by Corbin in 1973, only 0.1-0.6% of all removed appendices have been reported to be the site of primary isolated tuberculosis .
As Sir William Mayo had said, it is ironical as to how an area of extensive lymphatic tissue is so rarely involved as the primary site of tuberculosis. As the pre-operative symptoms are similar to that of acute pyogenic appendicitis, it is almost impossible to diagnose this condition without confirmatory histopathological examination.
Keeping in mind the extreme incidence of tuberculosis in the Indian subcontinent, we report a case of a female patient who came with the classical complaints of acute appendicitis and the treatment modality followed with the eventual diagnosis of tubercular appendicitis.
Mrs XY, a 47-year old female, came to the emergency services of KEM hospital with complaints of pain in right iliac fossa for3 days. The pain was severe and colicky in nature, not relieved by analgesics. She also had several bouts of vomiting. There was no history of fever, constipation, diarrhea or any urinary complaints. The patient had no history of respiratory complaints and no prior history of tuberculosis.
Physical examination revealed a moderately distressed woman, with temperature of 98.4 ̊F, pulse rate 100/min and blood pressure of 110/70. On abdominal palpation, tenderness was elicited in the right iliac fossa. Rebound tenderness and muscle guarding were present with audible bowel sounds. Rest of the examination was normal.
INVESTIGATIONS:Routine hematological and biochemical investigations were within normal limits except for slightly raised total leucocyte count (10,600/ml). Ultrasound and CT findings were consistent with that of acute appendicitis.
The patient was allotted an Alvarado score of 8 and taken up for surgery. Intra operatively the appendix was retrocaecal in position and adherent to the caecum. On releasing the appendix it was found to be inflamed with no obvious signs of perforation.
The rest of the surgery was unremarkable. The histopathological examination of the specimen revealed the presence of caseating granulomas, epitheloid cells and Langhans giant cells, characteristic of tuberculous inflammation.
Post-operative X-Ray and sputum examination excluded the presence of a pulmonary focus of primary infection. Attempts to identify another primary focus of infection were unsuccessful. Post-surgery patient had an uneventful course and was discharged on day 7.
She was started on a four-drug anti tubercular therapy as per WHO guidelines and asked to attend a follow-up clinic every month. At present, the patient has completed five months of anti-tubercular therapy and is asymptomatic.
Fig. 1 Tubercular appendicitis - Langhan giant cell characteristic of tubercular inflammation.
Discussion:With tuberculosis (TB) being endemic to our country, cases of extensively-drug-resistant TB are becoming more prevalent, and this means early diagnosis is necessary along with institution of the requisite anti-TB medications. Every surgeon must observe the intra-operative findings, and correlate them with clinical symptoms to reach a probable diagnosis so that early treatment can be started. Every resected appendix must be subject to histopathological examination.
The clinical spectrum of appendicular tuberculosis varies from local to systemic manifestations. Commoner of the two, the chronic form presents as intermittent lower abdominal pain with diarrhea, vomiting and low grade fever . The acute form presents either independently, or superimposed on chronic form, similar to an attack of acute pyogenic appendicitis. The latent form is more often than not, diagnosed during post-mortem.
There may be primary involvement of the appendix in 0.1-3% cases or secondary involvement (to ileo-caecal or genital tuberculosis) in 1.5-3% cases .
Primary involvement of the appendix is considered when no other focus of infection is detected on thorough investigation including laparotomy.
The probable cause of such infection is direct contact with food particles containing tubercle bacilli or a distal focus of sub-clinical infection. Causes of secondary involvement include: local extension of ileocaecal tuberculosis; retrograde lymphatic spread from distant lesions in the ileum or ascending colon and appendicular serositis/periappendicitis in peritoneal tuberculosis .
Detecting the etiology of appendicitis is also important because of the risk of post-operative fistula. After appendectomy, the main causes of such a fistula are appendicular tuberculosis, actinomycosis, regional enteritis and carcinoma colon. A tuberculous fistula will usually respond to specific chemotherapy.
Post-operatively, histopathological examination of the surgically-removed appendix is the most reliable method of diagnosing such a case. On diagnosis, these patients must be started on anti-tubercular treatment to prevent recurrence of this disease elsewhere in the body.
1.Shah RC, Mehta KN, Jullundwalla JM. Tuberculosis of appendix. J Indian Med Assoc 1967; 49: 138-40.
2.Singh MK, Arunabh, Kapoor VK. Tuberculosis of the appendix – a report of 17 cases and a suggested etiopathological classification. Post grad Med J 1987; 63: 855-7.
Garima Dahiya, Undergraduate
Abhijit Shridhar Dhale, Senior Resident
Jignesh A Gandhi, Unit Chief, General Surgery
Seth G.S. Medical College and KEM Hospital,Email for correspondence: [email protected]