大韓放射線햄學會誌 第 24 卷 第 4 號 pp. 645 - 647, 1988 Journal of Korean Radiological Society, 24(4) 645 - 647, 1988

Primary Peritoneal Tuberculosis Presenting as a Huge Cystic Mass

- A Case Report-

Yul Lee, M.D. , Jong SUp Yoon, M.D.

Department of Radiology, Co l1ege of Medicine, Hal1ym University

〈국문초록〉

거대 낭성종괴 소견을 보인 원발성 복막강 결핵

-증례보고-

한립 대학 의학부 방사선과학교실

01 열·윤 := i

= A세 I=f

위 장판계 의 침뱀 이 없는 원말성 복악강 결핵의 진단에는 아직 많은 어려움이 있마. 이 질환의 CT 및 초음파촬영소견 둥이 보고되고 있지만 내부분 수술 및 영러 조직 검사로 확신되 고 있다. 저자들은 거의

복강 전체를 차지하는 커다란 낭성 종괴의 소견을 보인 원발성 복막강 결핵을 경험하였기에 보고하는

바이 마.

Introduction

Primary peritoneal tuberculosis without involve­

ment of gastrointestinal tract is still a diagnostíc

problem. Though peritoneal tuberculosis has be­

come an uncommon disease in developed coun­

tries , it is occasionally encountered in endemic

areas. Various CT and sonographic findings of

peritoneal tuberculosis have been reported but

they are not characteristic and many cases could

be confirmed by laparotomy and pathologic ex­

amination . We report a case of peritoneal tubercu­

losis presenting as a huge cystic mass with a

fluid-fluid level and multiple internal solid mate-

이 논운은 1 988년 6월 30일에 접 수하여 1988년 7월 27일 에 채 택되었음. Received June 30, Accepted July 27 , 1988

rials.

Case Report

A 23 year old male patient presented with prog­

ressive abdominal distension for 7 years. On

physical examination a large protruding mass was

palpated in the abdomen which was firm , not ten­

der, not movable . Routine laboratory examina­

tions including chest X-ray were all normal. Ultra­

sonography showed a large cystic mass in the

abdomen. Multiple variable sized solid

hyperechoic materials were noted in the depen­

dent portion of the mass . A sharply delineated

fluid-fluid level was noted in the mass , upper part

was anechoic and lower part was hypoechoic(Fig.

lA). CT also demonstrated a cystic mass measur­

ing about 12x18x20cm in the abdomen. Ascending

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- 大韓放射線뽑學會誌 : 第 24 卷 第 4 號 1988 -

colon and small bowel were posterolaterally dis­

placed suggesting intraperitoneal location of the

mass. Multiple soft tissue density materials were

also noted in the mass some of which contained

caIcifications . But the fluid-fluid level which was

noted on sonography was not demonstrable on

CT(Fig. 1B). U.G. I., small bowel series and co­

lon study demonstrated only displaced bowels wi­

thout mucosal abnormality(Fig. l C). Preoperative

radiological diagnosis was an intraperitoneal cystic

tumor such as cystic Iymphangioma. At lapar­

otomy an intraperitoneal cystic mass was removed.

The capsule adhered densely to the peritoneum

and the mesentery. About 3000cc dark brownish

colored fluid was evacuated from the cyst and

muItiple yellowish soft tissue materials were also

found in the mass , some of which contained caIci-

Fig. lA. Abdominal sonography. A large cystic mass containing multiple internal hyperechoic solid materials. N ote a sharply delineated fluid-fluid level in the cystic portion of the mass; The upper part is anechoic and the lower part is hypoechic

Fig. lB . Abdominal CT , A well encapsulated cystic mass containing multiple partly calcified soft tissue density materials in the depen­dent portion. Posterolateral displacement of bowel loops suggest intraperi tonc:al location 。 f the mass. The fluid-fluid level which was noted on sonography is not shown

Fig. lC. Delayed film of small bowel series. Small bowel and colon are displaced by the mass but mucosal abnormality is not noted

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Yul Lee. et al.. Primary Peritoneal Tuberculosis Presenting as a Huge Cys tic Mass-

fications. Adjacent mesentery was diffusely thick- Usually the caseation necrosis of tuberculosis is

ened and several enlarged mesenteric lymph nodes cheese-like material , but sometimes it can solidify

were also found. Both the cystic mass and mesen- with or without calcifications and sometimes li-

teric lymph nodes were confirmed to be tuberculo- quify acquring a more fluid- like consistencyB). Our

sis on pathologic examination. case showed the possible different states of casea­

tion necrosis in peritoneal tuberculosis especially

Discussion

Peritoneal tuberculosis may occur without gas­

trointestinal tract involvement. Bhansali et al. re­

ported that among the 300 cases of abdominal

tuberculosis up to one thirds of patients had Iym­

phadenopathy or peritoneal disease without

alimentary canal involvement1) . Peritoneal tuber­

culosis on CT may produce some abnormalities

such as enlarged mesenteric lymph nodes , high

density ascites , diffuse peritoneal enhancement

and omental or mesenteric masses2-4

). Sonogra­

phy can also demonstrate ascites and abdominal

masses of variable echogenecity3 ,5). Among these

manifestations of peritoneal tuberculosis the in­

traabdominal mass or abscess type of presentation

may be a more difficult diagnostic problem be­

cause enlarged mesenteric lymph nodes , omental

or mesentric thickening , matted loops of bowels

all can be demonstrated as a mass on CT or

sonography with variable shape , CT No. or

echogenecity3,6)

The centrallow low density of tuberculous lym­

phadenopathy has been well known but it is not

charaeteristic for tuberculosis because it may be

found occasionally in metastatic malignancy , lym­

phoma , pyogenic infection and Whipple’s

disease2 ,7). Our case was such a huge mass that

preoperative diagnosis was a cystic tumor and

tuberculosis was not included in differential di­

agnosis. The fluid-fluid level which was noted on

sonography in our case has not been previously

described on the literature to o ur knowledge . It

was probably due to the different components of

the cystic fluid that could be delineated on

sonography , not on CT

on sonography: supernatent anechoic fluid , depen­

dent hypoechoic fluid and hyperechoic solid mate-

rials.

Our case is very unusual for peritoneal tubercu­

losis but in view of the protean clinical and

radiological manifestations , the possibility of peri­

toneal tuberculosis could be considered even with

cystic tumor-like appearance in endemic areas.

For there is an effective chemotherapy so good

prognosis can be expected if promptly diagnosed , but misdiagnosis of peritoneal tuberculosis is

traglc

REFERENCES

1. Bhansali SK: Abdominal tuberculosis: experiences

with 300 cases. A]R 67:324-337, 1977

2. Hulnick DH , Megibow A] , Naidich DP et al: Abdo­

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157'199-204 , 1985

3. Ebstein BM , Mann ]H: CT o[ abdominal tuberculo­

sis. A]R 139.'861 -866, 1982

4. Dahlene DH , ]r. , Stanley R] , Koehler RE et al

Abdominal tuberculosis: CT findings. ] comput

Assist Tomogr 8:443-445, 1984

5. Borgia G, Ciampi R, Nappa S et al: T.uberculous

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Clin UItrasound 13:491-493, 1985

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9:961-963, 1985

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4.630-633, 1980

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855-856, Mosby, S t. Louis, 1985

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