A benign cause of Sister Mary Joseph's nodule: Abdominal tuberculosis

A benign cause of Sister Mary Joseph's nodule: Abdominal tuberculosis: Vishal Sharma, Sobur Uddin Ahmed, Harshal S Mandavdhare



The International Journal of Mycobacteriology 2017 6(3):321-321



A 22-year-old male patient presented with a 3-month history of fever, pain abdomen, abdominal distension, loss of weight, and appetite. The patient also complained of episodes suggestive of intestinal obstruction. On examination, the patient had distended abdomen, palpable bowel loops, and an umbilical nodule [Figure 1]a. Contrast-enhanced computed tomography showed the presence of ascites, omental nodularity, clumped bowel loops with mural thickening and mesenteric lymphadenopathy, and the umbilical nodule [Figure 1]b. Mantoux skin test was positive (25 mm × 20 mm). Fine-needle aspiration from the umbilical nodule showed inflammatory changes, but no granuloma or acid-fast bacilli (AFB) were seen. Ascitic tap showed a straw-colored fluid with serum ascites albumin gradient of 0.6 g/dL and an adenosine deaminase value of 86 U/L, and the cytological examination for malignant cells was negative. The diagnosis of probable abdominal tuberculosis was established on the basis of consistent clinical, radiological findings, positive Mantoux test, and elevated adenosine deaminase in ascitic fluid. The patient was started on four-drug anti-tubercular therapy and at 2 months showed improvement in symptoms, gain of weight, and disappearance of umbilical nodule.

Figure 1: (a) Umbilical nodule and (b) computed tomography showing matted bowel loops and the umbilical nodule Click here to view

Nodular lesion of umbilicus can be caused by both benign and malignant etiology. Malignant umbilical nodules, called as Sister Mary Joseph's nodules is considered as the peripheral manifestation of advanced intra-abdominal malignancy caused by metastasis from tumors such as carcinoma stomach, pancreatobiliary carcinoma, colorectal carcinoma, carcinoma of female genital tract, cholangiocarcinoma, hepatocellular carcinoma, gall bladder carcinoma, malignant gastrointestinal stromal tumor, and primary peritoneal carcinoma.^[1],[2] Although in our patient the nodule did not demonstrate any AFB or granuloma, the appearance with other changes suggestive of abdominal tuberculosis and disappearance with antitubercular therapy suggest that extension of peritoneal inflammatory changes due to tuberculosis may have contributed to its genesis. The diagnosis of abdominal tuberculosis is often difficult, and the positivity of microbiological findings (AFB and granuloma) is often low in ascites and tissue specimen.^[3] Indeed, the utility of adenosine deaminase (>39 U/L) in ascites has been recommended for the diagnosis by recent guidelines.^[4] Further response to therapy, as seen in our patient with gain of weight and resolution of nodule and ascites within 2 months of treatment, is also recognized to have diagnostic utility (Logan's modification of Paustian criteria).^[5] To our knowledge, this is the first reported case of umbilical nodule caused by abdominal tuberculosis.

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Conflicts of interest

There are no conflicts of interest.

 

References

1.	Tsai CC, Hsieh CF, Hung CC, Chao CM, Lai CC. Sister Mary Joseph nodule. QJM 2015;108:983.
2.	Powell JL. Powell's pearls: Eponyms in medical and surgical history. Sister Joseph's Nodule; Sister Mary Joseph (1856-1939). J Surg Educ 2011;68:442-3.
3.	Sanai FM, Bzeizi KI. Systematic review: Tuberculous peritonitis – Presenting features, diagnostic strategies and treatment. Aliment Pharmacol Ther 2005;22:685-700.
4.	INDEX-TB Guidelines: Guidelines on Management of Extra Pulmonary Tuberculosis of India; 2016. p. 11-4.
5.	Logan VS. Anorectal tuberculosis. Proc R Soc Med 1969;62:1227-30.

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