Indian Journal of Surgery Medknow Publications on behalf of Association of Surgeons of India ISSN: 0972-2068 Vol. 65, Num. 5, 2003, pp. 440-441

Indian Journal of Surgery, Vol. 65, No. 5, Sept-Oct, 2003, pp. 440-441

Case Report

Primary biliary tuberculosis - an unusual case

J. S. Pandya, Jaydeep H. Palep, Nandita B. Shinkre, Nitin N. Patil, Vandana A. Palan

B. Y. L. Nair Ch. Hospital and T. N. Medical College, Mumbai.
Address for correspondence: Dr. Pandya J. S., B/101, Gokul Monarch, Thakur Complex, Kandivili (E), Mumbai 400101.E-mail: pandya_sv@yahoo.com

Paper Received: July 2001. Paper Accepted: August 2002. Source of Support: Nil.

How to cite this article: Pandya JS, Palep JH, Shinkre NB, Patil NN, Palan VA. Primary biliary tuberculosis - an unusual case. Indian J Surg 2003;65:440-1.

Code Number: is03090

ABSTRACT

A 25-year-old woman presented with intermittent pain in the right hypochondrium, and low-grade fever of six months duration. A diagnosis of acute on chronic cholecystitis was made. On exploratory laparotomy, the gall bladder was filled with pus and stones. A diagnosis of tuberculosis was made postoperatively by sending the pus for microbiological, and gall bladder for histopathological examination. The pus grew acid-fast bacilli. On culture, the pus and the stone grew mycobacterium tuberculosis. Anti-tubercular therapy resulted in complete recovery.

Key Words: Tuberculosis, Gall bladder.

INTRODUCTION

Tuberculosis infection of the biliary tract is extremely rare. Bergdahl and Proquist reviewed the world literature in 1972 and reported three cases of tuberculous cholecystitis.¹ Subsequently, it has been reported in India,^2,3 which cases included isolated biliary tuberculosis.⁴ We report an unusual presentation of isolated biliary tuberculosis where the stone and the pus grew mycobacterium tuberculosis.

CASE REPORT

A 25-year-old woman presented with intermittent pain in the right hypochondrium, low-grade fever and loss of weight of six months' duration. Systemic examination was unremarkable. Haematological investigations revealed an ESR of 80 mm/ hr but were otherwise normal. Ultrasonography revealed multiple gallstones with thinning of the wall. The common bile duct was normal. Preoperative radiogram of the chest was normal. At surgery, the gallladder was found to be filled with pus and stones. The pus was sent for microbiological examination and the exicsed gallbladder and the gallstones for histopathological examination. Histopathology of the gallbladder did not show any evidence of tuberculosis. However, the pus showed the presence of acid-fast bacilli (AFB). Subsequently, the calculi were examined for AFB, and showed microcolonies of AFB. Both pus and gallstones were cultured and grew mycobacterium tuberculosis (M. tuberculosis). There was no evidence of tuberculosis in the rest of the gastrointestinal tract. The patient was treated with antitubercular therapy and responded well to it.

DISCUSSION

Clinical studies show that gallstones may be of pathogenic significance in the development of the tuberculosis of the gallbladder.¹ Of the 44 cases reviewed by Bergdahl and Proquist only two seem to be acalculous; in one of these patients the gallbladder was filled with caseous material.³ It has been hypothesized that the bacilli reach the gallbladder by haematogenous route, via the lymphatics, by ascending / descending infection via the biliary passage or by direct extension from a neighbouring focus. In the last scenario the serosa will be primarily affected. Our case had no evidence of tuberculosis elsewhere and can be assumed to be primary biliary tuberculosis. When the bacilli travel by ascending infection through the biliary passages they form a nidus for the stone formation. Around the bacilli, multiple layers are laid down which leads to the formation of the stone. Also, the bile becomes infected with the presence of the bacilli. It has been suggested that cystic duct obstruction leads to the disappearance of the bile acids from the gallbladder and to a lowered resistance against tuberculous bacilli. The postulated theory may be able to explain why in our patient the gallbladder was normal and the pus and the stones grew colonies of M. tuberculosis.

REFERENCES

1. Bergdahl L, Boquist L. Tuberculosis of the gall bladder. Br J Surg 1972;59:289-92
2. Akhtar Amina, Zarger HU, Kaul HK, Bhan Brijmohan. Tuberculosis of the gall bladder. Indian Journal of Surgery 1975;37:218-20.
3. Misgar, Kariholu PL, Bhat DN, Fazili F, Yousuf M, Muhajid S. Tuberculosis of the gall bladder. J Indian Med Assoc 1980;74:196-97
4. Gupta NM, Chaudhary A, Talwar BL. Isolated biliary tuberculosis: Asian Med J 1985;(10):Vol 28:636-40
5. Rankin Fred W, Massie Francis ML. Tuberculosis of the gall bladder. Ann Surgery 1926;83:800-806.

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