Positive PPD negative Quantiferon, still TB?

My 12 year old has been very ill for 7 months. His symptoms are severe lethargy, night sweats, weight loss (21lbs) and the biggest problem, severe pain in his abdomen. He has rebound tenderness and usually right quadrant pain, though it is also at times in the middle of his abdomen, near his belly button. He had his appendix out about two years ago, and the doctor after told us she doubted it was true appendicitis, but that he had alot of ascities in his belly. His symptoms began with chest pain, we took him to the emergency room and he was x-rayed. The ER doc said he had "increased opacity at the right lung base, worrisome for infiltrate" his white blood count was 8.5 and the report says "a little lymphocytic predominance". He was put on Zythromax. Since then the pain migrated to his abdomen, no longer in his chest. He has become sicker and sicker, and is now admitedi n the hospital. He is not able to eat much as the pain in intolerable, and he has lost his appitite. The only blood results that are abnormal are Lymphocytes -47.5, Eosiniphil-10, Basophil-1.5, Bun/ Creat Ratio-18, Alkaline Phosphatase 162. Immediatly prior to becoming ill he broke 3 bones about 1 month apart,in minor play. A cat scan revealed Mesenteric Adenitis, but that's all. Last week his PPD for TB came back positive at 12 mm. At first the doctors were going to treat for TB, but they did an acid fast stain and Quantiferon that both came back negative. He had a colonoscopy today, which the GI doc thinks looks fine, no indication of TB. With TB being the ONLY diagnosis we've had in the 7 months my child has be severlly ill, is it still posible he has TB, with a neg stain and Quantiferon? He has no cough, his chest x-ray is fine, the pain is ONLY in his abdomen. Any thoughtsyou could give that I can pass on to the doctors is much appreciated. I'm teriffied of him being discharged with no diagnosis.

[David Tinkelman, M.D.]

Your description of your son’s progressively worsening illness suggests a dire situation, one in which there is an urgent need to quickly establish a definite diagnosis and begin appropriate therapy.  

The source of your son’s problem could be infection and, yes, the diagnosis could be peritoneal tuberculosis (even with a normal colonoscopy)  It could also be secondary to other infectious agents; one, in particular has been associated with an organism called Yersenia Pseudotuberculosis, a characteristic feature of which is enlargement of mesenteric lymph nodes.  Of non-infectious diseases, your son could have Crohn’s disease, a chronic inflammation of small bowel.  Or the problem could be some type of treatable tumor, with spread to the enlarged nodes. These are just examples.

There are many possibilities but there is no time to waste speculating what they might be.  The information you have provided suggests that the answer lies within your son’s abdomen, whatever the cause may be.  Specimens from the abdomen, such as lymph node biopsy or abdominal fluid (ascites) may provide the diagnosis.  These specimens can be obtained by conventional exploratory abdominal surgery or by a less invasive procedure called Peritonoscopy, the placement of an instrument through a small incision in the abdominal wall through which the doctor can visualize abdominal organs, lymph nodes, abdominal fluid (ascites) and take specimens from any of these tissues.  This examination should be performed only by a physician, very familiar with the technique, and very experienced with the performance of it:  usually a surgeon or gastroenterologist.

If this examination is performed, all tissues obtained should be stained and cultured for a variety of microbial organisms, including but not limited to TB and fungi.

Should the diagnosis be a tuberculous infection, consultation with an Infectious Disease specialist with a special interest in the treatment of the various types of TB would be ideal.

Whatever you elect to do at this time, do not delay any longer.  You may want to share the above considerations  and the citation below with one or more of your son’s doctors.

Good luck.  Please let us know how things go.


Authors Full Name: Târcoveanu, E. Dimofte, G. Bradea, C. Lupaşcu, C. Moldovanu, R. Vasilescu, A.
Institution: First Surgical Clinic, University Hospital "St. Spiridon" Iaşi, Romania. ***@****
Title: Peritoneal tuberculosis in laparoscopic era.
Source: Acta Chirurgica Belgica. 109(1):65-70, 2009 Jan-Feb.
Abstract: Peritoneal tuberculosis is uncommon in developed countries, but as the general incidence of tuberculosis is on the rise in Romania so is the case with peritoneal localization of the disease. The present study retrospectively analyzed 18 patients (8 males and 10 females, mean age 50 years, range 17-74 years) diagnosed in our department with peritoneal tuberculosis between 1995 and 2007. Results: Ascites was present in all but one case. Other common findings were weight loss (12 cases), weakness (5 cases), abdominal pain (16 cases), anorexia (6 cases) and night sweat (3 cases). Abdominal ultrasound has been used to demonstrate ascites in 16 cases. Only two patients had chest radiography suggestive for active tuberculosis. Laparotomy was performed in four cases, laparoscopy in 14 cases (two conversions). Intraoperative findings included multiple diffuse involvements of the visceral and parietal peritoneum, white "miliary nodules" or plaques, enlarged lymph nodes, ascites, "violin string" fibrinous strands, and omental thickening. Biopsy specimens showed granulomas, while ascitic fluid showed numerous lymphocytes. We conclude that the symptoms of abdominal tuberculosis vary greatly, and laparoscopy can be essential for diagnosis and management. The operation is safe, reliable with few complications and permits a prompt diagnosis, necessary to cure the patient.

[Lori707]

I had 2 positive Mantaux skin tests which came out positive. Then I took a Quantiferon test which came out negative. The Quantiferon is considered to be more reliable on TB than the Mangaux test. I had two Infectious Disease docs tell me I don't have TB but when I called the main TB clinic in my state, I was told that they have had a few cases where the patient tested negative for Quantiferon but still had TB.

There's Latent TB which is not active but sleeping due to the immune system protecting it from begin active. If the immune system is comprimized then it could activate.

If it was me, I would ask for another Quatiferon test but this time go to another lab that tested it the first time.

[alaskanabbott]

I so appreciate your reply. The hospital we were at ultimatly sent him home, with tube feeding for the weight loss, but nothing more. We are now trying to decide the best course of action, i.e which hospital would be the best to help us either confirm the dx of TB, or if not, then to help us find the actually cause of his illness. I was wondering if there is a way to send his medical info to National Jewish for them to see if it would behove us to bring him there.
Thank you,
Amber

[motox320]

Call them on the phone.

The doc on here will only reply once to your answer, so posting after he asnwers is a waste. You have to pay the fee again to get another answer.

Hope your son gets better