IDCases 4 (2016) 50–52

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Case Report

Peritoneal tuberculosis due to Mycobacterium caprae

T. Nebreda a,*, E. Álvarez-Prida b, B. Blanco c, M.A. Remacha a, S. Samper d, M.S. Jiménez e
a
Servicio de Microbiologı´a, Complejo Asistencial Universitario de León, León, Spain
b
Servicio de Cirugı´a General, Complejo Asistencial Universitario de León, León, Spain
c
Servicio de Medicina Interna, Complejo Asistencial Universitario de León, León, Spain
d
Instituto de Investigación Sanitaria Aragón, Instituto Aragonés de Ciencias de la Salud, Consorcio Centro de Investigación Biomédica en Red de Enfermedades
Respiratorias, Zaragoza, Spain
e
Centro Nacional de Microbiologı´a, Instituto Carlos III, Majadahonda, Madrid, Spain

A R T I C L E I N F O A B S T R A C T

Article history: The incidence of tuberculosis in humans due to Mycobacterium caprae is very low and is almost confined
Received 8 February 2016 to Europe. We report a case of a previously healthy 41-year-old Moroccan with a 6 month history of
Received in revised form 24 February 2016 abdominal pain, weight loss, fatigue and diarrhea. A diagnosis of peritoneal tuberculosis due to M. caprae
Accepted 24 February 2016
was made.
ß 2016 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND
Keywords: license ([Link]
Mycobacterium caprae
Peritoneal tuberculosis
Spoligotype SB0416

Introduction
A depressible, soft and painless abdomen was revealed on
examination with diffuse discomfort on palpation and no signs of
Peritoneal tuberculosis is an uncommon site of extrapulmonary
guarding. Laboratory tests showed a normal white blood cell count
infection in industrialized countries caused by Mycobacterium
and a normocytic anemia. A HIV antibody test was negative.
tuberculosis complex. The diagnosis can be challenging, since the
Mantoux test (17 mm) and interferon g release assays were both
most common findings are nonspecific, and a high index of suspicion
positive. Chest X-ray and chest CT scan were normal and an
is required to make the diagnosis in a timely manner. Mycobacterium
abdominal CT scan showed mild ascites with small bilateral
caprae causes tuberculosis in humans and animals, but the incidence
inguinal lymphadenopathy.
in humans is very low worldwide [1]. To our knowledge, we report
An intense plastic peritonitis was encountered at laparoscopy
the first case of peritoneal tuberculosis caused by M. caprae.
affecting all abdominal spaces with soft rubbery adhesions that
virtually blocked all initial access to the abdominal cavity.
Case report Countless amount of nodules were seen on the omentum and
both the parietal and the visceral peritoneum and mainly on
A 41-year-old Moroccan male, who had been living in Spain for Glisson’s sheath and digestive tube serosal surfaces (Fig. 1). A small
7 years, was admitted to the rapid diagnosis unit of Internal amount of fluid was observed around liver and spleen. Careful
Medicine of the Complejo Asistencial Universitario de León, Spain adhesiolysis was needed for exposure and to obtain fluid samples.
with a 6 month history of abdominal pain, weight loss (10 kg in Various biopsies were taken from the omental and peritoneal
two months), fatigue and diarrhea. The patient had no relevant nodules. All specimens were sent for microbiology, cytology and
past medical history. He lived in an urban area, working as an pathological examinations. Histopathology showed non-necrotiz-
electrician, and had no reported animal contact and denied ing granuloma. Acid fast stains of the tissue were negative. There
ingesting unpasteurized dairy products. was no evidence of malignancy. No acid fast bacilli (AFB) were seen
on stain of the peritoneal fluid. The fluid PCR and culture were also
negative for mycobacteria.
* Corresponding author at: Servicio de Microbiologı́a, Complejo Asistencial
Universitario de León, Avda. Altos de Nava s/n, León, Spain. Tel.: +34 606184089;
Mycobacterial DNA was identified in the biopsy by PCR (Xpert1
fax: +34 987235165. MTB/Rif PCR, Cepheid AB, Solna, Sweden). Mycobacterial growth
E-mail address: tnebreda@[Link] (T. Nebreda). was detected with BactecTM MGITTM 960 system, (Becton

[Link]
2214-2509/ß 2016 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license ([Link]
4.0/).
 T. Nebreda et al. / IDCases 4 (2016) 50–52 51

transmission in industrialized nations: pasteurization of dairy

products and culling of infected cattle herds [1]. Although, zoonotic
tuberculosis in some European countries has increased recently
due to the migration of people from areas more endemic for
M. bovis, this does not seem to be the case for infection with
M. caprae as most infected individuals have been native Europeans
[1,6]. Outside Europe, M. caprae has been reported in only 1 human
case in Morocco [7] and in 3 cattle cases (2 cases in Algeria and
1 case in Tunisia) [1]. The Morocco isolate showed spoligotype
SIT644 [7].
In Spain, M. caprae is widespread in domesticated goats and
cattle and in a variety of wild animals, representing 7.4% of all M.
tuberculosis complex isolates from animals [8]. The percentage of
human M. tuberculosis complex infections, however, is low, about
0.3% [2]. Althought SB0157 is the most dominant spoligotype, both
Fig. 1. Nodules and peritoneal adhesions seen at laparoscopy. in humans and animals, the SB0416 spoligotype found in our
patient is the second most common in animals in our region [8] and
Table 1 have seen isolated in humans in other regions of Spain, in Germany
Members of the Mycobacterium tuberculosis complex.
and in Austria [1], so it is likely that the infection was acquired in
Microorganism Primary host(s) Spain.
Mycobacterium tuberculosis Man Dürr et al. [9] found a strong association between zoonotic
Mycobacterium africanum Man (West Africa) tuberculosis and extrapulmonary diseases as compared to non-
Mycobacterium canettii Man (Horn of Africa) zoonotic human tuberculosis with, being lymph nodes and
Mycobacterium bovis Cattle and other animals genitourinary systems the most often affected primary sites. In
Mycobacterium bovis BCG Vaccine
European countries, patients with zoonotic tuberculosis suffered
Mycobacterium microti Voles and other small rodents
Mycobacterium caprae Goats, cattle and other animals (Europe) more from reactivation of old infections, which mainly leads to
Mycoabcterium pinnipedii Seals pulmonary tuberculosis. This could explain that only few cases due
to M. caprae have been reported in detail in case reports: 2 cases of
cuateous tuberculosis [10,11] and 1 each of pericarditis case [12],
urinary tract involvement [13] and meningitis [14].
Dickinson, Oxford, UK) on Day 26 of the peritoneal biopsy.
A high rate of tuberculosis is reported in Leon’s Health Area
Immunochromatographic test for MTC (TB Ag MPT 64 rapid,
with an incidence of active tuberculosis in 2013 of 18 per
Standard diagnostics, INC, Republic of Korea) classified this isolate
100.000 populations as [12] compared with Spain’s overall rate of
within the M. tuberculosis complex. Identification and susceptibility
12 per 100.000 [15]. Tubercular peritonitis is very uncommon with
testing were performed as described [2] at the National de
only 6 cases of abdominal tuberculosis of a total of 596 cases of TB
Mycobacterium laboratory, Instituto Carlos III, Majadahonda, Madrid,
have been confirmed in our laboratory between 2006 and 2015;
Spain as M. caprae being fully sensitive to isoniazid, streptomycin,
five of them were native people unlike others European studies in
ethambutol, rifampin and pyrazinamide. The M. caprae isolate
which a higher proportion of peritoneal tuberculosis in immigrant
corresponded to spoligotype SIT646 in the international SITVIT
populations from developing countries is found [16,17].
database and SB0416 in the Mycobacterium bovis spoligotype
In low incidence countries, the diagnosis of peritoneal
database ([Link] It was performed Aragon Insti-
tuberculosis is often delayed for more than 4 months or even
tute for Health Research (IIS Aragon), Zaragoza, Spain as previous
overlooked [16,17], partly due to a nonspecific clinical presenta-
described [3].
tion in the absence of lung involvement and in part because more
Treatment for tuberculous peritonitis was initiated after the
than 20% of patients do not have risk factors with nonspecific
laparoscopy with a 4-drug regimen of including isoniazid,
laboratory tests [17]. The diagnosis in our patient was made
rifampin, pyrazinamide and ethambutol. Two months after
following 6 months of symptoms.
starting antituberculous treatment, the patient reported improve-
Laparoscopy is the gold standard for diagnosis of peritoneal
ment of symptoms. The patient completed 2 months of four-drug
tuberculosis, yielding the diagnosis in up to 92% of cases [16]. It
therapy without complications and an additional 7 months of
permits a complete exploration of the peritoneal cavity and allows
isoniazid and rifampin. He is asymptomatic.
the ability to sample various tissues for biopsy and culture.
Peritoneal tuberculosis is a paucibacillar process and is rarely
Discussion possible to demonstrate acid-fast bacilli in ascitic fluid. In this case,
as reflected in the literature, AFB stain, PCR and culture did not
M. caprae, a member of the M. tuberculosis complex (Table 1) can assist in the initial management of the patient [16].
cause tuberculosis in man and many domesticated and wild
animals. The organism was first characterized in 1999 and the References
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