Tuberculosis (TB) remains a major global health threat, particularly in low- and middle-income countries. In 2023, the World Health Organization (WHO) estimated 1.3 million new cases of TB in children aged under 15 years, accounting for approximately 12% of the global burden of TB (1). Although pulmonary TB is the most common presentation, 15%–20% of pediatric TB cases are extrapulmonary tuberculosis (EPTB) (2, 3). Among EPTB, abdominal tuberculosis (ATB) is a clinically significant yet not fully recognized form, accounting for approximately 6% of all TB cases. Among the various forms of EXPT, ATB is an important contributor, especially in high-burden regions, such as South Asia and sub-Saharan Africa (2). Despite these numbers, the true prevalence of pediatric ATB may be underestimated due to insufficient reporting, diagnostic challenges, and lack of standardized case definitions (4, 5).

ATB, a form of EXPT, is the sixth most common site of extrapulmonary involvement and may affect the gastrointestinal tract, peritoneum, mesenteric lymph nodes, and occasionally solid organs like the liver, spleen, and pancreas; ATB continues to pose significant diagnostic challenges due to its wide spectrum, including acute, subacute, and chronic manifestations and non-specific symptoms that often mimic other intra-abdominal pathologies (6–8). This challenge is not limited to the pediatric population. Studies in adults have similarly emphasized the frequent misdiagnosis of abdominal or gastrointestinal tuberculosis. The disease's ability to affect multiple organs and present with a diverse array of symptoms adds to the complexity of diagnosis (9).

In pediatric populations, ATB frequently presents with vague, non-specific symptoms, such as chronic abdominal pain, distension, fever, and weight loss, which are common to a wide range of abdominal conditions. Peritoneal and nodal forms predominate in children and are particularly challenging to diagnose (10). This overlap with more common surgical and inflammatory conditions, such as appendicitis, intestinal obstruction, peritonitis, and Crohn's disease, can lead to frequent misdiagnosis, delayed treatment, and unnecessary surgical interventions (11). Such diagnostic errors not only subject children to potentially avoidable procedures, such as appendectomy or laparotomy, but also delay the initiation of appropriate anti-tubercular therapy, increasing the risk of complications like intestinal perforation, abscesses, and chronic morbidity (12, 13).

The limited specificity of constitutional symptoms further complicates early identification. Low-grade fever, anemia, malaise, night sweats, and weight loss are present in only approximately one-third of pediatric ATB cases, making them unreliable as early diagnostic indicators (12). The diagnostic dilemma is particularly evident in cases where abdominal distension, ascites, or palpable masses are present features that, without a high index of suspicion, are easily mistaken for other surgical emergencies.

Misdiagnosis of abdominal tuberculosis in children is not only common but has serious clinical implications. Studies indicate that ATB is frequently mistaken for conditions such as inflammatory bowel disease (IBD), gastroenteritis, or surgical abdomen, resulting in delayed diagnosis and inappropriate management strategies (7, 12). Such delays are associated with higher morbidity and, in some cases, mortality due to disease progression and the development of complications (13, 14).

Given these challenges, this systematic review and meta-analysis aimed to examine the clinical characteristics contributing to the initial misdiagnosis or delay in diagnosis of ATB in children. By synthesizing evidence across the literature, we sought to identify key clinical features and risk factors that may mislead clinicians during the initial assessment. Our objective is to enhance clinical recognition of ATB in children, reduce diagnostic delays, and improve treatment outcomes through better-informed decision-making.

This systematic review and meta-analysis were conducted and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2020 guidelines (15). The study design, literature search, data extraction, and reporting processes adhered to these guidelines to ensure methodological rigor and transparency. A PRISMA flow diagram was used to illustrate the study selection process, including the number of records identified, and the screening, inclusion, and exclusion of studies.

In this meta-analysis, a systematic search covering the period between 1900 and 2024 yielded a total of 645 studies from the databases (Figure 1). After removing 44 duplicate records, 601 studies were screened based on titles and abstracts. Of these, 566 records were excluded based on the predefined eligibility criteria (case reports without misdiagnosis details, reviews, editorials, letters, non-English publications, and unrelated topics).

Subsequently, 35 full-text articles were reviewed in detail. During this stage, 22 studies were excluded as they were individual case reports lacking analytical data, while five case series were excluded for not reporting outcomes related to misdiagnosis or delay in diagnosis. Ultimately, seven studies were included in the final meta-analysis.

The diagnosis of ATB in children remains particularly challenging due to its non-specific clinical presentation and overlap with other common pediatric abdominal conditions, which frequently leads to misdiagnosis or delayed diagnosis. However, ATB constitutes approximately 1%–3% of total TB cases and 12% of extrapulmonary TB cases in children under 15 years (21, 22).

ATB has been reported more frequently among children aged under 5 years, particularly in high-burden countries. However, recent studies from India, Taiwan, Turkey, and Tunisia suggest a shift toward older children and adolescents, with mean ages reported between 9.5 and 14.7 years (23, 24), suggesting evolving epidemiological patterns that may impact clinical suspicion thresholds. The wide clinical spectrum from chronic symptoms to acute surgical abdomen further complicates early recognition. In particular, the presence of comorbidities such as HIV or malnutrition may obscure classic features, delaying diagnosis and increasing the risk of complications (14).

This meta-analysis evaluated clinical characteristics observed in misdiagnosed cases of ATB in children. Ascites were more prevalent in the misdiagnosed group with an OR of 2.29 (p = 29), though a result was not statistically significant toward ascites being a misleading clinical characteristic. As a common feature in several gastrointestinal disorders, such as nephrotic syndrome or liver disease, ascites may divert clinical focus away from TB, especially in low-resource settings (14, 18). Similarly, abdominal distension was more frequent in misdiagnosed cases, with an OR of 2.65 (p = 0.18), reflecting its commonality in many gastrointestinal pathologies, such as obstruction, ileus, or severe malnutrition (17, 25). Although not statistically significant, this finding is consistent with the notion that such symptoms can mask ATB, especially when constitutional signs are mild or absent.

Interestingly, weight loss, often considered a hallmark of TB, was not protective against misdiagnosis in this cohort (OR: 0.50; p = 0.11). Despite its frequent occurrence in correctly diagnosed cases, its lack of specificity—given its presence in malnutrition, chronic infections, and malignancies—limits its diagnostic utility in distinguishing ATB from other causes of pediatric abdominal disease (26).

Overall, the analysis underscores that no single symptom reliably differentiates misdiagnosed from correctly diagnosed ATB cases. Common features such as abdominal pain, vomiting, fever, and anorexia were prevalent across both groups, emphasizing the necessity for a high index of suspicion, particularly in TB-endemic regions. Although trends suggested that ascites and abdominal distension may be more prevalent in misdiagnosed cases, the findings did not reach statistical significance, partly due to small sample sizes and heterogeneity among studies.

This study has several limitations. First, the incomplete and inconsistent reporting across primary studies limited the inclusion of comprehensive datasets, affecting statistical power. Second, we were unable to analyze the contribution of radiological or laboratory parameters, which are essential in diagnosing ATB. Third, the inclusion was restricted to case series, as other study designs did not report misdiagnosis-specific data. These limitations call for more robust, prospective research with standardized reporting and the inclusion of diverse study types to better understand and address diagnostic delays in pediatric ATB.

This meta-analysis reinforces the complexity of diagnosing pediatric abdominal tuberculosis based on clinical presentation alone. Despite observing trends toward misdiagnosis with symptoms like ascites and abdominal distension, the lack of statistical significance limits their predictive value. The results highlight the critical need for clinical vigilance, early use of diagnostic investigations, and consideration of ATB in differential diagnoses for children presenting with unexplained abdominal symptoms in high-burden areas. Future research should aim to validate these findings in larger cohorts and integrate laboratory and imaging data to support earlier, more accurate diagnoses.