Peritoneal Tuberculosis: If at First You Don't Succeed, Work Up and Work Up Again

1St. Luke's‐Roosevelt Hospital Center, New York, NY
2St. Luke's Roosevelt Hospital Center, New York, NY

Meeting: Hospital Medicine 2009, May 14-17, Chicago, Ill.

Abstract number: 195

Case Presentation:

A 73‐year‐old man with a history of hypertension was admitted for the evaluation of progressive, generalized weakness and fatigue of several months' duration. Aside from significant weight loss and lack of appetite, the patient denied other focal complaints including fever, chills, night sweats, cough, history of smoking or tuberculosis exposure, abdominal pain, dizziness, or paresthesias. On exam, the patient was noted to be cachectic and dehydrated. Basic laboratory tests were unremarkable other than mild azotemia and a normocytic anemia. Chest X‐ray revealed a large right‐sided pleural effusion occupying more than half the right thorax. Chest/abdomen/pelvis CT revealed large, bilateral pleural effusions without lung or chest wall mass, mild as‐cites, and poorly defined densities along the omentum thought to represent possible neoplastic disease. Thoracentesis revealed an exudative effusion with lymphocytic predominance. Bacterial culture, smear for acid‐fast bacilli (AFB), and pleural fluid cytology were negative, as were PPD and HIV testing. Paracentesis results including cytology, bacterial culture, and smear for AFB were also unrevealing, and subsequent pleural biopsy revealed chronic inflammation only. Given the nondiagnostic findings and consideration of underlying malignancy, laparoscopy was performed, revealing adhesions and multiple whitish nodules along the peritoneum, Directed biopsy specimens demonstrated granulomatous inflammation and identification of acid‐fast bacilli, thereby diagnostic of peritoneal tuberculosis.

Discussion:

Peritoneal tuberculosis, although still quite common in underdeveloped countries, has a relatively low incidence in developed countries, where it is reported as the sixth most common site of extrapulmonary tuberculosis. Although risk factors for infection include cirrhosis, HIV, underlying malignancy, diabetes, and patients on chronic peritoneal dialysis, the literature documents a significant number of cases in patients with no clear risk factor. The predominant mechanism of infection is thought to be via reactivation of latent peritoneal tuberculous foci, which have spread hematogenously from primary lung sites (either active or dormant). It has been reported that roughly 70% of patients have symptoms for more than 4 months prior to establishment of a diagnosis. Delay in diagnosis is most likely multifactorial because of its frequently variable clinical presentation with vague complaints, a low index of clinical suspicion by providers unfamiliar with the diagnosis, and the low yield of AFB detection in ascitic fluid by both smear and culture.

Conclusions:

Peritoneal tuberculosis is often a difficult diagnosis to make and may require exhaustive evaluation prior to final diagnosis. It may even mimic malignancy by imaging or clinical history; therefore, although challenging, establishment of the diagnosis can mean the difference between detection of a potentially curable disease versus that of a grim prognosis.

Author Disclosure:

N. Sevransky, none; R. Gurunathan, none.

To cite this abstract:

Sevransky N, Gurunathan R. Peritoneal Tuberculosis: If at First You Don't Succeed, Work Up and Work Up Again. Abstract published at Hospital Medicine 2009, May 14-17, Chicago, Ill. Abstract 195. Journal of Hospital Medicine. 2009; 4 (suppl 1). https://www.shmabstracts.com/abstract/peritoneal-tuberculosis-if-at-first-you-dont-succeed-work-up-and-work-up-again/. Accessed May 26, 2019.

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