A 35‐year‐old Haitian woman with a history of untreated latent tuberculosis (TB) presented with progressive abdominal distention, fatigue, and weight loss. She denied fevers, chills, night sweats, or cough. She denied sick contacts or recent travel outside the United States. She denied taking medications or using alcohol. On exam, her abdomen was soft and distended, with shifting dullness, without tenderness or organomegaly. She did not have caput medusa, spider angiomata, or scleral icterus. The rest of the exam was unremarkable. A CT scan demonstrated abdominal and pelvic ascites with enhancing nodular densities studding the peritoneum, along with a 2.8‐cm ovarian cyst with rim enhancement and lenticular‐shaped surrounding soft tissue. Based on these findings, our patient was admitted with the diagnosis of ovarian cancer with carcinomatosis. Serum CA‐125 was elevated, QuantiFERON‐TB Gold was positive. A paracentesis revealed elevated protein, lactate dehydrogenase, and adenosine deaminase. Gram/acid‐fast stains and cultures were negative. Cytology was negative for malignant cells. It was decided that prior to initiation of antibiotics for suspected TB infection, positive cultures or acid‐fast stain be obtained. Subsequent laparoscopic peritoneal biopsies and fluid samples were negative for organisms, acid‐fast staining, and malignant cells. A microscopic exam revealed epithelioid granulomas without acid‐fast staining. Based on the results of microscopic examination, adenosine deaminase, and QuantiFERON‐TB Gold, the patient was started on treatment for tuberculosis infection.
Peritoneal TB is a rare entity in the United States, accounting for 3.3% of extrapulmonary infections. Patients often present with ascites, abdominal distention, and fever. CT findings can mimic those of carcinomatosis. TB peritonitis can also lead to elevated CA‐125, which is exhibited in ovarian malignancies. The gold‐standard test is culture growth or Ziehl–Nielsen stain of bacilli in peritoneal fluid or biopsy samples. Mortality is high (>50%) and can be exacerbated by the time‐consuming nature of the required testing. Recently, it has been advocated for the combined use of QuantiFERON‐TB Gold and peritoneal fluid adenosine deaminase as a rapid screening test. At a cutoff of 35 IU/mL, adenosine deaminase has a sensitivity of 100% and specificity of 92.6%. Similar characteristics were noted with QuantiFERON‐TB Gold. Of note, these were the only tests that were positive in our patient and returned early in her hospital course.
This case underscores the difficulty in obtaining cultures or stains for the diagnosis of TB peritonitis. The time‐consuming nature of these tests can exacerbate a high mortality rate. Our experience supports the clinical applicability of the combined use of QuantiFERON‐TB Gold and peritoneal fluid adenosine deaminase for early diagnosis of peritoneal TB.
To cite this abstract:Faour F, Rasouli J, Bier R, Taurani C, Koulos J, Burger A, Chida R. Tuberculosis Peritonitis: A Diagnostic Challenge. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 327. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/tuberculosis-peritonitis-a-diagnostic-challenge/. Accessed May 24, 2019.