1668A An Unusual Presentation of Abdominal Tuberculosis

Abstract

INTRODUCTION: Peritoneal tuberculosis (TB) is an uncommon manifestation of extrapulmonary infection associated with significant mortality (51%). The delay in diagnosis due to insidious nature of disease and lack of specific symptoms result in significant morbidity and mortality. We report an unusual case of abdominal tuberculosis presenting with abdominal pain and vomiting. CASE DESCRIPTION/METHODS: A 58-year-old man with no significant past medical history came to the emergency department with nausea, non-bilious vomiting and generalized abdominal pain for two weeks. On examination, he had mild abdominal distension and hyperactive bowel sounds. His labs were significant for hyponatremia (119 mEq/L), hypokalemia (2.9 mEq/L) and metabolic alkalosis (bicarbonate 49 mEq/L). Chest X-ray showed right basilar lung infiltrate concerning for aspiration pneumonitis and computed tomography (CT) scan of abdomen revealed fluid filled distension of stomach and duodenum with moderate volume ascites (Figure 1). Patient was started on supportive management with intravenous fluids and bowel rest for suspected small bowel obstruction. Push Enteroscopy showed bilious fluid in stomach and duodenum but no obstructing lesion was seen till proximal jejunum. Patient underwent diagnostic paracentesis revealing high serum ascitic albumin gradient fluid ( >1.1) with neutrophil predominance (85%) and elevated adenosine deaminase (ADA) level (142 IU/L). On laparoscopic examination, he had nodular thickening of peritoneum and dense adhesions (Figures 2 and 3). Histopathology of nodules confirmed presence of acid-fast bacillus in fibrotic nodules. Patient was started on intravenous anti-tubercular regimen with improvement in symptoms over next 2 weeks and was discharged home. DISCUSSION: Peritoneal TB is a chronic disease which commonly results from the reactivation of latent pathogen and accounts for 4.7% of all tuberculosis patients in the USA. Patient usually present with complex ascites, abdominal pain, and fever which can progress to bowel obstruction if remained undiagnosed. Diagnosis is usually confirmed by peritoneal biopsy but in patients without cirrhosis, ascitic fluid ADA level of >39 IU/L has sensitivity and specificity of 100% and 97% respectively. Due to lack of specific symptoms and high morbidity in undiagnosed cases, the initial differential diagnosis of patients with suspected bowel obstruction should also include peritoneal TB. Moreover, ascitic fluid ADA level can assist diagnosis of peritoneal TB.