A case of peritoneal tuberculosis

Abstract

It's estimated that about one-third of the world population is infected with Mycobacterium tuberculosis. Although the lungs are the major site of infection, there are other forms of tuberculosis. The gastrointestinal/peritoneal tuberculosis represents only 1% of the total number of cases in Portugal, up to 3% worldwide, and 12% of the extrapulmonary cases of tuberculosis. We report a case of a 23-year-old female, Nepalese, living in Portugal for the past 2 years, with no medical history or chronic medication. She was admitted in the emergency room due to a flu-like syndrome in the previous ten days, with fever, dry cough and myalgia as the major complaints. Because she had no abnormalities in the clinical examination, chest radiography and laboratory values, she was discharged with antipyretics. Twenty days later she returned with same symptoms as well as a new, diffuse abdominal pain, denying any vomiting or diarrhea. She then pointed that a close family member was at the sixth month of treatment for tuberculosis. In the clinical examination she had an axillary temperature of 37.6 °C, tachycardia, no changes in pulmonary auscultation and had diffuse abdominal pain with no rebound tenderness. Laboratory findings showed a microcytic hypochromic anemia, electrocardiogram (EKG) showed sinus tachycardia and chest and abdominal radiographies were normal. We performed an abdominal ultrasound and a computerized tomography scan that showed a moderate volume ascites with signs of fibro-adhesive peritonitis, as well as a peri-ovarian cystic formation. In the laboratory findings she maintained the previous anemia and had an elevated erythrocyte sedimentation rate of 34 mm/h and CA-125 of 9453 U/ml. All viral serologies were negative. Abdominal surgery was performed and tissue biopsies, for cultural and histological studies, were obtained. Histology showed granulomatous inflammation with multiple granulomas with sparse necrosis. Acid-fast staining was negative and culture and molecular examinations identified M. tuberculosis susceptible to isoniazid, rifampicin, pyrazinamide and ethambutol. She was put on a 6 month treatment, with good response. We consider relevant the inclusion of extrapulmonary tuberculosis in the differential diagnosis of an unknown origin of fever syndrome, given that the migratory flows of the regions were tuberculosis is endemic.