A Rare Case of Abdominal Tuberculosis

Abstract

Case: A 43-year-old Filipino female with no significant past history presented to the hospital for a two week history of abdominal pain, fever, chills, and body aches. She was found to have fever (100.8 F) and tachycardia (110/min). Ultrasound of her abdomen showed ascites and she underwent paracentesis removing 800 cc of ascitic fluid. It showed1958 white blood cells (WBC) with 71% lymphocytes and a Serum Ascitic albumin gradient (SAAG) of 0.5. She underwent computed tomographic (CT) scan of the abdomen which showed increased soft tissue density to the omentum, suggesting possibility of omental metastasis. Tumor marker CA-125 level was elevated (235). Pelvic ultrasound showed no evidence of ovarian mass. Thpatient underwent upper endoscopy (EGD) and colonoscopy which revealed five small, non-bleeding ulcers in the ascending colon. Multiple biopsies were obtained which showed non-necrotizing granulomas, negative for fungi and mycobacterium. Patient underwent interventional radiology (IR) guided biopsy of omentum which was negative for malignancy, fungi, or mycobacterium and showed non-necrotizing granulomas. The ascitic fluid culture was negative for tuberculous bacilli. Patient received a Tuberculosis skin test which was positive, 21 mm. She had immigrated from the Philippines where she was exposed. A presumptive diagnosis of peritoneal tuberculosis was made. Patient was started on TB therapy, rifampin, isoniazid, pyrazinamide & ethambutol. After six months of treatment, patient responded well to therapy with resolution of recurrent ascites and abdominal pain. Discussion: TB can involve nearly any tissue or organ and the peritoneum is one of the most common extrapulmonary sites of tuberculous infection. We describe a difficult case of peritoneal TB presenting as an abdominal malignancy. Pathology from colon ulcerations showed non-necrotizing granulomas. While an uncommon finding, reports have documented both cases of pulmonary and extrapulmonary TB with findings of non-caseating granulomas and these diagnoses were confirmed via laboratory testing. Our case was further complicated with negative lab results for TB which can be seen in upto 15% of patients. Conclusion Prompt and accurate diagnosis of peritoneal tuberculosis is essential but remains a challenge because of its nonspecific symptoms. Given the challenges of laboratory testing, TB should be considered in high risk patients with these symptoms and early intervention should be considered.