Ascites as a Presenting Sign of Disseminated Tuberculosis in an Immunocompetent Patient

Abstract

Purpose: A 39 year-old black male presented with a two-month history of abdominal distension, weight loss (28 Kg), anorexia and fever. On physical examination he was found to have ascites and hepatomegaly. A paracentesis was performed revealing an exsudate with elevated adenosine deaminase (259 U/L). He also had anemia (hemoglobin 11.6 g/dL); high erythrocyte sedimentation rate (45 mm/hr), aspartate aminotransferase (155 U/L), alanine transaminase (106 U/L), alkaline phosphatase (732 U/L), ADA (144 U/L) and elevated C-reactive protein (116 mg/L) levels. Human immunodeficiency virus (HIV) 1 and 2, Hepatitis A, B and C serologies were negative. A thoracic abdomino-pelvic computed tomography (CT) scan showed epiploic adipose densification suggesting peritoneal inflammatory features or peritoneal carcinomatosis and bilateral micronodular pattern in the pulmonary intersticium. Polymerase chain reaction (PCR) for Mycobacterium tuberculosis and Ziehl-Neelsen stain for acid-fast bacilli in the peritoneal fluid, bronchoalveolar lavage (BAL), and urine (3 samples) were negative. Blood cultures were negative. Laparoscopy was performed, with absence of macroscopic peritoneal carcinomatosis and hepatic, intestinal and peritoneal biopsies were retrieved. Histology showed epithelioid hepatic granulomas and peritoneal granulomas with central necrosis. Antituberculous therapy were started (isoniazid, rifampicin, pyrazinamide, and ethambutol), although there has no laboratory confirmation of mycobacterial infection. The cultures from the peritoneal fluid, BAL, and urine were positive. He was discharged with no symptoms and with early recovery, under antituberculous therapy for disseminated tuberculosis (hepatic, renal, peritoneal and pulmonary). Workup for HIV was negative; immunoglobulin levels, lymphocyte subsets, and complement levels were normal. Disseminated tuberculosis is rare, particularly in immunocompetent host and is secondary to hematogenic dissemination of Mycobacterium tuberculosis. The estimated frequency is 2.8% of all cases of tuberculosis and 7.3% of extrapulmonar cases. Predisposing factors for the development of disseminated tuberculosis include advanced age, alcoholism, immunosuppressive therapy, neoplasm, hematologic malignancy or HIV infection. Our patient did not have any of these conditions.