Abstract
A 36-year-old man with no significant past medical history presented with two-month abdominal distention, night sweats, and weight loss of 15 Ib. He had no known exposure to tuberculosis. PPD test was negative prior to the hospital admission. Physical examination was notable for new onset ascites, but no superficial lymphadenopathy or stigmata of chronic liver disease was found. CT scan demonstrated enlarged mesenteric lymph nodes, and prominent retroperitoneal lymph nodes along with moderate ascites and omental infiltration. Diagnostic paracentesis yielded WBC of 295/mm3, lymphocytic predominance (70%), and serum ascitic albumin gradient of 0.1, consistent with exudate. Both the ascitic culture and AFB smear were negative, and ascitic cytology revealed nonmalignant cells. Exploratory laparoscopy for excisional biopsy of mesenteric lymph nodes was performed. Pathologic findings revealed caseous granulomas with scattered multinucleated giant cells. Mesenteric lymph node tissue culture subsequently grew Mycobacterium tuberculosis complex and the diagnosis of peritoneal tuberculosis was confirmed. The patient was started on quadruple therapy. A couple of days after the antibiotics were started, the small bowel obstruction started to resolve with resumption of bowel movements and tolerance of oral intake. A week later, ascites stopped accumulating and fever was no longer noted. He has been well and continues to be under observation.
Highlights
Most prevalent as a pulmonary disease, tuberculosis can affect any part of the body, including the peritoneum
We described a case of peritoneal tuberculosis in an immunocompetent patient who had no known risk factors and negative Purified protein derivative (PPD) test with clear chest X-ray
It was manifested by ascites, prominent mesenteric and retroperitoneal lymph nodes along with omental infiltration causing small bowel obstruction
Summary
Most prevalent as a pulmonary disease, tuberculosis can affect any part of the body, including the peritoneum. Extrapulmonary tuberculosis is the result of reactivation of latent disease established by hematogenous spread during primary pulmonary infection. In most cases, immunocompromising conditions predispose to peritoneal tuberculosis, and risk factors include liver cirrhosis, diabetes mellitus, use of systemic corticosteroids, HIV infection, and underlying malignancy [1]. Treating patients with a negative PPD test could be considered based on the pretest probability, and this clinical decision should be based on symptoms, physical examination, and baseline chest X-ray [2, 3]. The likelihood of reactivation of latent disease is considered low in an asymptomatic patient with a negative PPD test along with normal baseline chest X-ray
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