S2533 Peritoneal M. tuberculosis Infection Presenting as Pseudomyxoma Peritonei

Abstract

INTRODUCTION: Abdominal M. tuberculosis infections are rare in resource rich settings. When it occurs it can affect all areas of the gastrointestinal tract, solid viscera, peritoneum, and lymphatic system. Here we describe a rare instance of peritoneal tuberculosis mimicking intraabdominal malignancy and presenting with CT imaging findings pathognomonic for pseudomyxoma peritonei. CASE DESCRIPTION/METHODS: A 26 year old African American male prison inmate presented with four months of gradually worsening abdominal pain, fever, night sweats, and an unintentional weight loss of 18 kg. On admission he was febrile and tachycardic. Physical exam was remarkable for diffuse abdominal tenderness. Laboratory data was significant for hemoglobin of 6.9 g/dL and iron studies consistent with anemia of chronic disease. CT scan of his abdomen and pelvis demonstrated extensive mucinous implants and scalloping of the liver and spleen. Bacterial and fungal blood cultures were repeatedly negative as were fungal serologies for Coccidioides, Histoplasma, and Blastomyces. Fine needle aspiration of an intrabdominal mucinous implant found necrotizing granulomas negative for acid fast bacilli and malignant cells. An exploratory laparoscopy performed to obtain adequate biopsy sample during which peritoneal studding was observed intraoperatively. Biopsy revealed necrotizing granulomas positive for M. tuberculosis. He was initiated on RIPE therapy and achieved resolution of symptoms. DISCUSSION: Pseudomyxoma peritonei is a clinical syndrome characterized by diffuse gelatinous ascites that impresses on the liver and spleen and causes their edges to appear scalloped on CT imaging. It is typically associated with intrabdominal mucus secreting neoplasms, particularly mucinous adenocarcinoma of the appendix. This case represents an exceedingly rare presentation of peritoneal tuberculosis. Given that one-fifth of cases of tuberculosis in the US are extrapulmonary, early recognition of the signs of peritoneal tuberculosis and its confounders can expedite initiation of appropriate therapy.Figure 1.: Visceral scalloping from mucinous ascites.Figure 2.: Intraoperative laparoscopic imaging of peritoneal implants.Figure 3.: Intraoperative laparoscopic imaging of peritoneal implants.