Starry sky in the abdomen

Abstract

A Vietnamese woman aged 23 years with a 3-year history of intermittent abdominal pain presented to our outpatient clinic at Okayama City Hospital, Okayama, Japan. She had no previous significant cardiovascular or gastrointestinal problems. She also denied any drug abuse, lead poisoning, allergies, abdominal injury, or psychiatric disorders. Her vital signs were normal. She exhibited mild tenderness of her epigastrium without guarding or rebound tenderness. A chest x-ray showed no abnormality. Abdominal ultrasonography confirmed the presence of intermediate splenic and pelvic ascites, but there was no hepatosplenomegaly. CT showed calcified mediastinal nodes, diffuse thickening and nodularity of the omentum, mesenteric lymphadenopathy, and ascites (figure, A). We were unable to drain abdominal ascites because there was no safe route of access. A subsequent QuantiFERON-TB Gold test was positive. Exploratory laparoscopy showed numerous white, miliary nodules on the peritoneum, round ligament of the liver, and hepatic surface (figure, B). Analyses of ascitic fluid showed an adenosine deaminase concentration of 136·5 U/L. Although ascites culture and PCR for Mycobacterium tuberculosis were negative, caseating granulomas with Langhans giant cells were detected in specimens of omentum. Based on these clinical findings, we made a diagnosis of tuberculous peritonitis. The patient was given anti-tuberculous treatment with rifampicin, isoniazid, pyrazinamide, and ethambutol for 2 months, followed by rifampicin and isoniazid for 4 months. After treatment, her abdominal symptoms improved, and ascites resolved completely.