Case Presentation: 53y/o Hispanic woman with a history of cervical cancer in 2001 s/p treatment now in remission, HTN, and a recent diagnosis of inflammatory arthritis in 5/2023 on treatment with Infliximab who presented with recurrent fevers, diarrhea, and abdominal pain in the setting of new ascites for the past several weeks. Patient had previously been seen at an outside hospital where she had been treated with antibiotics despite negative infectious work-up. However, symptoms persisted and patient presented to our hospital. On admission, patient was noted to be febrile, appeared uncomfortable with distended abdomen and positive fluid wave, as well as +3 pitting edema of bilateral LE. Labs were notable for WBC 18, Na 125, AST 134, ALT 51, and albumin of 2.2. Procalcitonin was 3.72 ng/ml, BNP < 10 pg/ml. C diff and stool studies were negative. ANA was 1:160 and ascitic fluid was notable for albumin of 1.8g/dL, consistent with low SAAG, and PMN count of 62. CXR was negative. CT A/P showed concern for malignant ascites and omental caking. Patient was started on antibiotics and underwent omental biopsy. Gynecology, ID and GI were consulted. Given consultants concern for tuberculosis in the setting of immunosuppression, a rule-out was ordered. Patient’s Mycobacterium Tuberculosis (TB) PCR came back positive, and patient was immediately started on treatment with RIPE. AFB sputum were all negative. Pathology from her biopsy later returned with caseating granulomatous inflammation with acid-fast bacilli identified and no malignant cells observed further confirming the diagnosis of TB. Patient is currently being followed by the Department of Public Health.
Discussion: Peritoneal TB accounts for < 5% of extrapulmonary TB cases making it a challenging diagnose, especially when one factors in its insidious onset and constellation of non-specific symptoms. Patients typically present with progression of abdominal pain, distention from ascites, as well as constitutional symptoms including weight loss, fevers, and night sweats. Other symptoms that may be seen include diarrhea, constipation, hepatomegaly, and an abdominal mass. CT imaging of TB peritonitis can lead to delay in diagnosis as it presents similarly to peritoneal carcinomatosis with omental caking, ascites, and omental nodules. Definitive diagnosis is made when Mycobacterium tuberculosis bacilli are seen on ascitic fluid or biopsy from an involved site. Peritoneal TB should be suspected in patients who present with clinical symptoms, in addition to epidemiological risk factors (i.e. exposure/history of TB, endemic area, immunocompromised state, healthcare worker, etc).
Conclusions: Peritoneal TB can be diagnostically challenging due to its non-specific symptomatology and overlapping imaging findings with peritoneal carcinomatosis.