Author: Daniel Morrad PGY-4
Case:
A 27-year-old Spanish speaking female with no medical history presents with complaints of abdominal pain. She is approximately 3 months postpartum from a vaginal delivery complicated by oligohydramnios. For 2 weeks she has had fever and sweats that seem to come and go, and abdominal discomfort described as a generalized achiness throughout her abdomen associated with non-bloody and non-bilious vomiting, watery diarrhea, and decreased appetite. She feels like her abdomen has been increasing in size and that it is filled with fluid. She denies any alleviating or exacerbating factors, sick contacts, and has never experienced pain like this in the past. She denies any trauma, vaginal bleeding or discharge, dysuria, hematuria, rash, chest pain, or difficulty breathing. Tylenol has slightly helped her fever, but her symptoms have persisted and are slowly getting worse. The patient is originally from Ecuador and moved to the United States 2 years prior to her ED presentation.
Initial Vital Signs:
TEMP: 39 (oral)
HR: 116
BP 108/68
RR:18
Sp02: 95% on RA
Physical Exam:
Largely unremarkable however evaluation of the abdomen revealed mild to moderate ascites with a fluid wave. Palpation of the abdomen was significant for generalized abdominal tenderness more so on the left but no organomegaly or signs of an acute abdomen was noted.
Labs and CT imaging were ordered, and acetaminophen was given for control of her pain and fever.
Initial Labs:
Na 134
K 3.4
C02 20
BUN 6
Cr 0.51
Ca 8.0
Albumin 2.6
AST/ALT 19/15
Lipase 8
Bili total 1.0
Bili direct 0.5
WBC 9.7
Hgb 10.2
Platelet 305
Neutrophils 80.8
Urinalysis showed occasional bacteria with +Nitrite and Small Leuk Est, WBC 11-20
Blood Gas pH of 7.45, Lactic acid level 0.8
Imaging:
CT of the Abdomen and Pelvis with contrast:
1. Large volume ascites and omental nodularity which is worrisome for peritoneal carcinomatosis.
2. Cystic mass in the mid mesentery which is causing narrowing of the superior mesenteric vein. This is worrisome for primary or metastatic neoplasm.
Progression of Case:
Given the concerning CT scan, the patient was admitted to the hospital for further evaluation and for an IR guided paracentesis and biopsy of the omental mass. While initial cytology of the ascitic fluid did not reveal any malignant cells, biopsy results revealed inflammatory cells, macrophages, and mesothelial cells. Interventional radiology core biopsy of the omental nodularity revealed necrotizing granulomatous inflammation, no signs of malignancy, and negative AFB staining. The patient was eventually discharged and was to be treated in the outpatient setting with assumed metastatic neoplasm. She returned to the emergency department days later with worsening abdominal distention and pain with fever, hypotension, and tachycardia.
During her second admission, she underwent a diagnostic laparoscopy of the omental nodularity by they obstetrics team and a repeat paracentesis. While AFB staining continued to return negative, repeat biopsy again showed necrotizing granuloma. Given these findings, lack of malignant cells, and recent travel from a country with high transmission rates for Tuberculosis, the patient was diagnosed with Peritoneal Tuberculosis. Given concern by the infectious disease team, she had already started RIPE therapy which she was tolerating well.
Considerations of Ascites in an otherwise healthy patient
Ascites: accumulation of fluid within the peritoneal cavity
Causes: Cirrhosis (81%), Malignancy (10%), Heart Failure (3%), Tuberculosis (2%)(1)
Clinical Manifestations: progressive abdominal distension (painless or painful), can progress over days to months, weight gain, shortness of breath, early satiety, dyspnea (seen in later stages with increasing ascitic volume)
Diagnosis: established with combination of physical examination findings along with imaging (ultrasonography or advanced imaging with CT)
- Paracentesis typically required to evaluate cause of new onset ascites
- Analyzing ascitic fluid
- Appearance (clear, bloody, cloudy, milky)
- Cell count, differential
- Total protein
- Serum to ascites albumin gradient (SAAG) determination
- Culture
- Additional Ascitic fluid studies: culture, glucose concentration, LDH, Gram stain, amylase, concentration, Tuberculosis smear/culture/ adenosine deaminase activity, Cytology
Peritoneal tuberculosis (TB)
Most commonly occurs after reactivation of latent tuberculosis foci in the peritoneum which seeded there via hematogenous spread from a primary lung focus.2 Peritoneal TB may also occur via hematogenous spread during an active pulmonary TB or miliary TB infection. More rare is contiguous spread from tuberculous salpingitis or transmurally from infected small intestine.3 During the disease progression, there is spread of tubercles along the viscera and parietal peritoneum and ascites will develop secondary to proteinaceous fluid output from newly formed tubercules.
Specific to peritoneal TB, clinical manifestations will include ascites in 93% of cases, abdominal pain in 73%, and fever in over 50% of patients. These symptoms will have progressed for weeks to months before patients receive a diagnosis. Paracentesis will reveal a serum-ascites albumin gradient < 1.1 g/dL.4 In patients with more advanced peritoneal TB, which represents nearly 10% of cases, patients will present with a “doughy” abdomen or “dry” phase of the disease course related to fibro-adhesive changes. There should also be a higher clinical suspicion of TB peritonitis in patients who present with ascites but lack classic symptoms of chronic liver disease such as palmar erythema, spider angiomata, and dilated abdominal veins.5
Risk factors for TB peritonitis include cirrhosis, continuous ambulatory peritoneal dialysis, diabetes mellitus, underlying malignancy, steroid use, and acquired immunodeficiency syndrome (AIDS).6
If there is high concern for TB peritonitis, CT or MRI is helpful in the initial evaluation. CT imaging will commonly demonstrate ascites, thickening of the mesentery and omentum and of the peritoneum. Lymphadenopathy may be seen in the local mesentery and will likely show hypodense centers due to caseous liquefaction.7
Ascitic fluid analysis of those with TB peritonitis will likely show straw-colored ascites that will have a leukocyte count of 150 to 4000 cells/mm3 and consist of a lymphocytic pleocytosis. The protein will be over 3.0 g/dL and will have a SAAG of less than 1.1 g/dL unless they have an underlying cirrhosis. While sensitivity of AFB smears and mycobacterial cultures are low, culture sensitivity will increase with the amount of peritoneal fluid removed during the paracentesis.7
Treatment for patients with TB peritonitis is similar to patients with pulmonary TB and is usually accomplished with RIPE based therapy: Rifampin, Isoniazid, Pyrazinamide, Ethambutol. This regimen is given for 6 months.8
References:
1.) Runyon BA. Management of adult patients with ascites caused by cirrhosis. Hepatology 1998; 27:264.
2.) Mehta JB, Dutt A, Harvill L, Mathews KM. Epidemiology of extrapulmonary tuberculosis. A comparative analysis with pre-AIDS era. Chest 1991; 99:1134.
3.) Tang LC, Cho HK, Wong Taam VC. Atypical presentation of female genital tract tuberculosis. Eur J Obstet Gynecol Reprod Biol 1984; 17:355.
4.) Aguado JM, Pons F, Casafont F, et al. Tuberculous peritonitis: a study comparing cirrhotic and noncirrhotic patients. J Clin Gastroenterol 1990; 12:550.
5.) Vaid U, Kane GC. Tuberculous Peritonitis. Microbiol Spectr 2017; 5.
6.) Chow KM, Chow VC, Hung LC, et al. Tuberculous peritonitis-associated mortality is high among patients waiting for the results of mycobacterial cultures of ascitic fluid samples. Clin Infect Dis 2002; 35:409.
7.) Guirat A, Koubaa M, Mzali R, et al. Peritoneal tuberculosis. Clin Res Hepatol Gastroenterol 2011; 35:60.
8.) Johnson JL, Hadad DJ, Dietze R, et al. Shortening treatment in adults with noncavitary tuberculosis and 2-month culture conversion. Am J Respir Crit Care Med 2009; 180:558.
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