Peritoneal Tuberculosis in an Immunocompetent, Unknown Risk Patient

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. 1. Introduction Although most prevalent as a pulmonary disease, tuberculosis can affect any part of the body, including the peritoneum. Most often, 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]. The rationale of testing for latent tuberculosis infection is to identify individuals who are at increased risk for the development of tuberculosis. Purified protein derivative (PPD) test along with chest X-ray is a widely available screening method. Interpretation of negative PPD test raises a concern of the possibility of false negative, however no definite test exists to help determine between true negative and false negative. 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