Peritoneal Tuberculosis Mimicking Peritoneal Carcinomatosis

A 67-year-old male presented with fatigue, abdominal pain , and 30-pound weight loss over 3 months. Computerized tomography (CT) abdomen displayed ascites with thickening and enhancement of the peritoneum and mottled nodular appearing as soft tissue consistent with omental caking worrisome for peritoneal carcinomatosis. A paracentesis revealed white blood cell count of 2,500 with 98% lymphocytes and serum ascites albumin gradient of 0.9？g/L. No acid-fast bacilli were seen by microscopic exam and culture was negative. Purified protein derivative skin test (PPD) was negative and CXR did not reveal any infiltrates. Esophagogastroduodenoscopy (EGD) and colonoscopy were unrevealing. The patient underwent exploratory laparotomy with round ligament and peritoneal biopsies that revealed numerous necrotizing granulomas. Acid-fast bacteria Ziehl-Neelsen stain (AFB) of the biopsy specimen revealed single acid-fast bacilli. Treatment for M. tuberculosis was initiated and final culture revealed that mycobacterium tuberculosis was sensitive to Isoniazid, Rifampin, Ethambutol, and Pyrazinamide. After 6 months of treatment, the ascites and peritoneal carcinomatosis resolved. 1. Introduction Extrapulmonary tuberculosis (ETB) comprises 18.7% of all tuberculosis cases in the USA. Peritoneal tuberculosis, which is caused by mycobacterium tuberculosis, is an uncommon form of ETB and is seen only in 4.7% of all ETB cases [1]. Although both primary tuberculosis (PTB) and ETB cases have decreased over time in the USA, the slower decrease in ETB cases caused a relative increase in the ETB compared to PTB. Peritoneal involvement is the sixth most common site of ETB in the USA and usually is a result of hematogenous spread from a pulmonary focus or direct spread from adjacent organs. 2. Case Presentation A 67-year-old male presented with fatigue, anemia, and weight loss of 30 pounds in the last 3 months. He denied history of alcohol consumption and endorsed history of travel to Philippines. On physical examination he had pale conjunctiva bilaterally and shifting dullness on abdomen and rest of his physical examination was normal. Initial laboratory studies revealed Hb of 6.1？gm/dL, MCV 58 FL, creatinine 1.50？mg/dL, albumin 3.3？gm/dL, INR 0.77, normal ALT/AST/ALP, and total bilirubin. CXR did not reveal any infiltrates (Figure 1). CT abdomen showed moderate amount of ascites with diffuse thickening of peritoneal surfaces suggestive of peritoneal carcinomatosis (Figure 2). Due to these CT abdomen findings and history of recent weight loss, he underwent a work-up for malignancy with