University of South Florida Morsani College of Medicine Tampa, FL
Introduction: Peritoneal tuberculosis (TB) is a rare presentation of extra-pulmonary TB, comprising only 5% of extra-pulmonary TB cases. Patients oftentimes present with non-specific complaints and without typical Mycobacterium tuberculosis risk factors. Additionally, diagnostic testing lacks high sensitivity and specificity with further invasive methods frequently necessitated. We present an unusual case of peritoneal TB presenting as non-localized abdominal pain, facilitating insight into this uncommon disease.
Case Description/Methods: A 53-year-old female with a past medical history of hypothyroidism presented with joint pain diagnosed as seronegative rheumatoid arthritis and subsequently began treatment with methotrexate and adalimumab for one year.
Within the following year, she experienced chronic right lower quadrant (RLQ) abdominal pain, fevers, night sweats, fatigue, and ascites. Extensive work-up revealed a positive QuantiFERON gold TB test. A diagnostic laparoscopy with peritoneal biopsy successively demonstrated elevated CA-125 and large-volume ascites. Mycobacterium tuberculosis PCR and Grocott methenamine silver staining were negative. One of two acid-fast bacillus (AFB) smear and cultures yielded a positive result.
Our patient was treated for peritoneal TB. She continued to have several years of chronic RLQ abdominal pain several months after RIPE treatment completion, undergoing a cholecystectomy and three adhesion lysis procedures with mild symptomatic improvement and subsequent worsening thereafter. An operative note highlighted the large amount of adhesions from the patient’s liver to her diaphragm and anterior abdominal wall, appearing similar to Fitz-Hugh-Curtis syndrome. She continues to have chronic abdominal pain and is followed closely by her treatment team.
Discussion: Our patient was on immunosuppressive medications and had a history of travel to Mexico, a high TB burden country. Notably, AFB smear and culture has a poor sensitivity for peritoneal TB, oftentimes necessitating laparoscopic peritoneal biopsy for further diagnosis. Our patient was empirically treated for peritoneal TB before AFB culture yielded positive results, given her B symptoms and positive QuantiFERON test. She also had an elevated CA-125 value, which is associated with peritoneal TB and may be used in patients with a negative AFB stain. Our patient experienced recurrent adhesions, an unfortunate and persistent consequence of the inflammatory nature of peritoneal TB.
