SHM Converge Scientific Abstract ePoster Gallery-No Acid-Fast? Not So Fast...

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A 41-year-old woman from Haiti with uterine fibroids, menorrhagia, and iron deficiency anemia presented with two months of abdominal distension. She was tachycardic and had moderate ascites with diffuse tenderness. CT abdomen/pelvis showed small-to-moderate ascites, diffuse peritoneal enhancement, infiltrated mesenteric fat suggestive of possible omental caking, and mild colonic wall thickening.<br /><br />Diagnostic paracentesis revealed a low SAAG (0.6), high protein ascitic fluid, and lymphocyte predominance, pointing away from portal hypertension and toward inflammatory, infectious, or malignant causes. Tumor markers were notable only for elevated CA-125 and LDH. Gynecologic malignancy work-up, including transvaginal ultrasound, pelvic MRI, endometrial biopsy, and ascitic cytology, was negative.<br /><br />Given the patient’s origin from a TB-endemic area, constitutional symptoms, and prior positive TB screening, abdominal tuberculosis became a leading concern. Quantiferon gold was positive. Repeat paracentesis included specialized tests; ascitic ADA was markedly elevated at 72 U/L, supporting TB despite negative AFB smear and cultures. Because malignancy was not found and suspicion for TB remained high, empiric RIPE therapy was started.<br /><br />She later underwent diagnostic laparoscopy, which showed dense adhesions, omental caking, and peritoneal deposits—findings highly suggestive of abdominal TB. Biopsies from the peritoneum and omentum demonstrated multiple non-caseating granulomas, while AFB cultures remained negative.<br /><br />The case highlights a structured approach to new-onset ascites using SAAG, cell count, protein, and targeted testing. It also emphasizes that abdominal tuberculosis can be a clinical diagnosis even when microbiologic studies are negative, and treatment should not be delayed when suspicion is strong.

Asset Subtitle

Natalie Plick

Meta Tag

Author List Natalie Plick, Vinh-Tung Nguyen

Category Clinical Vignettes

Concept Cirrhotic Ascites

Concept Serum-Ascites Albumin Gradient

Concept Dry Adhesive Tuberculous Peritonitis

Concept Low Serum-Ascites Albumin Gradient

Concept Malignancy

Distinguished Non-Finalist

Presenter Organization Mount Sinai Hospital

Presenting Author Natalie Plick

Track Adult

Keywords

abdominal tuberculosis

ascites

low SAAG

peritoneal enhancement

omental caking

Quantiferon gold

ascitic ADA

RIPE therapy

granulomas

lymphocyte predominance

Cirrhotic Ascites

Serum-Ascites Albumin Gradient

Dry Adhesive Tuberculous Peritonitis

Low Serum-Ascites Albumin Gradient

Malignancy