SHM Converge Scientific Abstract ePoster Gallery-Unmasking the Unseen: Broadening the Differential for Ascites in Cirrhosis, a Case for Peritoneal Tuberculosis and Beyond

Pdf Summary

This case describes a patient with persistent ascites in whom the cause was not immediately clear. Initial paracentesis showed a low SAAG, elevated PMN count, and persistent fluid accumulation despite treatment for suspected spontaneous bacterial peritonitis. Because the patient also had a known left adnexal mass and elevated CA-125 and CA19-9, gynecologic oncology was consulted, but ovarian malignancy was felt to be unlikely.<br /><br />By day 9, symptoms continued, prompting further evaluation, including TMP-SMX, a TIPS procedure, QuantiFERON-TB Gold testing, and abdominal CT imaging. The QuantiFERON test was strongly positive, and CT findings suggested tuberculous peritonitis. Chest CT showed no evidence of pulmonary tuberculosis. After discharge, ascitic fluid cultures grew acid-fast bacilli, later confirmed as Mycobacterium tuberculosis, and the patient was started on RIPE therapy with infectious disease follow-up.<br /><br />The discussion emphasizes that peritoneal tuberculosis is a rare but important cause of ascites and typically occurs through hematogenous spread from lung foci. It often presents slowly, with common symptoms including ascites, abdominal pain, and fever, and diagnosis may take months. Evaluation relies on clinical suspicion, ascitic fluid analysis, imaging, and ideally smear, biopsy, or culture, since chest radiographs and PPD testing may lack sensitivity.<br /><br />This patient had complicated primary biliary cholangitis (PBC), which may have contributed to immunosuppression and increased susceptibility to TB. A prior cohort study found higher mortality in peritoneal TB patients with comorbidities such as cirrhosis, renal failure, diabetes, and malignancy. In this case, ascitic studies were somewhat atypical because neutrophils predominated rather than lymphocytes, and portal hypertension was not evident. Overall, the case highlights the need to consider peritoneal TB in persistent, unexplained ascites, especially when standard treatments fail.

Asset Subtitle

Natalia Caprile

Meta Tag

Author List Daniel Bianchi, Nanno Dandi, Natalia Caprile

Category Clinical Vignettes

Concept Dry Adhesive Tuberculous Peritonitis

Concept Cirrhotic Ascites

Concept Ascitic Fluid Analysis

Concept Serum-Ascites Albumin Gradient

Concept Polymorphonuclear Cell Count

Distinguished Non-Finalist

Presenter Organization Rush Medical College

Presenting Author Natalia Caprile

Track Adult

Keywords

peritoneal tuberculosis

persistent ascites

Mycobacterium tuberculosis

QuantiFERON-TB Gold

ascitic fluid culture

low SAAG

tuberculous peritonitis

RIPE therapy

primary biliary cholangitis

abdominal CT

Dry Adhesive Tuberculous Peritonitis

Cirrhotic Ascites

Ascitic Fluid Analysis

Serum-Ascites Albumin Gradient

Polymorphonuclear Cell Count