SHM Converge Scientific Abstract ePoster Gallery-Unusual Cause of Abdominal Pain: A Case of Peritoneal Tuberculosis

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This case report describes a 33-year-old Filipino man with a prior history of treated latent tuberculosis who presented with one month of worsening abdominal pain, nausea, poor appetite, weight loss, fevers, and night sweats. He had immigrated from the Philippines to Hawaii about 10 years earlier. On exam, he had abdominal distention, diffuse tenderness, shifting dullness, and periumbilical ecchymosis, suggesting ascites. Labs showed microcytic anemia and thrombocytosis.<br /><br />Initial evaluation raised concern for malignancy versus infection. Chest imaging was unremarkable. Paracentesis demonstrated lymphocyte-predominant ascites with low SAAG and elevated ADA, but ascitic fluid cultures, AFB smear, and cytology were negative. Because peritoneal tuberculosis can closely mimic peritoneal carcinomatosis, a peritoneal biopsy was performed. Biopsy revealed necrotizing granulomas with AFB positivity, and Mycobacterium tuberculosis PCR was positive, confirming the diagnosis of peritoneal tuberculosis. Sputum AFB was negative x3 and HIV testing was negative.<br /><br />The patient was started on RIPE therapy (rifampin, isoniazid, pyrazinamide, ethambutol), but treatment was complicated by acute liver injury, requiring temporary discontinuation. He was discharged with plans to restart therapy once liver enzymes improved, using rifampin and ethambutol briefly followed by isoniazid for six months.<br /><br />Key teaching points include: extrapulmonary TB accounts for about 18% of TB cases, and only a small fraction involves the peritoneum; peritoneal TB may be clinically and radiographically indistinguishable from malignancy; and peritoneal biopsy is often necessary for definitive diagnosis, especially when paracentesis is nondiagnostic. RIPE therapy remains first-line, but patients must be monitored for hepatotoxicity.

Asset Subtitle

Scott Nishioka

Meta Tag

Author List Christina Chong, Faris Abu Za'nouneh, Jessica Kim, Joshua Knapp, Katelyn Saiki, Scott Nishioka, Yusuke Miyatani

Category Clinical Vignettes

Concept Dry Adhesive Tuberculous Peritonitis

Concept Peritoneal Biopsy

Concept RIPE Therapy

Concept Cirrhotic Ascites

Concept Lymphocyte-Predominant Ascites

Distinguished Non-Finalist

Presenter Organization University of Hawaii

Presenting Author Scott Nishioka

Track Adult

Keywords

peritoneal tuberculosis

extrapulmonary tuberculosis

ascites

necrotizing granulomas

Mycobacterium tuberculosis

RIPE therapy

hepatotoxicity

peritoneal biopsy

lymphocyte-predominant ascites

latent tuberculosis

Dry Adhesive Tuberculous Peritonitis

Peritoneal Biopsy

RIPE Therapy

Cirrhotic Ascites

Lymphocyte-Predominant Ascites