Volume 3, Issue 4 | August 2016
Image| Pathology

Laparoscopic Appearance of Peritoneal Tuberculosis

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Moaz Sial, MD, Mohammad Bilal, MD, and Patrick Perri, MD

Department of Internal Medicine, Allegheny Health Network, Pittsburgh, PA

ACG Case Rep J 2016;3(4):e117. http://dx.doi.org/10.14309/crj.2016.90. Published online: August 31, 2016.

Case Report

A 37-year-old Indian male with history of daily alcohol use presented to the hospital with abdominal pain and distention for 2 weeks. Abdominal and pelvic computed tomography showed ascites, peritoneal thickening with omental infiltration. Chest x-ray was normal, and sputum analysis was negative for infection. Ascitic fluid analysis showed a serum ascites albumin gradient of 0.8 g/dL, total protein level of 5.4 g/dL, and lymphocyte predominant cells. Blood cultures were negative. The patient also had an elevated CA 125, but work up for malignancy was negative. Finally, a laparoscopy was performed, which revealed multiple small homogeneous whitish nodules scattered all over the peritoneum and omentum (Figure 1). A biopsy was obtained, which showed necrotizing granulomas (Figure 2). The diagnosis of peritoneal tuberculosis (PTB) was confirmed. The patient was placed on antituberculosis therapy and discharged with close out patient follow-up.

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Figure 1. Laparoscopy showing multiple small whitish nodules consistent with peritoneal tubercules.

Peritoneal tuberculosis is a rare disease in developed countries like United States. However, it should be considered high in the differential diagnosis in the immigrant population especially from areas endemic with tuberculosis. Peritoneal tuberculosis poses a great challenge in diagnosis because of the nonspecific features of the disease, which may lead to diagnostic delays and development of complications. This condition is regarded as a great mimicker of other abdominal pathology, especially intraabdominal malignancies, peritoneal carcinomatosis, and liver cirrhosis. A high index of suspicion is an important factor in early diagnosis. A recent study of 43 cases of PTB showed that initial screen for mycobacterium and final cultures in the ascitic fluid were negative in all the patients.1 However, surgically obtained peritoneal biopsies were positive in all 43 patients for mycobacterium.

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Figure 2. Peritoneal biopsy showing necrotizing granulomas along with Langhans giant cells.


Disclosures

Author contributions: M. Sial, M. Bilal, and P. Perri performed literature review and wrote the manuscript. P. Perri edited the manuscript and is the article guarantor.

Financial disclosure: None to report.

Informed consent was obtained for this case report.

Disclosure statement: This case was presented as a poster at the 2015 ACG Annual Meeting; October 16-21, 2015; Honolulu, Hawaii.

Correspondence: Mohammad Bilal, Department of Internal Medicine, Allegheny Health Network, 320 E North Ave, Pittsburgh, PA 15212 (mbilal@wpahs.org).

Received December 25, 2015; Accepted February 18, 2016


Reference

  1. Guirat A, Affes N, Rejab H, Trigui H, Ben Amar M, Mzali R. Role of laparoscopy in the diagnosis of peritoneal tuberculosis in endemic areas. Med Sante Trop. 2015;25(1):87–91. Article | PubMed

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© 2016 Sial et al. This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-nd/4.0.