Case Presentation

Ezana M. Azene

HPI – Day 1

• 35 y/o immigrant from Guatemala living in U.S. for past 3 years

• CC: 3 months burning left-sided abdominal pain radiating to epigastrium and back

Present Absent

Decreased appetite, 20 lb wt loss over 2-3 months

Subjective fever, chills, night sweats, incarceration, tattoos, blood transfusions, IV drug use

Watery diarrhea for 2 months Sexual activity (Married and sexually abstinent since leaving Guatemala)

Crowded living conditions (5 other immigrants)

SOB, headache, dysuria, skin rash, myalgias, arthralgias

1-2 weeks cough, occasionally productive Hemoptysis

Physical Exam – Day 1

• Febrile• Abdomen soft with moderate TTP diffusely, mild

guarding without rebound, normal bowel sounds, possible splenomegaly

• Remainder of exam normal

Relevant Initial Lab-work – Day 1

• Hct: 26↓, WBCC: 3.3 ↓ (4% ↓ lymphocytes)• Alb: 1.7 ↓, TP: 7.3 (gamma gap = 5.6↑)• AlkPhos: 727 ↑ (with GGT ↑), AST 116 ↑, ALT 81

↑• Lipase: normal

Initial CE CT – Day 1

2 cm MIP

Initial CE CT – Day 1

Initial CE CT – Day 1

Initial CE CT – Day 1

CT report – Day 1

• “… very suggestive of mycobacterial … infection. Extensive fat stranding makes lymphoma or other malignancy less likely.”

Admitting Plan

• IV fluids• HIV serology• TB w/u (including sputum AFB and sputum/blood

culture)• Negative pressure isolation and droplet

precautions

Abdominal U/S – Day 2

SpleenOmentum

Increased omental echogenicity

U/S Report

• “Mass-like thickening of the omentum. Findings worrisome for TB peritonitis”

Hospital Course• HIV positive (CD4 ~ 60) – Day 2• ID consult – Day 2

– DDx: Lymphoma > disseminated histoplasmosis > typhoid fever > TB > septic emboli

– “Would continue off antimicrobial therapy”– Recommended tissue biopsy

• Hematology consult – Day 4– DDx: Lymphoma > TB

Sputum

AF

B negative

Culture negative

Hospital Course

• Abdominal paracentesis – Day 5– Reactive cells, no malignancy– AFB negative– Cultures pending

• Respiratory isolation stopped – Day 5 or 6• Bone marrow biopsy – Day 6

– Negative

• Echocardiogram – Day 10– Normal

Sputum

AF

B negative

Culture negative

Hospital Course

• Unstable, ICU transfer – Day 10– Non-con CT: calcified perihepatic lymph node (missed

on CE CT)

• Liver core biopsy – Day 11– Granuloma with rare filamentous AFB

• TB Rx started – Day 11 (I think…)

Actinomyces?TB?Nocardia?

Hospital Course• CT guided omental biopsy – Day 12

– Benign fibroadipose tissue with focal granuloma

• Patient rapidly improved and discharged home – Day 19

Post-Hospital Course• Initial induced sputum cultures positive for TB 4

days after discharge• Initial blood cultures positive for TB 1 day after

discharge• Liver biopsy culture positive for TB 4 days after

discharge• Omental biopsy culture positive for TB 6 days

after discharge• Ascites was never positive for TB or AFB

Current Patient Status

• Not fully compliant with D.O.T.S. and HAART– May need incarceration

Mechanism of Spread to Peritoneum, Omentum, and Mesentery

• Infection of GI mucosa by contaminated milk or swallowed sputum followed by transmural spread

• Direct hematogenous spread

• Lymphatic spread with direct extension– e.g. from ruptured necrotic

lymph nodesEur Radiol (2004) 14:E103–E115

The Internet Journal of Infectious Diseases. 2010 Volume 8 Number 2

Ascites

Tiny peritoneal nodules(appear confluent on CT)

Omental thickening

Through the Laparoscope

Frequency of TBP

• TB peritonitis occurs in < 4% of TB patients• However, in developing countries, up to …

– 30% of non-pulmonary TB involves TB peritonitis– 20% of all ascites is due to TB peritonitis

• Increased risk with alcoholism, cirrhosis, renal failure, diabetes mellitus, malignancy, intravenous drug abuse, steroid therapy, and AIDS.

Singapore Med J 2008; 49(6) : 488

Eur Radiol (2004) 14:E103–E115

Mortality of TBP

• 15-60% in post-antibiotic era– Higher when hepatic cirrhosis present

• “The high mortality for tuberculous peritonitis is explained, at least in part, by its highly variable and often nonspecific clinical presentation and the practical difficulties in establishing an early bacteriologic diagnosis.”

• EARLY INITIATION OF THERAPY REDUCES MORTALITY

Chow et al. Clinical Infectious Diseases 2002; 35:409–13

Classic Types of TBP (basically useless)

• Wet type (90%)– Free or loculated ascites

• Fibrotic fixed type occurs (60%) – Omental masses and matted loops of bowel and

mesentery

• Dry or plastic type (10%)– Caseous lymph nodes, fibrous peritoneal reaction, and

dense adhesions

• Our case was Wet + Dry

Journal of Clinical Imaging 28 (2004) 340–343

Biochemical Diagnosis of TBP

• Adenosine Deaminase elevated in ascites– In one meta-analysis, ADA levels showed high

sensitivity (100%) and specificity (97%)

• CA 125 may be elevated (mimicking ovarian CA)

J Clin Gastroenterol Volume 40, Number 8, September 2006

Microbiological Diagnosis of TBP

• Ascites smear, PCR and culture have extremely low sensitivity (<5% in most studies)

• Lymphocytic exudate usually present• Tissue biopsy usually needed

– Omentum or lymph nodes– Granulomas (usually caseating)– Not always smear positive– High sensitivity with liquid culture

J Clin Gastroenterol Volume 40, Number 8, September 2006

CT Appearance Suggestive of TBP

• Smooth, mild, non-nodular peritoneal thickening with pronounced enhancement

• “Smudged” appearance of omentum (extensive stranding)

• Presence of mesenteric macronodules (> 5 mm)• Splenic hypodensities and splenomegaly• Low density and/or calcified lymph nodes• Ascites may be higher density than water

Journal of Computer Assisted Tomography Volume 20(2), March/April 1996, pp 269-272Eur Radiol (2004) 14:E103–E115Singapore Med J 2008; 49(6) : 488

US Appearance of TBP

• Increased omental echogenicity• Diffuse, hypoechoic peritoneal thickening (2-6

mm)• Echogenic fibrous strands creating locculations of

ascites• Most useful for guiding biopsy

DDx

• Omental and peritoneal findings– Malignancy (carcinomatosis (esp. ovaian), mesothelioma, lymphoma)– Non-TB peritonitis

• Hypodense lymph nodes– Whipple disease– Typhoid fever– Celiac Disease– Burkitt/Burkitt-type lymphoma– Treated lymphoma and necrotic metastases

• Splenic Hypodensities– Lymphoma– Sarcoidosis– Non-TB microabscesses– Lymphatic malformations– Vascular anomalies

Summary

• TB peritonitis carries high mortality and requires rapid treatment

• Image-guided biopsy (omental, lymph node) is best chance for definitive diagnosis– Usually no need for surgical biopsy

• Imaging, especially CT, may be 1st clue to diagnosis– If characteristic findings are present in appropriate

epidemiological setting… TREAT, then stop treatment if you’re wrong

Summary

• Think of TB Peritonitis if 2 or more…– Extensive omental and mesenteric fat stranding– Hypodense abdominal lymph nodes– Splenic hypodensities– Higher than normal density ascites (not like blood,

though)– Smooth peritoneal thickening– Moderate peritoneal enhancement