A 22-year-old woman presented with abdominal distention and intermittent left lower quadrant pain for 3 weeks. She also complained of hot flashes, night sweat, anorexia, and weight loss of 5 Kg within 20 days. Laboratory examination in the primary hospital revealed the serum-ascites albumin gradient (SAAG) <11 g/L (albumin level in serum and ascites were 34.3 g/L and 24.2 g/L, respectively), but no malignant cells was found in ascitic fluid specimen. The diuretics had limited therapeutic effects on relieving symptoms, and the patient was transferred to our hospital for further diagnosis and treatment thereafter.
On admission, physical examination was significant for pale skin, percussive dullness on the left chest and left lower quadrant tenderness with shifting dullness. Laboratory tests showed the decreased hemoglobin (80 g/L, normal 115-150 g/L), decreased leukocyte (2.17 x 109 /L, normal 3.5-9.5 x 109 /L), normal platelet counts, increased aspartate aminotransferase (53 IU/L, normal <35 IU/L), decreased albumin (35 g/L, normal 40-55 g/L), and prolonged prothrombin time (14.5 s, normal 9.6-12.8 s). The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were both elevated (45 mm/h and 95 mg/L, respectively). Severe esophageal varies was found by esophagogastroduodenoscopy. Contrast-enhanced computed tomography (CT) suggested massive pleural effusion on the left chest (Figure 1A), swollen and thickening peritoneum, and multiple enlarged and calcified lymph nodes located at porta hepatis and peripancreatic regions (Figure 1B). The portal venous stenosis resulted in cavernous transformation of portal vein (CTPV), distal portal venous aneurysm, and enlarged spleen with dilated splenic vein (Figures 1C,D). Additionally, pleural fluid proves to be exudative with an elevated adenosine deaminase (ADA) level (41 IU/L) and ultrasound-guided pleural biopsy was performed afterwards. The histopathological changes showed granulomatous inflammation and TB-DNA was detected by real-time quantitative polymerase chain reaction. Conclusively, the patient was diagnosed with extrapulmonary TB involved the pleura, peritoneum and celiac lymph nodes.
The symptoms completely resolved after six-month ATT with the combination of isoniazid, rifampicin, ethambutol and levofloxacin. ESR and CRP returned to the normal range and chest CT revealed the effective control of pleural effusion (Figure 2A). However, the abdominal distension with massive ascites recurred six months later. The SAAG (>11 g/L, albumin level in serum and ascites were 42.4 g/L and 28.2 g/L, respectively) indicated the ascites is due to PHT. Furthermore, abdominal CT angiography (CTA) with three-dimensional reconstruction showed severe stenosis of main portal vein constricted by the calcified lymph nodes (Figures 2B-D). Considering the poor response of the vascular complication to ATT, portal venous angioplasty by balloon dilation and stent implantation was performed via percutaneous transhepatic approach. The proximal-distal pressure gradient of the portal vein decreased from 19 to 6 mmHg. Besides, portal vein at the hepatic hilum was clearly displayed, and collateral varices could not be seen after the procedure (Figure 3). The ascites resolved promptly and continued ATT were administrated after discharge, with no recurrence of ascites occurred during the six-month follow-up.