We present a case of a 24-year-old woman who works as a teacher on an indigenous reservation in a rural area. She often shared meals with the community, including dairy products like unpasteurized cheeses produced in the region. The patient has actively participated in animal sterilization events for dogs and cats and has been exposed to outdoor poultry. She has two children and no significant medical history, including hypertension or diabetes. The patient has never smoked or used drugs and has no significant sick contact, known TB exposure or recent travel to other endemic areas.
The patient consulted the emergency department due to a six-month history of constitutional and gastrointestinal symptoms, including bloating and diarrhea, along with a critical weight loss (15 kg), low-grade fever, nocturnal diaphoresis, gradual onset of ascites, and abdominal pain. The patient had previously consulted a local medical center, receiving treatment for gastrointestinal and urinary infections with frequent courses of antibiotics without clinical improvement. During the consultation, the patient reported no headache, cough, dyspnea, chest or joint pain, urinary symptoms, or menstrual cycle irregularities. Her vital signs were the following: Blood pressure of 100/70 mm Hg, heart rate of 90 beats/minute, respiratory rate of 14 breaths/minute, and temperature of 37.5 C .
On physical examination, she appeared thin and pale, and tolerated decubitus. The most significant finding was abdominal distension with a positive ascitic wave without collateral circulation, telangiectasias, or pain upon palpation. The moist mucosa showed no signs of ulcers; there was no jaundice, no jugular vein distention, no neck masses, a rhythmic heart without murmurs, and normal lung sounds. The extremities had no edema present, and the neurological exam was unremarkable.
The patient underwent initial laboratory tests outlined in (Table 1). The PPD skin test was negative, and the results of autoimmune testing showed some alterations and an elevated CA-125 level. A chest X-ray was conducted but yielded no significant findings. However, an abdominal computed tomography (CT) scan revealed thickening of the parametrium, parietal peritoneum, omentum, gastric cavity, intestinal lining, and intraperitoneal liquid with intermediate density in all compartments (Fig. 1). To further analyze the ascitic fluid, abdominal paracentesis was performed. The fluid was predominantly lymphocytic and had a serum ascites albumin gradient (SAAG) index of 0.3 (Table 2), which ruled out portal hypertension. Therefore, additional investigations were conducted to exclude the possibility of malignant pathologies, infectious, and inflammatory diseases.
The patient was evaluated by a gynecologist who performed a transvaginal ultrasound to investigate the possibility of gynecologic malignancies but found no abnormalities. Similarly, to rule out gastrointestinal malignancies, the patient underwent both endoscopy and colonoscopy, which were unremarkable. On the fourth day of hospitalization, a diagnostic laparoscopy revealed a friable peritoneum with numerous miliary-like micronodules covering the entire peritoneal and pelvic cavity (Fig. 2). Three days later, the pathology report revealed fibroconnective tissue with multiple confluent granulomas, high histiocytic cellularity and multinucleated giant cells surrounded by a lymphoplasmacytic inflammatory infiltrate, some of which contained central necrosis (Fig. 3).
Under the suspicion of peritoneal tuberculosis (PTB), the patient was started on anti-tuberculosis therapy eight days after admission. She began a six-month regimen of isoniazid, rifampicin, pyrazinamide, and ethambutol. The patient showed progressive improvement with the current treatment. A positive adenosine deaminase (ADA) test result of the peritoneal fluid was reported the following day and supported the diagnosis of PTB. Despite negative microbiological culture for bacteria of ascites fluid, gram stain, Auramine-rhodamine stain, and GeneXpert MTB/RIF, peritoneal tuberculosis was confirmed four weeks after the diagnostic laparoscopy through a positive culture for mycobacteria in the peritoneal tissue.
The patient was discharged 15 days after admission with a noticeable improvement in the initial symptoms. She has been followed up in the infectious disease clinic for a year after finishing the antituberculous treatment. She reported weight gain, adequate oral tolerance, and no new episodes of diarrhea.