A 41-year-old Moroccan male, who had been living in Spain for 7 years, was admitted to the rapid diagnosis unit of Internal Medicine of the Complejo Asistencial Universitario de Leon, Spain with a 6 month history of abdominal pain, weight loss (10 kg in two months), fatigue and diarrhea. The patient had no relevant past medical history. He lived in an urban area, working as an electrician, and had no reported animal contact and denied ingesting unpasteurized dairy products.
A depressible, soft and painless abdomen was revealed on examination with diffuse discomfort on palpation and no signs of guarding. Laboratory tests showed a normal white blood cell count and a normocytic anemia. A HIV antibody test was negative. Mantoux test (17 mm) and interferon gamma release assays were both positive. Chest X-ray and chest CT scan were normal and an abdominal CT scan showed mild ascites with small bilateral inguinal lymphadenopathy.
An intense plastic peritonitis was encountered at laparoscopy affecting all abdominal spaces with soft rubbery adhesions that virtually blocked all initial access to the abdominal cavity. Countless amount of nodules were seen on the omentum and both the parietal and the visceral peritoneum and mainly on Glisson's sheath and digestive tube serosal surfaces (Fig. 1). A small amount of fluid was observed around liver and spleen. Careful adhesiolysis was needed for exposure and to obtain fluid samples. Various biopsies were taken from the omental and peritoneal nodules. All specimens were sent for microbiology, cytology and pathological examinations. Histopathology showed non-necrotizing granuloma. Acid fast stains of the tissue were negative. There was no evidence of malignancy. No acid fast bacilli (AFB) were seen on stain of the peritoneal fluid. The fluid PCR and culture were also negative for mycobacteria.
Mycobacterial DNA was identified in the biopsy by PCR (Xpert  MTB/Rif PCR, Cepheid AB, Solna, Sweden). Mycobacterial growth was detected with Bactec  MGIT  960 system, (Becton Dickinson, Oxford, UK) on Day 26 of the peritoneal biopsy. Immunochromatographic test for MTC (TB Ag MPT 64 rapid, Standard diagnostics, INC, Republic of Korea) classified this isolate within the M. tuberculosis complex. Identification and susceptibility testing were performed as described at the National de Mycobacterium laboratory, Instituto Carlos III, Majadahonda, Madrid, Spain as M. caprae being fully sensitive to isoniazid, streptomycin, ethambutol, rifampin and pyrazinamide. The M. caprae isolate corresponded to spoligotype SIT646 in the international SITVIT database and SB0416 in the Mycobacterium bovis spoligotype database (http://www.Mbovis.org). It was performed Aragon Institute for Health Research (IIS Aragon), Zaragoza, Spain as previous described.
Treatment for tuberculous peritonitis was initiated after the laparoscopy with a 4-drug regimen of including isoniazid, rifampin, pyrazinamide and ethambutol. Two months after starting antituberculous treatment, the patient reported improvement of symptoms. The patient completed 2 months of four-drug therapy without complications and an additional 7 months of isoniazid and rifampin. He is asymptomatic.