A 47-year-old previously healthy female presented with generalised body swelling, disproportionate ascites, loss of appetite, and loss of weight for four months' duration. She denied any fever, night sweats, yellowish discolouration of the eyes, hematemesis, melena, chronic cough, and haemoptysis. She reported no history of orthopnoea and paroxysmal nocturnal dyspnoea, and her urine output remained normal.
Her past medical history was not significant for any liver, renal, or cardiac disease. She denied any past or contact history of TB. She reported no use of alcohol or herbal medications and no intravenous drug abuse. She was in a monogamous relationship and she denied any family history of liver or renal disease.
She was afebrile on admission and her vitals included a pulse rate within normal limits. On exam, she was emaciated with a body mass index of 18, and she had significant ascites with mild ankle oedema. She was anicteric and did not have any lymphadenopathy, hepatosplenomegaly, or the peripheral stigmata of chronic liver disease. Respiratory system and cardiovascular examinations were within normal limits. On eye exam, there was no evidence of choroid tubercles.
The initial laboratory findings are summarised in Table 1.
The anaemia workup, including serum iron studies, vitamin B12, and folate testing, was normal. A blood picture revealed normochromic normocytic anaemia and thrombocytosis, suggestive of anaemia of chronic disease. Thyroid function tests were normal. She did not have any proteinuria, and her international normalised ratio (INR) was normal. Repeated blood cultures, urine culture, and sputum culture were sterile, and a human immunodeficiency virus (HIV) fourth-generation test was negative. CA 125 was mildly elevated to 175 U/ml (<46 U/ml).
The initial chest x-ray (CXR) was normal, and her transthoracic two-dimensional echocardiography showed normal systolic and diastolic functions and no evidence of constrictive pericarditis. A transvaginal ultrasound (US) did not reveal any ovarian pathology. Meanwhile, an abdomen US revealed a mildly hyperechoic liver with moderate ascites. Contrast Enhanced Computed Tomography (CECT) of the abdomen and pelvis revealed a normal-sized liver with evidence of heterogenicity of the liver parenchyma with minimal nodularity of the liver surface and moderate ascites with no portal vein thrombosis or lymphadenopathy. The spleen, gallbladder, biliary tract, and intestines were normal, as were the ovaries. The findings were in favour of possible decompensated chronic liver disease (CLD). However, the CLD workup did not reveal any potential aetiology (Table 2). Upper gastrointestinal endoscopy (UGIE) was normal and did not show any evidence of portal gastropathy or varices.
The initial diagnosis of possible cryptogenic CLD was made, and the patient was started on spironolactone and furosemide. Even though the diagnostic paracentesis was planned on admission, it was delayed due to the patient's refusal, but we were to do initiate after a few days. The analysis of the ascitic fluid revealed an exudative picture. There was no evidence of spontaneous bacterial peritonitis, and the ascitic fluid cytology was negative for malignant cells.
With elevated inflammatory markers and an exudative type of ascites, we decided to proceed with further investigations to rule out possible peritoneal TB. The ascitic fluid acid-fast bacilli (AFB) test was negative. The ascitic fluid bacterial, TB culture, and TB Gene Xpert were negative. The tuberculin sensitivity test (Mantoux) was positive at 17 mm without ulceration. Her repeated sputum for AFB, TB culture, and GeneXpert were negative.
Because the clinical picture did not fit the imaging findings, we decided to proceed with diagnostic laparoscopy and peritoneal biopsy. The laparoscopy was in favour of miliary TB (Figure 1) and the peritoneal biopsy revealed granulomatous inflammation with caseous necrosis favouring TB. She was started on anti-TB treatment (ATT), and on initial follow-up, she showed improvement in her clinical, biochemical, and radiological parameters. Her fever settled with ATT, and her ESR was 15 mm/1st hour and CRP was 12 mg/l at 3 weeks after the initiation of ATT.