A 78-year-old man with no significant history was found to have prostate cancer stage cT2cN0M0, Gleason score of 4 + 5 with a serum prostate-specific antigen value of 8.05 ng/cc in June 2016. He underwent RALP with extended lymph node dissection. The operation time was 339 minutes and bleeding volume was 150 cc. The Foley catheters were removed on postoperative day 6, according to the usual protocol. No urinary leakage from the anastomosis sites was observed. He was discharged without event on postoperative day 14. Pathologic diagnosis was pT3b, Gleason score of 4 + 5, and positive resection margin. Lymph node metastasis was not detected.
On postoperative day 25, he presented with fever and general fatigue. Physical examination showed body temperature of 38.2 C, regular pulse (84/min), blood pressure 145/84 mm Hg, and a distended abdomen. Initial laboratory findings were a normal white blood cell (WBC) count and increased C-reactive protein level (11.2 mg/dL). Liver and renal functions were normal. Computed tomography (CT) showed massive ascites and extensive thickened peritoneum (Fig. 1). CT of lungs showed slightly worsening granular shadows and a mucous plug in the left upper lobe (Fig. 2). Initial ascites sample was cloudy, with increased WBCs and normal creatinine level, precluding urinary leakage. Bacterial infection of a lymphocele was considered and cefmetazole 2 g/day for 3 days was prescribed but was ineffective. Blood, urine, sputum, and ascites cultures were negative.
Repeat abdominocentesis revealed 2900 WBCs/mm3 (87% lymphocytes) and adenosine deaminase of 140 IU/L (normal 0-33 IU/L). Ziehl-Neelsen staining and initial polymerase chain reaction (PCR) for M. tuberculosis were negative. Interferon-gamma release assay was indeterminate. Abdominocentesis was performed repeatedly, attempting to diagnose peritoneal TB. The fourth ascites sample was positive. The cultures and PCR of urine, sputum, and gastric lavage for TB were negative. The patient was found to have peritoneal TB. Anti-TB therapy with isoniazid (INH) (300 mg/day), rifampicin (RFP) (450 mg/day), ethambutol (EB) (1000 mg/day), and pyrazinamide (PZA) (1200 mg/day) was initiated. His temperature dropped immediately, and his general condition improved (Fig. 3). After the initial 2-month phase, INH and RFP were given for another 4 months. Three months after oral treatment completion, there was no recurrence of infection or ascites.
CT of the left upper lung:. preoperative, and.