The patients, 25 years old man, normotensive, non-diabetic, from middle class socioeconomic background presented with abdominal pain, abdominal distention and fever for 1 month. He had no history of joint pain, hematemesis and/or melena, cough or breathlessness, chest pain or palpitation, facial puffiness and urinary complains. He never experienced jaundice and his bowel habit was normal. On clinical examination, the patient was ill looking, anemic, icteric, well oriented and cooperative with average built and nutrition. He had no bony tenderness, lymphadenopathy and any organomegaly. He had ascites and sluggish of bowel sound but liver dullness was not obliterated. He had no edema, flapping tremor and stigmata of chronic liver disease. Others systemic examination revealed no abnormality. Finally, the patient was admitted to a tertiary care hospital for proper evaluation.
Hematological investigations revealed hemoglobin 8.6 gm/dl, ESR-40 mm/lst hour, platelets 890 x 109/l, and total count of WBC 41,100/mm3. Peripheral blood film showed microcytic hypochromic anemia and neutrophilic leukocytosis with thrombocytosis. He tested negative for HBsAg, anti-HCV, anti-HEV Ig M, and anti-HAV Ig M. His bilirubin level was 5.8 mg/dl, serum ALT 24 U/L, serum AST 44 U/L, serum alkaline phosphatase 75 IU/L, LDH 259 U/L and serum albumin 3.3 gm/l. He had normal prothrombin time and D-dimer level. His random blood sugar was 5.6 mmol/l, serum creatinine 0.8 mg/dl and uric acid level 6 mg/dl. He also tested negative for ANA, ASMA, RK39 and malarial parasite. He had CEA 1.97 ng/ml.
Ultrasonography and computed tomography (CT) scan of whole abdomen revealed hepatosplenomegaly and moderate ascites. Endoscopy, colonoscopy and chest X-ray revealed normal findings. A tuberculin skin test was negative and sputum were negative for AFB in three occasions. Ascitic fluid was taped and studied. Ascitic fluid showed lymphocytes 95%, negative for AFB, gram stain and malignant cell. His ascitic fluid protein 38 gm/l, sugar 6 mmol/l and ADA 22.6 U/l. Bone marrow examination was also done. It demonstrated panmyelosis. He had normal Hb electrophoresis study.
In spite of all investigations, definitive diagnosis could not be made. He was identified as a tuberculosis (TB) suspect and was started on treatment with anti-TB drug (CAT-1) and patient gradually felt better. He was subsequently discharge home to directly observed therapy (DOT). His fever improved over the initial weeks of therapy, ascites resolved and engaged himself with his normal daily activities. Two months later, repeat scans and laboratory tests are to be in normal range.