A 39-year-old, white, female healthcare worker, with a past medical history significant for diverticulosis, was presented to the emergency department with acute abdominal pain. She also complained of increased stress, severe night sweats, and progressive weight loss beginning more than 10 weeks prior to admission. On physical examination, she was febrile and cachectic with no appreciable clinical lymphadenopathy. Erect chest radiograph was done to rule out cardiopulmonary causes, and the results were normal. Due to a history of diverticulosis, CT of the pelvis and abdomen was done to rule out diverticulitis.
The result showed abnormally dilated loops of the small bowel throughout the abdomen and pelvis, with the gas/fluid levels as shown in Figure 1. Multiple loops of distal small bowel demonstrated abnormal circumferential wall thickening with extensive mesenteric fat edema and inflammation. There was a large amount of free fluid in the pelvis and a 5.0 x 3.6 cm low-density lesion in the right adnexa with a thick ring of soft tissue. Laboratory tests revealed WBC 16,500 with a differential of 40 polymorphonuclear leukocytes with 58 bands, one metamyelocyte, and one mononuclear cell; hemoglobin 12.3, CA-125 39 U/mL, Na 132, K 3.4, Cl 93, CO2 26, and creatinine 0.93. Due to the patient's reproductive age combined with the CT and laboratory results, pelvic inflammatory disease leading to tubo-ovarian abscess was suspected, and the gynecology service was consulted.
Diagnostic laparoscopy followed by laparotomy was performed. The laparoscopy on the right adnexa revealed an enlarged ovary with multiple small cystic lesions. The cyst was characterized as a mucinous-like yellow cyst measuring approximately 5 x 5 mm and was sent for culture. The left ovary was normal. Further dissection revealed extensive peritonitis with granuloma located at the left upper abdominal wall near the splenic flexture (Fig. 2), which was biopsied. Pathology reported signs of chronic inflammation but no malignancy. The culture obtained from draining the pyosalpinx was negative for aerobes and anaerobes; however, the cytology was not ordered. Special bacteriological stain used to identify acid-fast organisms, such as Ziehl-Neelson stain, was also not sent despite the clinical suspicion of tuberculosis. The postoperative diagnoses were right pyosalpinx and clinical tuberculous peritonitis. The patient was then discharged because the pathology report did not support the clinical diagnosis of tuberculosis.
Ten days later, she presented back to the hospital Emergency Room complaining of pleuritic chest pain. CT scan of the chest showed calcified granuloma in the right lower lobe with no hilar adenopathy and nonspecific pleural thickening, which corresponded to the location of the pain. Electrocardiogram and cardiac enzymes were negative. Quantiferon gold was obtained and was equivocal. The pain was believed to be secondary to pleurisy. After re-evaluating the patient's symptoms and CT results, disseminated tuberculosis was suspected. A biopsy was planned to rule out histopathology diagnosis with diagnostic laparoscopy. Thoracoscopy was declined by chest surgeons due to insufficient evidence of pulmonary TB to justify a lung biopsy.
A second laparoscopy was performed to obtain biopsies of the clinically suspected tuberculous lesions, which showed similar - but more extensive - findings as the first laparoscopy. Disseminated lesions were observed throughout the abdomen and pelvic/parietal/visceral peritoneum (Fig. 3). Biopsies and documentary digital photographs were obtained. Cultures were sent for tuberculosis, actinomyces, and fungus, and they all came back negative. Due to continued symptoms of severe night sweats and fever, other possible etiologies were considered, including histoplasmosis. This was tested for using a histoplasmosis urine antigen test that returned positive at 6.47 (negative results are 0.00-3.50, positive results are >4.50). The patient was placed on itraconazole for disseminated histoplasmosis. After several weeks of treatment, the patient was symptom free.