A 34-year-old man presented to our institution with complaints of cough, low-grade fevers, abdominal pain, nausea/vomiting, and a 2-week history of weight loss. His past medical history included rheumatoid arthritis with concomitant long-term use of infliximab and a PPD conversion, during which the patient underwent 11 months of isoniazid therapy. Physical examination was unremarkable. Laboratory tests showed a mild leukocytosis of 12.5 x 103 cells/mL (normal 3.8-10.6). ESR was elevated at 108 mm/hr (normal, 0-20). CRP was 16.6 mg/dL (normal 0-0.9). A chest x-ray showed a left pleural effusion and a cluster of nodular opacities in the right upper lobe. A 7-day course of moxifloxacin resulted only in mild symptom relief.
A later CT scan with contrast showed diffuse thickening and nodularity of the omentum, infiltration of the mesentery, and a small amount of hemoperitoneum. Additionally, there were multiple prominent mesenteric lymph nodes and diffuse thickening of the small bowel. In the pelvis, there was a small volume of ascites in the rectovesicle space and enhancement of the peritoneal reflections due to peritonitis (Fig. 1). During a laparascopic biopsy done two days after the CT, extensive adhesions and infiltration of the peritoneum with thickened adhesions were noted between the omentum, bowel, and abdominal wall. The small bowel was covered with micronodular inflammatory nodules typical of a miliary spread of infection (Fig 1D). An omental biopsy showed omental fat with caseating and noncaseating granulomatous inflammation with acidfast organisms, consistent with tuberculosis. Treatment began with a multidrug protocol: rifampin, ethambutol, and moxifloxacin. The patient was discharged to home after two weeks of continued medical therapy. A CXR and CT of the chest of this patient demonstrating right-upper-lobe airspace opacities can be seen in Figure 2.
CT showing a subtle cluster of airspace opacities in the right upper lobe (arrow).