We are reporting a 32-year-old woman known to have diabetes mellitus who presented to the emergency department initially with a 2-week history of abdominal distention and increased abdominal girth associated with shortness of breath. She denied any nausea, vomiting, abdominal pain, loss of appetite, early satiety or unintentional weight loss, hematemesis, melena, or hematochezia. The patient denied any past surgical history. She was born and raised in the USA and never traveled outside the USA. Her social history was significant for active tobacco and marijuana smoking. She had no known allergies. Her initial vitals were blood pressure of 131/79 mm Hg, a pulse of 83 bpm, respiratory rate of 18, and temperature of 98.6 F. On examination, the abdomen was soft and distended with positive shifting dullness. Bowel sounds were normal.
Computed tomography (CT) scan of the abdomen and pelvis with contrast showed a large amount of ascites with normal hepatic architecture. Ultrasound of the pelvis showed large-volume ascites and normal appearing ovaries and uterus. The patient underwent paracentesis showing a low SAAG value (of 1 and repeat 0.6) with high protein (6.4 and repeat 7), neutrophilic predominance initially (total WBCs 6,760 with 95% neutrophils), then lymphocytic predominance (total WBCs 3,840 with 64% lymphocytes); cytology of ascitic fluid was negative for any malignant cells. Of note, she was found to have an adenosine deaminase (ADA) level of 113 in ascitic fluid; upon repeat testing, the level was 100.6. Acid-fast staining, MTB PCR, and mycobacterium cultures were negative in ascitic fluid. Ascitic fluid amylase level was 46 U/L, TAG level was 22 mg/dL, and LDH level was 554 U/L. HIV testing, HCV testing, HAV IgM, and auto-immune workup, including ANA, ANCA vasculitis antibodies, anti-smooth muscle antibodies, and liver kidney microsomal antibodies, were also negative. Serum pro-BNP was 40 pg/mL, lipase 37 U/L, ceruloplasmin level 38 mg/dL, alpha-1-antitrypsin level 144 mg/dL, ESR 100 mm/h, and CRP was 85 mg/L. Her serum immunofixation showed a dense polyclonal pattern suggestive of chronic inflammation. Urine testing for Chlamydia trachomatis and Neisseria gonorrhoeae was negative. CT of the chest and CT of the abdomen and pelvis with contrast material were negative for any malignant focus. She underwent exploratory abdominal laparoscopy, which revealed fibrinous exudate on the peritoneal surface, and had a biopsy of the peritoneum. The pathology report from the peritoneal biopsy showed granulomatous inflammation with no malignancy (Fig. 1). PAP smear showed atypical squamous cells of undetermined significance. Endometrial biopsy was also negative for any malignancy. Transvaginal ultrasound showed normal ovaries. She also had EGD and colonoscopy to rule out gastrointestinal malignancy and in view of the unknown origin of ascites. EGD and colonoscopy both were unremarkable, and biopsy reports were negative for any malignancy. The patient was lost to follow-up, and treatment was not initiated.