A 20-year-old Hispanic woman, living in Laredo, a city on the Mexican border, presented to the emergency room with complaints of recurrent fever, chills, abdominal distension, bilateral lower extremity swelling, nausea, nonbloody emesis, and watery diarrhea. She was discharged from the hospital one week prior, after undergoing a primary low transverse cesarean section at 37.6 weeks of pregnancy. The delivery was performed without any surgical or medical complications. The patient denied any prior medical conditions, use of alcohol or illicit drugs, exposure to known TB contacts, recent travel to Mexico, and a family history of cancer. There are no sick contacts or animals at home.
On initial presentation, the patient was febrile with a temperature of 102.0 F, had tachycardia with a heart rate of 129 beats per minute, and had a blood pressure of 104/56 mm Hg. Physical examination demonstrated abdominal distension and tenderness, shifting dullness to percussion, a positive fluid wave sign, 3+ bilateral peripheral pitting edema, generalized lymphadenopathy and rales and rhonchi in both lungs. The liver and spleen were not palpable. Jaundice, palmar erythema, and spider angiomatosis were not noted. The laboratory reported a microcytic, hypochromic anemia (Hgb = 9.5 g/dL, Ht = 30.8%) with slight anisopoikilocytosis. The platelet count was 305 x 103/mcL and WBC was 7.92 x 103/mcL with 80% neutrophils and 9.3% lymphocytes. Procalcitonin was elevated at 10.68 ng/ml (normal range 0-0.5 ng/ml). CRP was elevated at 13.39 mg/dl (normal range 0.2-0.9 mg/dl) and ESR was elevated at 29 mm/hr (normal range 0-20 mm/hr). Plasma total protein and albumin were reduced at 4.5 g/dL and 2.33 g/dL, respectively. A 24-hour urine protein collection yielded 0.4 g/24 h. Renal function, liver function, and electrolytes were within normal limits.
The presenting X-ray demonstrated diffuse alveolar and interstitial opacities in both lungs, with more extensive findings in the upper lobes and right perihilar region, consistent with pneumonia (Figure 1). The CT of the chest showed extensive bilateral infiltrates with a tree-in-bud configuration (Figure 2). A CT scan of the abdomen/pelvis demonstrated ascites, colonic wall thickening, omental thickening, peritoneal thickening, and mesenteric lymphadenopathy, initially read by radiology as suggestive of carcinomatosis and consistent with the elevated CA-125 level (Figures 3 and 4). There was no hepatosplenomegaly or evidence of cirrhosis. A transthoracic echocardiogram demonstrated a left ventricular ejection fraction of 65% with mild mitral and tricuspid regurgitation. There was no pericardial effusion or evidence of left ventricular thrombus.
The patient was admitted with a presumed diagnosis of sepsis secondary to bilateral pneumonia and ascites of undetermined etiology. The patient was started on treatment empirically with broad spectrum intravenous antibiotics, vancomycin, and piperacillin-tazobactam. Because of persistent tachycardia and fever for several days, vancomycin therapy was switched to doxycycline. Blood tests for syphilis, Rickettsia typhi, Rocky Mountain spotted fever, Q fever, CMV, EBV, HIV, and hepatitis were negative. Blood, urine, and vaginal cultures showed no bacterial growth. Autoimmune antibodies and TB QuantiFERON PCR (QIAGEN, LABCORP) were negative.
Because of the presence of mesenteric adenopathy and concern about a malignant process, tests for tumor markers revealed a mildly elevated CA-125 at 199.5 units/mL (normal range 0-35 units/mL) and an elevated alpha fetoprotein (AFP) at 13.67 ng/mL (normal range 0-5.63 ng/mL). Carcinoembryonic Antigen (CEA), CA 15-3, and CA 19-9 were within normal limits at 0.5 ng/mL (normal range 0-4), 27.4 units/mL (normal range <30) and 23.1 units/mL (normal range 0-37 unit/mL), respectively.
The patient underwent a diagnostic paracentesis which showed a lymphocytic predominance. The calculated serum ascitic albumin gradient (SAAG) was greater than 1.1 and the lactate dehydrogenase (LDH) level in the ascitic fluid was elevated at 399 IU/l. Ascitic fluid culture was negative for bacteria, and cytology was negative for malignant cells.
Subsequently, the Mycobacteria PCR of the ascitic fluid was reported to be positive, and the level of adenosine deaminase (ADA) in the ascitic fluid was reported elevated at 34.9 U/l (normal <7.6 U/l). Around this time, the culture for acid-fast bacilli (AFB) in the sputum was reported to be positive.
Because of the high suspicion of peritoneal TB in this patient, antituberculosis therapy (Rifampin, Isoniazid, Pyrazinamide, Ethambutol (RIPE)) was initiated, prior to the return of the AFB cultures. To confirm the diagnosis of peritoneal TB, the patient underwent a diagnostic laparoscopy with a peritoneal biopsy, which demonstrated an inflammatory response with caseating granulomas and a positive AFB stain, confirming the diagnosis of peritoneal tuberculosis.
After 3 weeks of RIPE therapy, the patient's clinical condition improved and CA-125 decreased from 199.5 units/mL to 89.6 units/mL, CRP decreased from 13.39 mg/dL to 2.55 mg/dl and ESR fell from 29 mm/hr to 23 mm/hr.