The patient is a 27-year-old woman who emigrated from Guatemala ten years prior to presentation with no significant past medical history. She was not aware of ever having a tuberculosis skin test or of any prior exposure to tuberculosis. Eight months earlier, she had undergone her third normal spontaneous vaginal delivery. Two months prior to presentation, the patient began to experience abdominal pain and distention. At the time of presentation, abdominal ultrasound demonstrated ascites and bilateral adnexal masses. CT scan suggested tubular structures within the adnexa, demonstrating circumferential enhancement. Initial paracentesis revealed a white cell count of 1330 (78% lymphocytes) and serum-ascites albumin gradient of 0.2 g/dL. All cultures and acid-fast bacillus smears were negative at that time. Recurrent ascites prompted repeat paracentesis which yielded 1300 mL of greenish fluid that was again culture and acid-fast bacillus smear negative. Two days following the initial paracentesis, the patient was readmitted for persistent abdominal distention and pain, fevers, nausea, vomiting, chills, and night sweats. Repeat CT scan showed pronounced thickening of the peritoneum, a large amount of ascites, and dilation of the fallopian tubes. Serum CA-125 was elevated at 344 (N < 35).
Preoperative diagnosis was peritoneal carcinomatosis possibly due to ovarian cancer complicated by pelvic inflammatory disease. The patient underwent a primary debulking procedure including an abdominal hysterectomy, salpingoophorectomy, appendectomy, and omental biopsy. During surgery, bilaterally enlarged ovaries, inflamed fallopian tubes adherent to the pelvic sidewalls, a large amount of ascetic fluid with fibrinoid exudate, and inflammation covering the peritoneal surface, uterus, and bowel were noted. Postoperatively, the patient was treated with ertapenem for peritonitis thought to be secondary to salpingitis; however, fevers, chills, and night sweats persisted.
Histopathology of the resected tissue showed granulomatous salpingitis, periovarian caseating granulomatous inflammation, and granulomatous serositis of the peritoneum (Figures 1 and 2). Subsequently, a T-SPOT.TB (ELISPOT test for interferon gamma levels in the peripheral blood) was positive, and PCR tests of the surgically removed tissues documented the presence of Mycobacterium tuberculosis. HIV testing was negative. Thus, the patient was diagnosed with tuberculous peritonitis and started on standard 4-drug antituberculosis treatment. All symptoms resolved. Approximately 6 weeks later, her original ascitic fluid cultures grew Mycobacterium tuberculosis.