A case of tuberculous peritonitis: NEJM
A previously healthy 24-year-old man presented to the emergency department with a 1-month history of abdominal distention, abdominal pain, and fever. On physical examination, he was noted to have bulging flanks with a fluid wave.

Analyses of ascitic fluid revealed a predominance of lymphocytes, a high protein level that was similar to that in serum, and an adenosine deaminase level of 150 U per liter (reference range, 8.6 to 20.5). The results of acid-fast staining and polymerase-chain-reaction (PCR) testing for Mycobacterium tuberculosis were negative.

A computed tomographic scan obtained after the administration of contrast material showed a large amount of ascites, a thickened peritoneum, and multiple enlarged mesenteric lymph nodes (Panel A). Exploratory laparoscopy revealed numerous white, miliary nodules on the peritoneum and omentum (Panel B).

Caseating granulomas with Langerhans giant cells were detected on peritoneal histopathological analysis. A specimen of an omental lesion was obtained on biopsy, and the results of PCR testing and culture of the tissue were positive for M. tuberculosis. A test for infection with the human immunodeficiency virus was negative.

The sensitivity of ascitic-fluid culture for M. tuberculosis is low, and the diagnosis can require peritoneal biopsy. This patient was treated with isoniazid, rifampin, ethambutol, and pyrazinamide for 2 months, followed by isoniazid and rifampin for 4 months. The ascites and associated symptoms resolved.

Source: https://www.nejm.org/doi/full/10.1056/NEJMicm1713168
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