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Case Reports in Infectious Diseases

Volume 2018, Article ID 4970836, 3 pages
https://doi.org/10.1155/2018/4970836

Case Report
A Case Report of Peritoneal Tuberculosis:
A Challenging Diagnosis

Dilara Bulut Gökten , Bilal Katipoglu , Ekrem Basara, Ihsan Ates, and Nisbet Yılmaz
Department of Internal Medicine, Ankara Numune Training and Research Hospital, Ankara, Turkey

Correspondence should be addressed to Dilara Bulut Gökten; dilarabulut26@hotmail.com

Received 1 November 2017; Accepted 10 December 2017; Published 11 January 2018

Academic Editor: Paola Di Carlo

Copyright © 2018 Dilara Bulut Gökten et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.
Peritoneal tuberculosis is a disease which can mimick malignancy especially in women who present with ascites and elevated
CA125 levels. It should always be considered in differential diagnosis, but the diagnosis is rarely easy for clinicians. A young female
patient who presented with abdomen tenderness and diagnosed with peritoneal tuberculosis as a result of performed tests is
discussed hereby in the case report. We expect that this case report adds to the existing literature on this subject.

1. Introduction 2. Case Report

Tuberculosis which is one of the ancient diseases is known to A 16-year-old female was admitted to the hospital with a
affect human health and is caused by the bacteria Mycobac- 7-day history of tenderness in the abdomen who was referred
terium tuberculosis. This old disease may be fatal within just from another centre to us with reported ascites in ultraso-
5 years in more than 50% of cases [1]. Extrapulmonary tu- nography. No chronic diseases, no alcohol use, no family
berculosis (ETB) accounts for 18.7% of all tuberculosis patients history, no herbal agents, or no suspected drug use were
in the USA, and peritoneal tuberculosis is not a common form reported. Vital signs of the patients were in the normal ranges
of it. It is seen just in 4.7% of all patients [2]. Turkey is a country with 36.3 body temperature, 120/70 arterial blood pressure,
that has a moderate level of TB. With the implementation of and 82/min heart rate. Our physical examination referred
the Health Transformation Programme, our health indicators ascites in the abdominal region, and there was no other
reached the same level as those in upper-income countries. abnormal finding. Our laboratory results reported no anemia,
Tuberculosis prevalence decreased from 38 per 100,000 pop- no white blood cell elevation, and no thrombocyte abnor-
ulation in 2002 to 24 per 100,000 population in 2011 in mality. Her peripheral smear was normal with no atypical
provinces and district centres [3]. According to the World cells. No renal function or hepatic function abnormality and
Health Organization (WHO) Global Tuberculosis Report 2017, no electrolyte abnormality were also reported. CRP was 39
estimated tuberculosis incidence is 6 (5.1–6.9) per 100,000 in (normal range: 0–5 mg/L) and erythrocyte sedimentation
the female group, 8 (6.8–9.2) per 100,000 in the male group, level was 42 (normal range: 0–20 mm/h). Her chest X-ray was
and 14 (12–16) per 100,000 population totally in Turkey [4]. completely normal with no infiltrations or effusions. Her
Also, peritoneal tuberculosis is a disease which can mimick abdominal ultrasonography reported abdominal free liquid
malignancy especially in women who present with ascites and deposition, septations in the fluid accumulation, and multiple
elevated CA125 levels. Ascites of tuberculosis is an exudative implants in peritoneal surfaces in hepatic diaphragmatic
form just as in malignancy cases. Moreover, they share many region and right paracolic area, in which the biggest one was
similarities in symptoms and radiology and laboratory results. 16 millimetres. Endometrium thickness was in the normal
True diagnosis with and correct follow-up can decrease patient range, but in the left ovary, there was a septated cyst with
morbidity and deaths. Peritoneal tuberculosis is a rare entity in dimensions of 39∗27 millimetres (hemorrhagic cyst?). We
the literature and will be discussed in this case report. suspected from ovarian pathology and performed paracentesis
2 Case Reports in Infectious Diseases

and sent this fluid to pathology laboratory. Pathology re-

ported inflammatory cells which are rich in lymphocytes.
There were no malignant cells in the fluid. According to the
laboratory results, serum albumin ascites gradient was <1.1,
and this showed us that the fluid was exudate. The patient’s
thyroid function tests were completely normal. Laboratory
investigations showed the following values: AFP level 2.48
(normal range: 0–7 ng/mL), CEA level 0.39 (normal range:
0–3.8 ng/mL), CA15-3 level 26.15 (normal range: 0–26.4 U/mL),
CA19-9 level 1.14 (normal range: 0–27 U/mL), and elevated
CA125 level of 107.5 (normal range: 0–35 U/mL). Brucella
markers and viral markers were negative. Although the patient
had no encounter with any tuberculosis patient, we performed
tuberculin skin test for differential diagnosis. As a result, it was
Figure 1
anergic. Tuberculosis quantiferon PCR was negative, and as-
cites fluid direct microscopic examination revealed that there
were no tuberculosis bacilli and acid-fast stain was negative. swelling. CA125 levels can be high in both these cases.
Tomography of the thoracoabdominal region revealed naso- Moreover, radiological imaging of abdomen is very similar
pharyngeal soft tissue with the dimensions of 20∗18 milli- in both these cases such as ascites, nodular irregularities in
metres, bilateral lymphadenopathies in the levels of 1a, 1b, 2, 3, the peritoneal surface, adnexal and fallopian masses, and
4, and 5, and right supraclavicular area in the cervical region. septated and multiloculated ovarian cysts [5]. Also, there are
The nasopharyngeal biopsy revealed just lymphoid hyperplasia. some clues to distinguish these cases, peritoneal carcino-
Paratracheal and subcarinal lymphadenopathies were also seen, matosis and ovarian cancer are usually seen in older ages
and the biggest one was 20∗13 millimetres. Also, there were according to tuberculosis cases. CA125 levels are usually
bilateral anterior diaphragmatic and right cardiophrenic higher in peritoneal carcinomatosis cases. But, it should be
lymphadenopathies. Abdomen tomography showed fluid noted that CA125 can elevate to about 10-fold of normal
accumulation and hepatic peritoneal surface nodular le- value in patients who have peritoneal tuberculosis [6].
sions. There were a reticular density increase in the omental Our case was mimicking ovarian cancer completely.
area and a cyst in the left ovary with the dimensions of Thus, peritoneal tuberculosis must always be considered in
23∗18 millimetres. There were also lymph nodes in the differential diagnosis of ovarian carcinoma especially in the
mesenteric fatty tissue. Although malignancy was important developing countries or underdeveloped countries.
for differential diagnosis, ADA (adenosine deaminase) level In the literature, most of the cases have encounter with
was 62 (normal range: 0–30 U/L). These results strongly tuberculosis patients and have different symptoms, cavitations
supported tuberculosis. Then, we sent peritoneal fluid to the in the lung or pulmonary focus appearance. Additionally, the
pathology laboratory again and no malignant cells were patients who have peritoneal tuberculosis also have other
reported. Abdomen magnetic resonance imaging reported comorbidities like immunocompromisation, cirrhosis, renal
bilateral cysts in both the ovarian regions, bilateral expanded failure, diabetes mellitus, and malignancy [7]. But, in our case,
fallopian tubes, nodular opacities in the peritoneal region, there were no symptoms other than ascites, no pulmonary
and ascites (Figure 1). We performed trucut biopsy from complaints, no encounter with any tuberculosis patient, no
nodular opacities in that peritoneal surface, and pathology pulmonary foci in the chest X-ray or physical examination,
laboratory reported granulomas with histiocytic cells in that and also there were no other medical conditions which can be
specimen. We communicated with infectious diseases helpful to suspect tuberculosis.
committee and started four-agent tuberculosis treatment There are a lot of diagnostic procedures for tuberculosis
(isoniazid, ethambutol, pyrazinamide, and rifampin) to the in the literature, but none of them is completely specific or
patient. After 6 months of treatment, she had good clinical sensitive. Radiologic imaging techniques are not sensitive or
response and ascites were completely absent. specific for diagnostic purposes. Ascitic fluid cytology has
a low negative predictive value. Although the test for acid-
3. Discussion fast bacilli in the peritoneal fluid is highly specific for the
diagnosis, it lacks sensitivity. There are high false-negative
Peritoneal tuberculosis is a very rare disease in developed rates for tuberculosis skin tests. New diagnostic procedures
countries but always should be considered in developing like PCR assay for bacteria could help to identify this subject,
countries. It accounts for 0.1% to 0.7% of tuberculosis cases since they can decrease the time taken to get a true diagnosis
[2]. It manifests the symptoms such as fever, loss of weight, and specially helpful when AFB test is negative. In our case,
infertility, abdominal and pelvic pain, and irregularities of PCR, AFB, and cytology were performed from abdominal
menstruation. The other symptoms include ascites, adnexal ascites fluid and were negative. We tried to identify My-
masses, and increased level of CA125. cobacterium tuberculosis in the samples, but all of the sample
This tuberculosis case is very difficult to distinguish from materials had negative result (urine sample, peritoneal fluid,
abdominal malignancy cases. Symptoms can be similar, for sputum, and blood). We also performed quantiferon test to
example, weight loss, fever, abdominal pain, and abdominal the patient, and it was also negative. In the literature, it is
Case Reports in Infectious Diseases 3

said that the use of the quantiferon assay for the detection of 4. Conclusion
TB infection in patients with active pulmonary tuberculosis
yielded sensitivity of 86 %, specificity of 94 %, PPV of 16.7 %, By information given in this case report, one can understand
and NPV of 96.1 % [8]. Quantiferon test is precious for latent that peritoneal tuberculosis can often mimick advanced
tuberculosis infection. ovarian cancer and peritoneal carcinomatosis. It should
Despite the fact that identification of mycobacteria in any always be considered in differential diagnosis, but the di-
material is the gold standard method to evaluate the disease, agnosis is rarely easy for clinicians. True diagnosis and then
negative result of culture cannot exclude the tuberculosis correct and careful follow-up can save the patient’s life, and
diagnosis. Activity of ascitic fluid adenosine deaminase (ADA) doctors should start the treatment as soon as possible.
has been proposed as a useful test for abdominal tuberculosis
cases. In countries with a high incidence of tuberculosis, Conflicts of Interest
measurement of ADA may be a helpful screening test. A value
of ADA higher than 0.40 uKat/l has 100% sensitivity and The authors declare that they have no conflicts of interest.
a specificity of 99% for diagnosing tuberculous peritonitis [9].
However, in developed populations with low incidence of References
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