Peritoneal tuberculosis: diagnostic options.

BACKGROUND: Extrapulmonary tuberculosis has vague symptoms and few signs. It is essential to recognize and diagnose this curable disease prior to performing definitive surgery. Newer tests such as DNA or RNA amplification allow for early diagnosis but have limitations. CASE: We report a case of peritoneal tuberculosis in an immigrant woman. She had vague symptoms of low-grade fever, mild abdominal pain, obstipation, and bloating. Diagnostic laparoscopy was performed to establish the diagnosis. Tuberculosis was confirmed by DNA extraction from the frozen section specimen with subsequent analysis using polymerase chain reaction. CONCLUSION: Peritoneal tuberculosis is a disease that often simulates malignancies. With the increasing prevalence of human immunodeficiency virus in developed countries, tuberculosis is also on the rise and should be considered in the differential diagnosis of a patient with an abdominal/pelvic mass and ascites.

from the frozen section specimen with subsequent analysis using polymerase chain reaction.
Conclusion: Peritoneal tuberculosis is a disease that often simulates malignancies. With the increasing prevalence of human immunodeficiency virus in developed countries, tuberculosis is also on the rise and should be considered in the differential diagnosis of a patient with an abdominal/ pelvic mass and ascites. Infect. Dis. Obstet. Gynecol. 7:244-247, 1999. (C) 1999Wiley-Liss, Inc. KEY WORDS tuberculosis; diagnosis; polymerase chain reaction; laparoscopy he incidence of tuberculosis in the United States has recently increased due to the resurgence of human immunodeficiency virus. Individuals at high risk for developing tuberculosis include patients with acquired immunodeficiency syndrome, immigrants from underdeveloped countries, the urban poor, prisoners, and nursing home residents. Nonspecific symptoms and signs are a hallmark of tuberculosis, necessitating a high index of suspicion to diagnose this disease, z CASE A 33-year-old woman, gravida 2, para 1, who immigrated from Cameroon to the United States in August 1998 presented to the urgent care department reporting bloating, obstipation, vague abdominal pain, and low-grade fever of nine months' duration. She had a normal spontaneous vaginal delivery in December 1997. Physical examination was remarkable for a distended abdomen with an ascitic fluid wave but no tenderness or mass. The pelvic exam revealed a friable cervical ectropion but no cervical motion tenderness. Her uterus was anteverted, nontender, and normal sized. Both ovaries were nontender and palpable in the posterior cul de sac. Laboratory investigations showed a hemoglobin level of 9.2 g/dL with hypochromic, normocytic red blood cell indices, platelets of 487 K/UL and an erythrocyte sedimentation rate (ESR) of 49 mm/h. Liver and kidney function tests were normal except for the presence of hypoalbuminemia (albumin, 2.5 g/dL). A chest X-ray was normal. Her purified protein derivative level was positive, measuring 10 mm. A Papanicolaou test showed benign cellular changes. An abdominal pelvic ultrasound revealed loculated ascites with a normal uterus measuring 6.8 cm and bilateral ovarian enlargement with complex ovarian cysts. A computed tomography scan of the abdomen and pelvis was consistent with the ultrasound results. Diagnostic paracentesis revealed an exudative ascitic fluid with predominant lymphocytosis. The chemistries on the ascitic fluid showed lactate dehydrogenase of 934 U/L; albumin, 2.3 g/dL; glucose, 11 mmol/L; lipase, 73 g/dL; and total protein, 6.7 g/dL. Gram staining of the fluid showed 0-5 polymorphonuclear cells and no microorganisms. Ascitic fluid was sent for aerobic, anaerobic, and mycobacterial culture. The patient was then referred to the Division of Gynecologic Oncology to rule out the diagnosis of ovarian carcinoma. The patient's preoperative CA 125 level was elevated to 138 U/mL. Open diagnostic laparoscopy was performed and showed several thick, caseous peritoneal adhesions with multiple peritoneal nodules and plaques covering the abdominopelvic peritoneum. The ascites was loculated (Fig 1) in both the upper abdomen as well as the pelvis. Uterus and adnexa were encased in thick caseous adhesions limiting the view of the adnexa. Evaluation of a frozen section of the peritoneal nodule showed granuloma formation with caseating necrosis.

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Analysis by polymerase chain reaction (PCR) of the specimen demonstrated a DNA sequence diagnostic of Mycobacterium tuberculosis. The patient was started on isoniazid, rifampicin, and ethambutol, the standard triple drug regimen for extrapulmonary tuberculosis. 3 The patient's 4-week postoperative follow-up evaluation showed a decrease in the CA 125 level to 40 U/mL. Postoperative pelvic ultrasound showed resolution of ascites and normal ovaries with no evidence of any residual cystic change.

DISCUSSION
Tuberculous peritonitis usually follows either the direct spread of tubercle bacilli from ruptured lymph nodes, intraabdominal/pelvic organs, or hematologic seeding from a primary focus elsewhere in the body. The differential diagnosis in a patient with ascites and pelvic mass includes ovarian malignancies, cirrhosis with portal hypertension, Crohn disease, gastrointestinal malignancies, malignant lymphomas, and sarcoidosis.
Infertility and irregular menses are the most common symptoms of genital tuberculosis. 4 Normal menstruation and a recent normal vaginal delivery in our patient did not suggest the presence of genital tuberculosis. Her chest X-ray was also normal but 50% of patients with active tuberculous peritonitis have negative chest radiographs. Nonspecific signs of tuberculous peritonitis include anemia of chronic disease, elevated ESR, ascitic lactate dehydrogenase greater than 90 U/L, 5 ascitic lymphocytosis, complex ascites, 6 and elevated levels of CA 125. 7 The presence of these nonspecific signs (positive purified protein derivative skin test, elevated ESR, ascitic fluid lactate dehydrogenase level of 934 U/L, lymphocytic ascitic fluid, and complex ascites) favored the diagnosis of peritoneal tuberculosis prior to diagnostic laparoscopy. Mycobacterial culture is the gold standard for diagnosing tuberculosis despite its long incubation period and requirement for biochemical testing to identify the isolated microorganism. 8 Polymerasechain-reaction-based assay proved to be a valuable diagnostic tool for Mycobacterium tuberculosis. The direct amplification of a defined DNA sequence of Mycobacterium tuberculosis established the diagnosis within 48 hours. This is in contrast to the 8 weeks required for mycobacterial culture. Testing by PCR can be performed on sputum samples, body