3. Discussion
Tuberculous peritonitis is a form of abdominopelvic TB that might affect
the peritoneum, gastrointestinal tract, lymph nodes or solid viscera.
However, less than five percent of all cases suffer from this form of
TB.(5)
Due to the lack of specific presentations and laboratory results, TB has
a diagnostic challenge. In addition, presentations of peritoneal TB may
be similar to several other infectious or malignant diseases(6). The
most prevalent symptoms include fever, weight loss, and abdominal
swelling. Meanwhile, non-specified symptoms include abdominal
distension, ascites, and abdominal mass. It is included in the
differential diagnosis of fevers with unknown origin, peritoneal
carcinomatosis, ovarian cancer, and ascites of portal hypertension or
cardiac origin (7). In addition, not always pulmonary lesions are
considered as TB or the disease may not have any evidence on chest
radiograph. Furthermore, for a number of patients, pleural effusion may
be the only radiologic presentation (8). Frequent ultrasonography and
computed tomographic presentations include ascites, thickening of the
viscera (omental, mesenteric, peritoneal, and intestinal), adhesions
between viscera, and lymphadenopathy (9, 10), the same as our patient.
Laparoscopic studies reported exudative, cloudy ascites with multiple
whitish nodules or tubercles studding the visceral and parietal
peritoneum, extensive adhesions and omental thickening.(11) In our case
imaging and operative findings showed ascites, extensive adhesions,
omental thickening and nodular peritoneal implants. In histological
examination existence of Caseating granulomatous inflammation may be
necessary for a definite diagnosis and is a hallmark of tuberculous
peritonitis, as in our patient’s pathology report. The culture of
affected tissues or the PCR can be used to confirm the diagnosis.
Nevertheless, it should be noted that culturing is not an appropriate
technique for fluids obtained from babies, as there is a low chance.
Patients with ascites have improvement within a few weeks of initiating
treatment in 90 percent of cases. (12) Its management contains a
sensible combination of antitubercular therapy and surgical
interventions, which may be necessary to address complications like
intestinal obstruction and perforation. While it can be cured using
currently available techniques, it claims several lives and infects many
cases. Those who presented complications like perforation, abscess,
fistula, bleeding, and/or high-grade obstruction may require surgery.(8)
Females with advanced levels of TB and those who simultaneously suffer
from HIV infection often have the worst prognosis of TB.(4) TB is a
significant cause of maternal mortality during pregnancy.
Pregnancy-related complications contain increased spontaneous abortion
rate, being smaller relative to the weeks of pregnancy, suboptimal
weight gain in pregnancy, labor before 37 weeks of pregnancy, low birth
weight, and enhance neonatal mortality. Delay in the diagnosis of this
infection is an independent factor that is associated with both enhanced
obstetric morbidities and preterm labor by four- and nine-folds,
respectively. Several factors contribute to pregnancy-related effects of
TB, like its severity, its prognosis during pregnancy, the presence of
extra pulmonary infections, HIV coinfection, and time to start
treatment.(4) In this case, also we reported a rare combination of
disseminated tuberculous peritonitis after spontaneous abortion with the
feature of acute abdominal pain that underwent diagnostic laparotomy and
6 months tuberculosis treatment.
In Conclusion, Tuberculous peritonitis is a form of abdominopelvic TB
which can mimic many other infectious or malignant diseases. The
diagnosis is challenging and it could be made by CT imaging, explorative
laparoscopy, evaluation of biopsies from specimens and culture or PCR
from ascites fluid or infected tissues. Also, females whose diagnosis is
made at puerperium often have the worst TB prognosis, so early diagnosis
is important to prevent morbidities.
Conflict of Interests The authors declare no conflict of interests.
figure 1: sonography view of abdominopelvic cavity