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