Image of the Month—Diagnosis

The intraoperative findings, including multiple diffuse involvement of the visceral and parietal peritoneum, white military nodules, ascites, violin string–like fibrinous strands, and omental thickening, as shown herein, typically signify the diagnosis of tuberculous peritonitis. Granulomatous inflammation of the peritoneum with multinucleated giant cells was also demonstrated microscopically. Acid-fast bacilli were found. Fibrous tuberculous peritonitis was confirmed. The patient recovered by using 4 combined antituberculous medications.

The first reported case of tuberculous peritonitis dates back to 1843.¹Approximately 3.5% of patients with pulmonary tuberculosis have tuberculous peritonitis.²It represents 2% of the causes of ascites.³According to a summary of 11 series,⁴25% to 83% of cases of tuberculous peritonitis are associated with pleuropulmonary tuberculosis. sixty-two percent of patients have alcoholic liver disease. Continuous ambulatory peritoneal dialysis and human immunodeficiency virus are other risk factors.

Although recognized early historically, the diagnosis of tuberculous peritonitis still poses significant challenges. Clinical features, including fever, abdominal pain, and ascites, are not specific. Ascitic fluid analysis might show predominant lymphocytes and a high protein level (>2.5 g/dL [to convert to grams per liter, multiply by 10]), but results of acid-fast staining of fluid are seldom positive for tuberculous peritonitis. Culture of fluid is positive in only 25% of patients. Polymerase chain reaction, with sensitivity up to 95% in smear-positive patients, was disappointingly low in smear-negative patients with tuberculous peritonitis.⁵Adenosine deaminase activity in the ascitic fluid seems to be a promising diagnostic measure.⁵

Peritoneal carcinomatosis, sarcoidosis, starch peritonitis, and Crohn disease may mimic the features of tuberculous peritonitis. Peritoneal biopsy, therefore, must be performed to make a diagnosis if no other foci suggest tuberculosis. Currently, to our knowledge, there are no randomized controlled trials comparing image-guided biopsy, laparoscopy, and laparotomy. Laparotomy, however, is reserved for patients with the fibroadhesive type of tuberculous peritonitis, as in the present patient. Most patients with acute symptoms are diagnosed using only laparotomy.⁶

If left untreated, the overall mortality of tuberculous peritonitis may be as high as 51%.⁷Epidemiologically speaking, extrapulmonary tuberculosis is rarely infectious. Transmission is likely, nevertheless, in rare cases of contact with discharge (such as from an open wound) that contains tuberculous bacilli.⁸Surgeons should be alert for this possibility when performing similar consulting operations.

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Correspondence:Po-Huang Lee, MD, PhD, Department of Surgery, National Taiwan University Hospital, 7 Chung-Shan S Rd, Taipei 100, Taiwan (miningho@ntu.edu.twor pohuang@ha.mc.ntu.edu.tw).

Accepted for Publication: November 1, 2006.

Author Contributions:Study concept and design: Ho and Lee. Acquisition of data: Lee. Analysis and interpretation of data: Ho and Lee. Drafting of the manuscript: Ho. Critical revision of the manuscript for important intellectual content: Lee. Administrative, technical, and material support: Ho. Study supervision: Lee.

Financial Disclosure:None reported.