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\begin{document}

\title{Peritoneal TB: A Challenging Presentation in a Young Woman with Acute
Abdominal Symptoms}



\author[1]{Samira Dehghani}%
\author[1]{saloomeh mohammadi}%
\author[2]{Atefeh Mahmoudi}%
\author[3]{Fatemeh Riyahi Zaniyani}%
\author[1]{Sasan Shafiei}%
\author[4]{Afrouz Emzaei}%
\author[5]{yasaman tavakoli}%
\author[6]{Roozbeh Narimani Javid}%
\author[1]{Athena Behforouz}%
\affil[1]{Shahid Beheshti University of Medical Sciences}%
\affil[2]{Shaheed Beheshti University of Medical Sciences}%
\affil[3]{Islamic Azad University Tehran Medical Sciences}%
\affil[4]{Isfahan University of Medical Sciences}%
\affil[5]{Mazandaran University of Medical Sciences}%
\affil[6]{Hamadan University of Medical Sciences}%


\vspace{-1em}



  
  \date{May 18, 2024}


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\textbf{''Peritoneal TB: A Challenging Presentation in a Young Woman
with Acute Abdominal Symptoms''}

Samira Dehghani\textsuperscript{1}, Saloomeh
Mohammadi\textsuperscript{2}, Atefeh Mahmoudi\textsuperscript{1},
Fatemeh Riyahi Zaniyani\textsuperscript{3}, Sasan
Shafiei\textsuperscript{4}, Afrouz Emzaei\textsuperscript{5}, Yasaman
Tavakoli\textsuperscript{6}, Roozbeh Narimani Javid\textsuperscript{7},
Athena Behforouz\textsuperscript{1*}

1. Preventive Gynecology Research Center, Shahid Beheshti University of
Medical Sciences, Tehran, Iran

2. Department of Pathology, Mahdieh Hospital, Shahid Beheshti University
of Medical Sciences, Tehran, Iran

3. Faculty of Medicine, Islamic Azad University, Tehran Medical Sciences
Branch, Tehran, Iran

4. Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti
University of Medical Sciences, Tehran, Iran

5. Hojjat Hospital, Isfahan University of Medical Sciences, Isfahan,
Iran

6. Student Research Committee, Department of Medicine, Mazandaran
University of Medical Sciences, Mazandaran, Iran

7. Student Research Committee, Hamadan University of Medical Sciences,
Hamadan, Iran

\textbf{AbstractIntroduction:} Tuberculosis (TB) is a significant health
problem worldwide. The rate of active tuberculosis in pregnancy is
rising and it is a considerable cause of maternal mortality during
pregnancy.

\textbf{Case presentation:} This study reports a young woman who was
suffering from TB peritonitis, a rare, highly progressive clinical
course following the spontaneous abortion of 16-week gestation. She
underwent a diagnostic laparotomy that showed several small-scale
implants on the peritoneum and viscera. Histopathology revealed chronic
caseating granulomas with necrosis. With the possible diagnosis of
tuberculosis, anti-mycobacterial therapy was initiated and she received
these drugs for 6 months. The patient's clinical manifestations
completely disappeared and the chest CT scan became normal after the
treatment.

\textbf{Conclusion:} The diagnosis of peritoneal tuberculosis is
challenging and it could be made with a combination of CT imaging,
explorative laparoscopy, and evaluation of biopsies from specimens and
culture or PCR from ascites fluid, or infected tissues.

\textbf{Keywords:} TB, peritoneal tuberculosis, extrapulmonary
tuberculosis, acute abdomen, pregnancy

\textbf{1.Introduction} Tuberculosis (TB) is a significant health
problem worldwide. The geographic incidence of TB in 2023 has been
reported as the following rates per 100 000 person-years (95\% CrI: 2242
in Africa , 807 in the Americas, 793 in Eastern Mediterranean, 1184 in
Europe, 1419 in South-East Asia and 1104 in Western Pacific. The Global
rate is reported to be 1148 per 100,000 person-years (95\% CrI) (1).
About 25\% of the whole world's population is estimated to be infected
with mycobacterium tuberculosis. Although it is a preventable and
treatable disease, according to the WHO reports, TB infected about 10
million cases and claimed 1.5 million lives in 2018 (2). It was
estimated that the rate of active tuberculosis in pregnancy is rising in
the United States (3). Most of these pregnant women lived in Africa and
Southeast Asia (4). TB is a significant cause of maternal mortality
during pregnancy. Pregnancy-related complications include increased
spontaneous abortion rate, suboptimal weight gain in pregnancy, labor
before 37 weeks of pregnancy, low birth weight, and enhanced neonatal
mortality. Delay in the diagnosis of this infection is an independent
factor associated with both increased obstetric morbidities and preterm
labor by four- and nine-fold, respectively (5). The vertical
transmission rates of TB from mother to the fetus is reported to be low,
the same as low reported rates for the viruses like SARS-CoV-2 (6, 7).
While TB mainly affects the lungs, about 33\% of TB cases might suffer
from extrapulmonary disease. The peritoneum is known as a usual
extrapulmonary site of TB (8).

Herein, we present a woman with a 16-week spontaneous abortion who was
referred to our emergency ward with the acute abdomen features as the
first sign of tuberculosis.

\textbf{2. Case History/ Examination} A 20-year-old G2P1Ab1 woman who
aborted spontaneously at 16-week pregnancy at home 11 days before, was
referred to our hospital with general abdominal pain from 10 days ago.
The abdominal pain was intensified and associated with nausea, vomiting,
anemia, and massive ascites. She also had complaints of anorexia,
fainting, and sweating. On the physical examination, the vital signs
were reported as follows: PR=120/min, BP=90/60mmHg, RR=18/min, OT=38,
\selectlanguage{english}and O2sat=97\%, and she had abdominal distension with diffuse tenderness
and guarding especially in the lower abdomen, and positive cervical
motion tenderness suggestive of a hemorrhage or massive ascites.
Transvaginal ultrasonography confirmed the presence of ascites (Figure
1-2). Laboratory data revealed Hb=5/6 gr/dL, white blood count of 6100,
C reactive protein= 3+, and ESR=120. In addition, U/A, U/C, and PCR for
COVID-19 were evaluated due to abdominal pain and coronavirus pandemic.
The results of tests performed to evaluate renal function and blood
levels of hepatic transaminases did not indicate unusual values.

\textbf{3.Method (Differential diagnosis, investigation and treatment)}

The differential diagnosis including, uterus rupture, hemoperitoine,
ruptured ectopic pregnancy, and ovarian cyst.

The patient subsequently underwent diagnostic laparotomy due to
suspicious unsafe abortion in the history, abdominal examination, and
severe anemia with the probable diagnosis of acute abdomen. Laparotomy
revealed 3 liters thick yellow pus in the abdominopelvic cavity, and
substantial adhesions between viscera, and several small-scale nodular
implants on the surface of the peritoneal, liver, and stomach. The
intestine, omentum, mesentery, uterine, ovaries, and fallopian tubes
were normal except for inflammation. Irrigation of the abdominopelvic
cavity and adhesiolysis were conducted. There was no specific site for
the purulent ascites in exploration. Tissue samples from the peritoneum,
omentum, and lymph nodes were sent to pathology and some tissue samples
and ascetic fluid were sent for the microbiology, cytology, and PCR for
tuberculosis examinations. The patient was treated with intravenous
broad-spectrum antibiotics for 72 hours. Tissue samples of the
pathological study showed granulomatous inflammation and samples for
smear and culture and cytology revealed negative findings. In addition,
COVID-19 PCR was reported to be negative.

According to a large amount of intraperitoneal pus without a specified
source and granulomatous inflammation on pathology report (figure 3, 4),
PPD test, and chest radiography were conducted with the probable
diagnosis of tuberculosis. PPD was negative but CXR revealed patchy
consolidations. The family history and past history of the patient's TB
were negative. Meanwhile, there were no previous computed tomography
(CT) scans or CXR being conducted for this patient.

\textbf{4. Conclusion and results (outcome and follow-up)}

Despite 72 hours of antibiotic therapy, there was no improvement in
clinical condition so according to the laboratory findings and medical
records, a thoracic CT scan was performed for further evaluation of the
ascites etiology, which revealed bilateral pleural effusion,
atelectasis, pulmonary parenchymal consolidations, and sub-plural patchy
consolidation (figure 5). Abdominopelvic ultrasonography was normal.
With the possible diagnosis of tuberculosis, anti-mycobacterial therapy
with isoniazid, rifampin, pyrazinamide, and ethambutol was prescribed
and the patient received these drugs for 6 months until the treatment
course completion. Eventually, the patient's clinical manifestations
completely disappeared and the chest CT scan became normal after the
treatment.

\textbf{5. 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
(8).

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 (9). 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 (10). In addition, pulmonary lesions are considered TB,
or the disease may not have any evidence on the chest radiograph.
Furthermore, for a number of patients, pleural effusion might be the
only radiologic presentation (11). Frequent ultrasonography and computed
tomographic presentations include ascites, thickening of the viscera
(omental, mesenteric, peritoneal, and intestinal), adhesions between
viscera, and lymphadenopathy (12, 13), the same as our patient.
Laparoscopic studies reported exudative, cloudy ascites with multiple
whitish nodules or tubercles with the visceral and parietal peritoneum
demonstrating extensive adhesions and omental thickening (14). 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 the body, as there is a low chance of
being detected. Patients with ascites have improvement within a few
weeks of initiating treatment in 90 percent of cases (15). 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
(11). Females with advanced levels of TB and those who simultaneously
suffer from HIV infection often have the worst prognosis of TB (5). TB
is a significant cause of maternal mortality during pregnancy. Several
factors contribute to the pregnancy-related effects of TB, like its
severity, prognosis during pregnancy, the presence of extrapulmonary
infections, HIV coinfection, and time to start treatment (5). 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 of
tuberculosis treatment.

In conclusion, Tuberculous peritonitis is a form of abdominopelvic TB
that can mimic many other infectious or malignant diseases. The
diagnosis is challenging for many reasons, including no family or
history of TB, no symptoms of pulmonary TB, or negative PPD, and
diagnosis requires a combination of testing and medical judgment and
doing an interventional test like laparotomy to confirm the diagnosis.
The diagnosis could be made by a combination of CT imaging, explorative
laparoscopy, evaluation of biopsies from specimens and culture, or PCR
from ascite 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.

\textbf{Conflicts of interest}

The authors declare no conflict of interests.

\textbf{Acknowledgments}

The Authors would like to thank all staffs of the Masih Daneshvari
Hospital for their helps in care of the patient.

\textbf{Funding}

There was no funding support for the case report.

\textbf{Data availability statement}

The data that support the findings of this study are available from the
corresponding author upon reasonable request.

\textbf{Patient consent}

Written informed consent was obtained from the patient's parents and is
available for review upon request.

Author contribution

Samira Dehghani: Conceptualization, Writing -- original draft

Saloomeh Mohammadi: Data curation, Writing -- original draft

Atefeh Mahmoudi: Investigation, Writing -- original draft

Fatemeh Riyahi Zaniyani: Project administration, Writing -- original
draft

Sasan Shafiei: software

Afrouz Emzaei: Methodology

Yasaman Tavakoli: Writing -- review \& editing

Roozbeh Narimani Javid: Resources

Athena Behforouz: Supervision

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et al. Global, regional, and national estimates of tuberculosis
incidence and case detection among incarcerated individuals from 2000 to
2019: a systematic analysis. The Lancet Public Health.
2023;8(7):e511-e9.

2. World Health O. Guidelines for treatment of drug-susceptible
tuberculosis and patient care. 2017 update ed. Geneva: World Health
Organization; 2017 2017.

3. El-Messidi A, Czuzoj-Shulman N, Spence AR, Abenhaim HA. Medical and
obstetric outcomes among pregnant women~with tuberculosis: a
population-based study~of~7.8~million~births. American journal of
obstetrics and gynecology. 2016;215(6):797.e1-.e6.

4. Sugarman J, Colvin C, Moran AC, Oxlade O. Tuberculosis in pregnancy:
an estimate of the global burden of disease. The Lancet Global health.
2014;2(12):e710-6.

5. Ormerod P. Tuberculosis in pregnancy and the puerperium. Thorax.
2001;56(6):494-9.

6. George C, Jeffery H, Lahra M. Infection of mother and baby. Keeling's
Fetal and Neonatal Pathology. 2022:207-45.

7. Karimi H, Mansouri V, Rezaei N. Vertical transmission and maternal
passive immunity post-SARS-CoV-2. Future Virol. 2023.

8. Sharma SK, Mohan A. Extrapulmonary tuberculosis. The Indian journal
of medical research. 2004;120(4):316-53.

9. Jadvar H, Mindelzun RE, Olcott EW, Levitt DB. Still the great
mimicker: abdominal tuberculosis. AJR American journal of roentgenology.
1997;168(6):1455-60.

10. al-Quorain AA, Facharzt, Satti MB, al-Freihi HM, al-Gindan YM,
al-Awad N. Abdominal tuberculosis in Saudi Arabia: a clinicopathological
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11. Kapoor VK. Abdominal tuberculosis. Postgraduate Medical Journal.
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12. Rathi P, Gambhire P. Abdominal Tuberculosis. J Assoc Physicians
India. 2016;64(2):38-47.

13. Debi U, Ravisankar V, Prasad KK, Sinha SK, Sharma AK. Abdominal
tuberculosis of the gastrointestinal tract: revisited. World journal of
gastroenterology. 2014;20(40):14831-40.

14. Ding D-C, Chu T-Y. Laparoscopic diagnosis of tuberculous peritonitis
mimicking ovarian malignancy. Taiwanese Journal of Obstetrics and
Gynecology. 2011;50(4):540-2.

15. Demir K, Okten A, Kaymakoglu S, Dincer D, Besisik F, Cevikbas U, et
al. Tuberculous peritonitis--reports of 26 cases, detailing diagnostic
and therapeutic problems. European journal of gastroenterology \&
hepatology. 2001;13(5):581-5.

figure 1: sonography view of abdominopelvic cavity\selectlanguage{english}
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Figure 4: granulomatous inflammation in omental specimen

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