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.