A Peritoneal Tuberculosis Mimicking Advanced Cancer: A Case Report

Abstract

Tuberculosis (TB) could be presented with different manifestations. On many occasions, further evaluation in patients with the first diagnosis of the lung, pancreas, ovarian, or bladder cancer leads to the definite diagnosis of TB and the symptoms subside by treatment. Concerning the easy access to diagnostic tests and dramatic treatment responses, it is essential that physicians in endemic areas consider TB in patients with suspicious symptoms and in the differential diagnosis of malignancies, to diagnose the disease sooner and by simple and inexpensive tests; thus, avoiding imposing extra expenses to patients and the health system. We reported a 45-year-old female who was evaluated for abdominal pain, significant weight loss, and ascites for the past 4 months. The mediastinal and abdominopelvic Computed Tomography (CT) scan was performed in the initial evaluations of the patient. Accordingly, massive para-aortic and mediastinal lymphadenopathies and two thyroid nodules were detected. Furthermore, considering peritoneal thickening and moderate ascites, lymphoproliferative disorders were highly suggested as the diagnosis. The laboratory test data revealed bicytopenia, Erythrocyte Sedimentation Rate (ESR:57), and a high Cancer Antigen 125 (CA125). Unfortunately, the results of paracentesis were unavailable, though cytology was negative for malignancy. Due to anemia and weight loss, endoscopy and colonoscopy were performed twice in two different clinics, of which only gastritis was reported. Multiple abdominal and vaginal sonography was performed; these assessments suggested mild splenomegaly, mesenteric engorgement and thickening, multiple para-aortic and iliac adenopathies, as well as healthy uterus and ovaries. At the beginning of admission in Imam Khomeini Hospital, the patient denied any relevant medical history or family history. With further detailed questioning, we noticed a positive TB history in the patient’s grandmother, who lived with her. A Purified Protein Derivative (PPD) test was performed, which provided a negative result. Diagnostic laparoscopy was conducted, according to the observation of whitish nodules on the peritoneum and omentum, and the characteristic findings of TB, the surgeon, highly suggested TB as the definitive diagnosis. The pathology report mentioned granulomatous inflammation with a small focus of necrosis. Anti-TB treatment was initiated for the patient, and she was discharged accordingly. During three months of follow-up, the symptoms alleviated dramatically. Constitutional symptoms reduced, and bicytopenia eliminated. The most considerable issue, in this case, was unnecessary diagnostic tests and, subsequently, extra cost imposed on the health system. Such additional expense could be declined with obtaining a detailed history and performing appropriate tests toward the differential diagnosis. This issue is, unfortunately, a common mistake occurring in numerous outpatient clinics due to the high number of patient referrals.