2410 Unusual Cause of Ascites in Liver Cirrhosis: Peritoneal Tuberculosis

INTRODUCTION: Peritoneal tuberculosis is a rare disease with increasing incidence in recent years, especially in patients with immunocompromised state. Tuberculous peritonitis (TBP) in cirrhotic patients can mimic spontaneous bacterial peritonitis (SBP) and infrequently considered in differential diagnosis, resulting in delayed diagnosis and mortality. We present a case of TBP in a patient with cirrhosis. CASE DESCRIPTION/METHODS: 37-year-old man with history of alcoholic cirrhosis and alcohol abuse presented with gradually worsening abdominal distension for 3-6 months and abdominal pain for 2 days. Patient had pulmonary tuberculosis 20 years ago for which he received multi-drug regimen for 6 months. On presentation, vitals were stable and he had epigastric tenderness. Labs revealed AST - 61 U/L and normal CBC. CT abdomen showed moderate ascites with thin peripheral enhancement suggestive of peritonitis. He was started on empiric antibiotics for presumed SBP. Paracentesis removed 1.4 L of straw colored fluid with WBC 791 cells/L with lymphocytes (94%), SAAG-0.4 g/dl, negative gram stain, ascitic fluid culture and cytology showed benign mesothelial cells and small mature lymphocytes. Given continued low-grade fever upto 100.4 F and lymphocytic predominance in the ascitic fluid, serum Quantiferon gold was done which came back positive. A laparoscopic peritoneal biopsy revealed exudates, loculated ascites and biopsy showed granulomatous inflammation with caseous necrosis confirming Mycobacterium tuberculosis. Patient was started on Ethambutol, Isoniazid, Pyrazinamide and Rifampin for 2 months followed by isoniazid and Rifampin for 4 months. DISCUSSION: Tuberculous peritonitis should be considered as differential diagnosis, in addition to SBP in cirrhotic patients who presents with ascites and abdominal pain. Similar to SBP, TBP in patients with cirrhosis presents with nonspecific signs and symptoms including abdominal distension, fever and abdominal pain. However, treatment of TBP and SBP differs vastly. TBP should be considered with the following criteria: cirrhotic patients with Child Pugh B; TB identified at additional sites; lymphopenia in the peripheral blood; ascitic protein >25 g/l; lymphocytes predominance in ascites; ascitic ADA activity >27 U/l; and ascitic LDH >90 U/l. Treatment of TBP with anti-tuberculosis drugs for atleast 6 months with 4-drug regimen for initial 2 months followed by two-drug regimen. 20%–40% of patients with TBP presents with an acute abdomen and need surgical intervention.