S2915 When Microbacterium Tuberculosis Travels to the Gut

Introduction: Gastrointestinal (GI) tuberculosis (TB) accounts for 1-3% of all TB cases worldwide, it can occur in the context of active pulmonary disease or as a primary infection without pulmonary involvement. Case Description/Methods: A 27-year-old Asian male presented with abdominal swelling for two weeks. Review of system was otherwise negative. Vital sign showed sinus tachycardia 110 beats per minute; there was abdominal distension with fluid waves. Labs showed AST 253 U/L, ALT 177 U/L, normal bilirubin, elevated ESR and CPR. Hepatitis panel was negative. Abdominal ultrasound showed large ascites. Patient reported no medical history, no medication or herbal use, no alcohol use, and no family history of liver disease. He underwent paracentesis with 2.7L fluid removal, fluid analysis showed serum-ascites albumin gradient < 1.1 and elevated adenosine deaminase (ADA), no signs of spontaneous bacterial peritonitis. Despite getting furosemide and spironolactone, patient continued to have recurrent ascites and underwent multiple paracenteses. Abdominal MRI showed diffuse peritoneal nodularity. HIV testing was negative; lab studies for chronic liver disease were unrevealing. A transjugular liver biopsy showed rare focus of ceroid-laden macrophages within the portal tract and a high hepatic venous pressure gradient of 10 mmHg. Abdominal TB was suspected; patient underwent a laparoscopic omentectomy with biopsy that revealed extensive serosal involvement by necrotizing granulomas suggestive of a mycobacterial infection. Chest x-ray and quantiferon TB gold test were negative. Patient was started on standard anti-tuberculosis medications with Ethambutol, Rifampin, Pyrazinamide and Isoniazid. He showed progressive improvements on subsequent office visits and abdominal ascites was resolved. Discussion: Peritoneal TB is a form of abdominal TB; it is a rare disease in developed countries and poses a diagnostic challenge as it typically presents with non-specific clinical and radiology features and can mimic other chronic liver diseases and malignancy. Although there is no single diagnostic test for GI TB and quantiferon testing may be false-negative in patients with extrapulmonary TB, an elevated ADA in ascetic fluid have been reported to be a good diagnostic marker. GI TB responds well to standard anti-TB drugs. If diagnostic testing is unyielding and clinical suspicion remains high, patients should be started empirically on anti-TB therapy, response to therapy is proposed as a criterion for the diagnosis of GI TB.