Disseminated Tuberculosis Masquerading as Pleural Effusion and Ascites: A Diagnostic Challenge

Abstract Tuberculosis, an infectious disease caused byMycobacterium tuberculosis (TB), may invade any organ but mainly involves the lungs. While pulmonary TB can be challenging to identify, diagnosis becomes harder with extrapulmonary involvement. A 35-year-old man presented to the hospital due to complaints of mild dyspnea on exertion and abdominal distention. Aside from reporting alcohol use three times per week since 2007, he endorsed no other medical problems and reported no other symptom complaints. He was found to have a large left pleural effusion and mild ascites and underwent left thoracentesis. Paracentesis was also considered but due to mild fluid being seen, intervention was deferred. Pleural cultures showed growth of staphylococcus epidermidis and he was treated empirically with antibiotics but, given no other lab or symptom abnormalities, cultures were thought to be contaminant. His condition improved and he reported resolution of symptoms and was discharged. He returned two weeks later with similar complaints of exertional dyspnea and abdominal distention andonce again reported no other symptoms. A computerized tomography (CT) of the chest and abdomen was performed and revealed, a large left pleural effusion and moderate amounts of complex ascites with peritoneal carcinomatosis. Pulmonary services were consulted once again and due to strong concerns for infectious vs malignant etiology, diagnostic thoracentesis and paracentesis were performed. Pleural fluid again revealed staphylococcus epidermidis with acid fast bacilli (AFB) and fungal cultures being negative and additional studies for cytology, immunostaining and flow cytometry revealing negative results. Peritoneal fluid was also analyzed and revealed negative results. Due to high suspicion of TB being the likely source, given imaging showing peritoneal nodularity on repeat assessment and the patient originally living in an endemic country with TB prevalence before moving in 2014, surgery was contacted, and the patient underwent an exploratory laparotomy with peritoneal biopsy. Biopsy results showed necrotizing granuloma with specimen confirmed to be Mycobacterium Tuberculosis by PCR. Following confirmation, the patient was started on appropriate TB regimen and established for close outpatient follow up and discharged from the hospital. TB is usually associated with atypical manifestations and rarely does it present with minimal symptoms. This case highlights the importance of considering TB in patients with unexplained ascites and pleural effusions, especially with relevant epidemiologic exposure.