Tuberculous peritonitis in pregnancy is a rare form of extrapulmonary tuberculosis that is not easily diagnosed. The clinical presentations of tuberculous peritonitis are usually non-specific and mimic those of other diseases, such as ovarian malignancy or chronic liver disease, and this non-specificity can cause diagnostic delays and complications. The authors report the case of a 31-year-old primigravida woman who presented with uncontrolled fever, dyspnea, elevated liver enzymes, and mild abdominal distension at 13+2 weeks of gestation. At 14+2 weeks, a therapeutic abortion was conducted and tuberculous peritonitis was confirmed by laparoscopic excisional biopsy of peritoneal nodules and histopathologic examination. The patient recovered on antituberculosis therapy and abdomen and chest follow up radiographic findings have confirmed improvement.
In pregnancy, Tuberculous peritonitis (TP) is an uncommon form of extrapulmonary tuberculosis, and its diagnosis is likely to be delayed because the results of radiologic evaluations and laboratory investigations are usually non-specific [
A 31-year-old primigravida woman of parity 0-0-0-0 was referred to our emergency room at 13+2 weeks of gestation with uncontrolled fever, chill, dyspnea, elevated liver enzymes, and mild abdominal distension. The fever (up to 38.0℃) had started at 11+5 weeks, and the diagnosis made at the time was acute pyelonephritis, which was addressed with 10 days of antibiotic treatment. However, the fever was not controlled and the patient's general condition and laboratory findings worsened. There was no medical history of hepatitis, pulmonary tuberculosis, thyroid disease, or diabetes mellitus.
The patient was 157 cm tall and weighed 54 kg (body mass index 21.9 kg/m2). At admission her blood pressure was 98/55 mmHg, heart rate 100/min, respiratory rate 18/min, and body temperature 38.0℃. Her abdomen was mildly distended and bilateral mild costovertebral angle tenderness were observed.
Laboratory tests results were as follow; white blood cell (WBC) count 7,160/mm3, hemoglobin 10.9 g/dL, hematocrit 30.8, neutrophil count 87.7%, platelet count 166,000/mm3, erythrocyte sedimentation rate 50 mm/hr, C-reactive protein 6.31 mg/L, and CA 125 level 472 U/mL. Liver function testing showed; aspartate aminotransferase (AST) 511 U/mL, alanine transaminase (ALT) 383 U/mL, serum Na+ 133 mEq/L, K+ level 3.1 mEq/L, CL− 103 mEq/L, and albumin 2.8 g/dL. Serology was negative for viral hepatitis (B and C). The renal function test results were; pH 6.0, ketone body 2+, red blood cells many per high power field, and WBCs 6 to 10 per high power field. Abdominal ultrasound revealed ascitic fluid in anterior and posterior uterine spaces and both paracolic gutters (4 to 5 cm), normal ovaries, and a single fetus with a crown rump length of 5.9 cm (12+3 weeks). Paracentesis was performed to determine the nature of the ascites. The aspirated fluid was clear and straw colored and had a WBC count of 1,275/mm3, 40% of cells were lymphocytes and 43% were polymorphonuclear leukocytes, its glucose level was 50 mg/dL, protein 3.1 g/dL, albumin 1.6 g/dL, and adenosine deaminase (ADA) 107.6 IU/L. Polymerase chain reaction (PCR) was negative for
Initially, she was treated conservatively by intravenous administration of fluid and antibiotics (cefotaxime, metronidazole, and azithromycin), but her clinical condition and laboratory tests did not improve. Body temperatures fluctuated daily between 35℃ and 39℃. On hospital day 3, blood WBC count was 5,030/mm3, hemoglobin 9.0 g/dL, AST 388 U/mL, and ALT was 341 U/mL, and chest radiography showed moderate pulmonary congestion and pleural effusion. From this time, her general condition deteriorated and the abdominal distension and dyspnea progressively worsened, and she could not sleep or take food. On hospital day 8, a therapeutic abortion was conducted. Unfortunately, no
On hospital day 11, the spiking fever disappeared and the patient's general physical condition was satisfactory. Her blood WBC count was 4,220/mm3, hemoglobin 8.7 g/dL, AST 38 U/mL, and ALT 33 U/mL, but plain chest radiography continued to show aggravated pulmonary congestion and pleural effusion. However, on hospital day 18, chest radiography showed the pleural effusion had diminished. Although, at first,
Tuberculous peritonitis is extremely rare in pregnancy, and the rate of TP among all forms of tuberculosis varies from 0.1% to 0.7% worldwide [
The pathogenesis of TP probably involves hematogenous spread from a primary pulmonary tuberculosis focus or the reactivation of latent tuberculosis foci in peritoneum [
Although the clinical symptoms of TP are non-specific, it is commonly associated with abdominal distension, pain, fever, chill, and weight loss. Our patient exhibited symptoms of unexplained prolonged fluctuating fever, chill, abdominal distension, and dyspnea. Because of the non-specific nature of its symptoms and difficulties associated with surgical intervention, there is a tendency to defer extensive diagnostic radiological investigations, but this can delay the diagnosis of TP in pregnancy. Furthermore, investigations and radiologic investigations are of limited diagnostic value. An elevated serum CA 125 level can be confused with ovarian cancer, although it can be used as a follow-up marker [
The gold standards for the diagnosis of TP are the identification of
In summary, the diagnosis of TP in pregnancy is challenging, and therefore, it should be suspected when ascites and uncontrolled fever are present during pregnancy. Accurate diagnosis requires histopathologic examination and the isolation of