A case of diffuse Peritoneal Tuberculosis

Clinical History

A 28-year-old Ethiopian-born male patient presented with weight loss, epigastric pain and vomiting.

Imaging Findings

The patient underwent a barium swallow which showed delay of gastric emptying and a possible pyloric stricture. He was subsequently lost to follow up and represented 2 years later with similar symptoms. A CT abdomen/pelvis was completed which showed diffuse thickened and irregular peritoneum with retroperitoneal nodes and stellate mesentery. The possibility of peritoneal TB was discussed. A HIV and hepatitis screen was negative. He had a surgical biopsy of the peritoneum which showed caseating granulomatous disease on histology. Peritoneal fluid also showed granulomatous change in keeping with tuberculosis. He was started on anti-tuberculosis agents (rifampicin, isoniazid, pyrazinamide, ethambutol and pyridoxine). He is currently still receiving treatment which he is tolerating and responding well to.

Discussion

When mycobacterium tuberculosis is extrapulmonary, peritoneal involvement is the most common clinical manifestation. This can affect up to one third of all patients diagnosed [1]. It is rare in isolation and usually represents a widespread intra-abdominal disease. Tuberculosis infiltration to the peritoneum can be caused by haematological spread, ruptured lymph nodes, salpingitis in women and intestinal lesions [2].

There are three main types of patterns of peritoneal infiltration of tuberculosis with considerable overlap between the types:
1- Wet type: Large volumes of free or loculated hyper-attenuating ascites
2- Fibrotic type: Omental/mesenteric masses, fixed mesentery and matted bowel loops
3- Dry type: Mesenteric thickening, fibrous adhesions and rarely nodules (as in this case)

Specific features more likely to represent peritoneal tuberculosis as opposed to malignant peritoneal infiltration include macronodules, smooth continuous thickened omentum and mesenteric changes such as stellate mesentery [3].

Peritoneal tuberculosis remains a challenge for radiologists to diagnose but knowledge of the types of peritoneal infiltration and specific mesenteric findings can be suggestive of the infection.

Differential Diagnosis List

Final Diagnosis

Peritoneal tuberculosis

URL:	https://eurorad.org/case/14077
DOI:	10.1594/EURORAD/CASE.14077
ISSN:	1563-4086