Tuberculosis Peritonitis after spontaneous Abortion: A Case
ReportAbstract:Introduction: Tuberculosis (TB) is a significant problem
worldwide. The rate of active tuberculosis in pregnancy is rising and it
is a significant cause of maternal mortality during pregnancy.
Case presentation: This study is about a young woman who was
suffering from TB peritonitis, which is rare, with a highly progressive
clinical course following the spontaneous abortion of 16-week gestation
that refer with abdominal pain. Our case received a diagnostic
laparotomy that showed several small-scale implants on the peritoneum
and viscera. Histopathology revealed chronic caseating granulomas with
necrosis. With the possible diagnosis of tuberculosis anti-mycobacterial
therapy was started and she received these drugs for 6 months. The
patient’s clinical manifestations completely disappeared and chest CT
scan was normal after treatment.
Conclusion: The diagnosis of peritoneal tuberculosis is
challenging and it could be made by CT imaging, explorative laparoscopy,
evaluation of biopsies from specimens and culture or PCR from ascites
fluid or infected tissues.
Key words: TB, peritoneal tuberculosis, extra pulmonary
tuberculosis, acute abdomen, pregnancy
1. Introduction Tuberculosis (TB) is a significant problem worldwide. About 25% of
whole world population are estimated to be infected with mycobacterium
tuberculosis. Although it is a preventable and treatable disease, but
according to the WHO reports, TB infected about 10 million cases and
claimed 1.5 million lives in 2018.(1) It was estimated that the rate of
active tuberculosis in pregnancy is rising in United States(2). Most of
these pregnant women lived in Africa and Southeast Asia(3). TB is a
significant cause of maternal mortality during pregnancy.
Pregnancy-related complications contain increased spontaneous abortion
rate, being smaller relative to the weeks of pregnancy, suboptimal
weight gain in pregnancy, labor before 37 weeks of pregnancy, low birth
weight, and enhance neonatal mortality. Delay in the diagnosis of this
infection is an independent factor that is associated with both enhanced
obstetric morbidities and preterm labor by four- and nine-folds,
respectively (4). While TB mainly affects the lungs, about 33% of TB
cases might suffer from extra pulmonary disease. The peritoneum is an
usual extra pulmonary site of TB.(5)
We presented a woman with a 16-week spontaneous abortion who referred to
our emergency ward with the feature of acute abdomen as the first sign
of tuberculosis, a rare case of tuberculosis peritonitis.
2. Case Presentation A 20-year-old G2P1Ab1 woman who aborted spontaneously a 16 week
pregnancy at home in 11 days ago, referred to our hospital with general
abdominal pain from 10 days ago. The abdominal pain was intensified and
associated with nausea, vomiting, anemia and, massive ascites. She had a
complaint of anorexia, fainting, and sweating.
On the physical examination; PR=120/min, BP=90/60mmHg, RR=18/min, OT=38̊
and O2sat=97% and she had abdominal distension with diffuse tenderness
and guarding especially in the lower abdomen, and positive cervical
motion tenderness that suggested a hemorrhage or massive ascites.
Transvaginal ultrasonography confirmed the presence of ascites. (Figure
1-2). Laboratory data revealed Hb=5/6 gr/dL, white blood count were
6100, C reactive protein= 3+ and ESR=120. In addition UA, UC and PCR for
covid 19, were sent due to abdominal pain and corona virus pandemic. The
results of tests performed to evaluate renal function and level of
hepatic transaminase did not indicate unusual values.
The patient subsequently underwent diagnostic laparotomy due to
suspicious unsafe abortion in history, abdominal examination, and severe
anemia with the probable diagnosis of acute abdomen. Laparotomy revealed
3liters thick yellow pus in the abdominopelvic cavity and substantial
adhesions between viscera, and several small-scale nodular implants on
the surface of peritoneal, liver, and stomach. Intestine, omentum,
mesentery, uterine, ovaries and fallopian tubes were normal except for
inflammation. Irrigation of abdominopelvic cavity and adhesiolysis were
done. There was no specific site for the purulent ascites in
exploration. Tissue samples from the peritoneum, omentum and lymph nodes
were sent to pathology and some tissue samples and ascetic fluid were
sent for the microbiology, cytology and PCR for tuberculosis
examinations. The patient was treated with intravenous broad-spectrum
antibiotics till 72 hours. Tissue samples of pathological study showed
granulomatous inflammation and samples for smear and culture and cytology
revealed negative findings. In addition, covid19 PCR was reported
negative.
According to large amount of intraperitoneal pus without a specified
source and granulomatous inflammation on pathology report (figure 3),
with the probable diagnosis of tuberculosis, PPD and Chest radiography
were done. PPD was negative but CXR revealed patchy consolidations.
Despite 72hours of antibiotic therapy, there was no improvement in
clinical condition so according to the laboratory findings and medical
records, thoracic computed tomography (CT) scan was performed for
further evaluation of the ascites etiology (figure 4). Bilateral pleural
effusion, atelectasis, pulmonary parenchymal consolidations and sub
plural patchy consolidation were seen. Abdominopelvic Ultrasonography
was normal. With the possible diagnosis of tuberculosis
anti-mycobacterial therapy with isoniazid, rifampin, pyrazinamide, and
ethambutol was prescribed and the patient received these drugs for 6
months till complete the course of treatment. The patient’s clinical
manifestations completely disappeared and chest CT scan was normal after
treatment.