Tuberculous peritonitis (TP) is a rare, extrapulmonary manifestation of tuberculosis [1] [2]. TP mainly occurs via the hematogenous spread of Mycobacterium tuberculosis microorganisms from the affected lungs. It may also spread from infected abdominal or pelvic structures, however, this is a rare occasion [3]. Cases of tuberculosis (TB), including TP, have recently risen. Risk factors for developing TP include human immunodeficiency virus (HIV) infection, diabetes, peritoneal dialysis, and malignancy [2].

Diagnosis of TP is not straightforward, as the clinical picture differs between patients, and often the symptomatology is vague [2]. TP symptoms may be especially overlooked in pregnancy [4]. Furthermore, comorbidities such as liver cirrhosis could mask existing symptoms and thus lengthen the delay in diagnosis [5].

Commonly reported symptoms and signs are fever, ascites, abdominal pain, constipation, and diarrhea [6]. Manifestations such as weight loss and night sweats have been reported to varying degrees [2]. Ascites, which is almost always present, may be obvious or subtle [7]. The latter occurs in the minority of patients and may be palpated as a doughy abdomen or perceived by imaging or during surgery [7] [8]. The color of the ascitic fluid is pale yellow, but rarely may be bloody.

Unrecognized and untreated TP leads to death in over 50% of cases [9].

• Fever

  The patient presented with persistent fever and intermittent cough for 1 month, but had no gastrointestinal symptoms. [ncbi.nlm.nih.gov]

• Weight Loss

  A young American Indian male with alcoholic cirrhosis and ascites presented with low grade fever and weight loss. A diagnosis of tuberculous peritonitis was made by laparoscopic guided peritoneal biopsy. [ncbi.nlm.nih.gov]

• Chills

  Signs and symptoms of PAD include abdominal tenderness; distended abdomen; nausea and vomiting; cloudy dialysis fluid; fever; chills. [diagnose-me.com]

  Pain, fever, chills, weight loss and abdominal pain are common complaints [ 6 ]. In pregnant women, diagnosis of tuberculosis may be delayed by the non-specific nature of early symptoms and because they are often attributed to pregnancy [ 6 ]. [jmedicalcasereports.biomedcentral.com]

  She denied fevers, chills, night sweats, or cough. She denied sick contacts or recent travel outside the United States. She denied taking medications or using alcohol. [shmabstracts.com]

  Miliary TB is most common among Children 4 yr Immunocompromised people The elderly Symptoms include fever, chills, weakness, malaise, and often progressive dyspnea. [merckmanuals.com]

  Symptoms include fatigue, loss of weight, night fevers and chills, and persistent coughing with sputumstreaked blood. The virulent form of the infection can then spread to other parts of the body. [encyclopedia.com]

• Noncompliance

  A rare fibroadhesive form of tuberculous peritonitis associated with the paradoxical response to antituberculous therapy was considered by excluding noncompliance, drug resistance and adverse effects, and other concomitant infections. [ncbi.nlm.nih.gov]

  Such noncompliance is believed to be the main reason for the upsurge in drug-resistant strains of the TB bacilli, many of which are resistant to more than one drug. [encyclopedia.com]

• Abdominal Pain

  A case of tuberculous peritonitis complicating continuous ambulatory peritoneal dialysis (CAPD) in a 37-year-old man who presented with fever, abdominal pain, and a malfunctioning Tenckhoff catheter is reported. [ncbi.nlm.nih.gov]

• Abdominal Distension

  Tuberculous peritonitis has to be clinically suspected in all patients with slowly progressive abdominal distension, particularly when it is accompanied by fever and pain. [ncbi.nlm.nih.gov]

• Constipation

  Commonly reported symptoms and signs are fever, ascites, abdominal pain, constipation, and diarrhea. Manifestations such as weight loss and night sweats have been reported to varying degrees. [symptoma.com]

  The patient was a 62-year-old woman (Para IV) who consulted our hospital with chief complains of lower abdominal pain and constipation. Ultrasonography and CT demonstrated ascites. [ci.nii.ac.jp]

  • Abdominal discomfort associated with alternate diarrhoea/constipation • Dilated veins along side lower abdominal wall • Shifting dullness • In male child congenital hydrocele appear sometime • Umbilical hernia occur due to increased intraabdominal [slideshare.net]

  have done a meta-analysis of 35 studies and found abdominal pain in 64.5%, fever in 59%, weight loss in 61%, diarrhea in 21.4%, and constipation in 11% of patients with TBP. [14] Aguado JM et al., have reported in their study that 49% of patients with [saudijgastro.com]

  None of the patients experienced alternate constipation and diarrhea or a doughy feeling on palpation of the abdomen. The laboratory findings are summarized in table 3. [academic.oup.com]

• Abdominal Tenderness

  Due to the symptoms fever, ascites, and diffuse abdominal tenderness on palpation of unknown origin, a CT scan of the abdomen was performed and led to the suspected diagnosis of a peritoneal carcinomatosis. [ncbi.nlm.nih.gov]

  Ascites, fever, wasting, pallor, and abdominal tenderness were common findings. Ultrasonography demonstrated ascites in all patients who underwent this procedure; 21% also had adhesions. [ajtmh.org]

  Signs and symptoms of PAD include abdominal tenderness; distended abdomen; nausea and vomiting; cloudy dialysis fluid; fever; chills. [diagnose-me.com]

  tenderness and abdominal guarding, which are exacerbated by moving the peritoneum, e.g., coughing (forced cough may be used as a test), flexing one's hips, or eliciting the Blumberg sign (a.k.a. rebound tenderness, meaning that pressing a hand on the [en.wikipedia.org]

  Thorough clinical examination, with stress on the presence of pallor, jaundice, fever, manifestations of hepatocellular failure, ascites and its amount, abdominal tenderness, palpable abdominal masses, and localized or generalized lymphadenopathy. [azmj.eg.net]

• Loss of Appetite

  A 49-year-old female patient on continuous ambulatory peritoneal dialysis presented with fever, abdominal pain and loss of appetite. [ncbi.nlm.nih.gov]

  Possible symptoms include: cough that lasts a long time coughing up blood or lots of mucus* *mucus (MYOO-kus) is a thick, slippery substance that lines the insides of many body parts. chest pain loss of appetite and weight loss weakness and exhaustion [encyclopedia.com]

• Tachycardia

  Signs and symptoms • Vague and consist of nothing more than lassitude, anorexia and failure to thrive • Pyrexia (often low-grade), tachycardia, leucocytosis and localised tenderness common • Later on, a palpable mass may develop • When palpable an intraperitoneal [slideshare.net]

  Other symptoms [ edit ] Diffuse abdominal rigidity (" abdominal guarding ") is often present, especially in generalized peritonitis Fever Sinus tachycardia Development of ileus paralyticus (i.e., intestinal paralysis), which also causes nausea, vomiting [en.wikipedia.org]

• Night Sweats

  In the multivariate analysis, presence of fever (P 0.001), night sweats (P 0.001), age under 40 years (P 0.008), and normal serum CA 19-9 level (P 0.044) were independent predictor of diagnosis of TBP. [ncbi.nlm.nih.gov]

  We also identified fever and night sweats concomitantly in the same patients. [saudijgastro.com]

  Manifestations such as weight loss and night sweats have been reported to varying degrees. Ascites, which is almost always present, may be obvious or subtle. [symptoma.com]

  The most frequent complaints were abdominal pain, fever, anorexia, night sweats, abdominal swelling, and weight loss. Ascites, fever, wasting, pallor, and abdominal tenderness were common findings. [ajtmh.org]

• Secondary Amenorrhea

  In this article, we discuss a rare case of a 40-year-old Nigerian female presenting with abdominal pain, distension and secondary amenorrhea, and show that a high clinical suspicion combined with minimally invasive procedures can help physicians make [ncbi.nlm.nih.gov]

Most laboratory tests involve the analysis of the ascitic fluid. The culture of the ascitic fluid or bioptic material attained by means of paracentesis or peritoneal biopsy is the gold standard. Biopsy specimens are obtained efficiently through ultrasound or computerized tomography (CT) guidance. A newer, more rapid technique is the BACTEC radiometric system. Unlike conventional culture methods, results are available for approximately 2 weeks [9]. Other tests include assessing the protein content of the ascitic fluid, as well as polymerase chain reaction (PCR). Diagnostic minilaparotomy and laparoscopy are also important in the identification of tuberculous peritonitis.

In certain patients, active pulmonary TB may be visible on chest X-ray, but most radiographs show no specific findings. Ultrasound and CT of the abdomen are more valuable than chest X-ray. Using these modalities, it is possible to visualize omental and peritoneal abnormalities such as peritoneal thickening and an increase in the number of mesenteric lymph nodes [10]. Furthermore, the combined use of these imaging techniques increases their diagnostic precision [11].

Patients who have risk factors for TP, present with ascites that contains a predominance of lymphocytes, and have no apparent etiology should be managed with a high level of suspicion of tuberculosis with peritoneal involvement. The serum-ascites albumin gradient (SAAG) is often less than 11g/L. More advanced diagnostic methods are being developed, such as the ascitic adenosine deaminase test.

1. SiaI G, Wieland ML. Current concepts in the management of tuberculosis. Mayo Clin Proc. 2011;86(4):348-361.
2. Sanai FM, Bzeizi KI. Systematic review: tuberculous peritonitis–presenting features, diagnostic strategies and treatment. Aliment Pharmacol Ther. 2005;22(8):685-700.
3. Mehta JB, Dutt A, Harvill L, Mathews KM. Epidemiology of extrapulmonary tuberculosis. A comparative analysis with pre-AIDS era. Chest. 1991;99(5):1134–1138.
4. Ormerod P. Tuberculosis in pregnancy and the puerperium. Thorax. 2001;56(6):494-499.
5. Mamo JP, Brij SO, Enoch DA. Abdominal tuberculosis: a retrospective review of cases presenting to a UK district hospital. QJM. 2013;106(4):347–354.
6. Rasheed S, Zinicola R, Watson D, Bajwa A, McDonald PJ. Intra-abdominal and gastrointestinal tuberculosis. Colorectal Dis. 2007;9(9):773–783.
7. Demir K, Okten A, Kaymakoglu S, et al. Tuberculous peritonitis-report of 26 cases, detailing diagnostic and therapeutic problems. Eur J Gastroenterol Hepatol. 2001;13(5):581–585.
8. Nafeh MA, Medhat A, Abdul-Hameed AG, Ahmad YA, Rashwan NM, Strickland GT. Tuberculous peritonitis in Egypt: value of laparoscopy in diagnosis. Am J Trop Med Hyg 1992;47(4):470–477.
9. Chow KM, Chow VC, Hung LC, Wong SM, Szeto CC. Tuberculous peritonitis-associated mortality is high among patients waiting for the results of mycobacterial cultures of ascitic fluid samples. Clin Infect Dis. 2002;35(4):409–413.
10. Demirkazik FB, Akhan O, Ozmen MN, Akata D. US and CT findings in the diagnosis of tuberculous peritonitis. Acta Radiol. 1996;37(4):517–520.
11. Jain R, Sawhney S, Bhargava DK, Berry M. Diagnosis of abdominal tuberculosis: sonographic findings in patients with early disease. AJR. American journal of roentgenology. 1995;165(6):1391–1395.