Tuberculous peritonitis in hemodialysis patients with chronic liver disease

Tuberculous peritonitis (TBP) remains a major medical problem in many developing countries, wherein the incidence of tuberculosis (TB) is still high. Since the clinical presentation may be insidious and variable, diagnosis of TBP may be delayed or missed, resulting in undue patient morbidity and mortality. Tests frequently associated with TB such as chest radiograph and Mantoux test are not usually sensitive enough for the diagnosis of TBP. The diagnosis becomes all the more difficult in the presence of chronic liver disease and/or renal failure, since the ascitic fluid may not be of the exudative type and lymphocytosis may not be the predominant cell picture. We present here three cases of TBP in diabetic Saudi patients on maintenance hemodialysis who also had associated chronic liver disease. All three patients responded satisfactorily to standard anti-tuberculous therapy. We stress that high index of suspicion is required to establish early diagnosis of TBP particularly in patients with chronic renal and/or liver disease. Laparoscopy with tissue biopsy for histology and, microbiological examination including culture are the most sensitive and specific diagnostic procedures.