Discovering the elusive underlying cause of a bilateral effusion combined with ascites

A 77-year-old Asian man presented to the emergency department with bilateral pleural effusion and ascites accompanied with generalized weakness, dyspnea, tachycardia, and tachypnea. After an extensive workup that ruled out heart failure, pulmonary embolism, pneumonia, and malignancy-including extensive laboratory tests, electrocardiograms, chest x-ray, computed tomographic angiogram, computed tomography scans of the abdomen and pelvis, colonoscopy, thoracentesis, paracentesis, and exploratory laparoscopy-an elusive peritoneal tuberculosis was successfully identified. This case suggests that clinicians should consider extrapulmonary tuberculosis in their practice, given increasing immigration and the variety of populations present in our society. When tuberculosis is suspected, a negative smear for acid-fast bacillus, a lack of granulomas on histopathology, and failure to culture Mycobacterium tuberculosis do not exclude the diagnosis. Exploratory laparoscopy or minilaparotomy has a high level of sensitivity and specificity so should be considered.