When Peritoneal Tuberculosis Mimics Carcinomatosis: A Diagnostic Enigma

Abdominal tuberculosis (TB) can present with the involvement of the peritoneum, stomach, intestinal tract, hepatobiliary tree, pancreas, perianal area, or lymph nodes. Peritoneal TB is one of the most challenging forms to diagnose and usually occurs through reactivation of latent TB infection or through hematogeneous spread in the setting of active pulmonary TB. A 25-year-old male from Guinea-Bissau, with multiple visits to the emergency department in the last month due to several daily soft stools and generalized abdominal pain. He returned with an abdominal computed tomography (CT) revealing irregular ascites and suspected peritoneal carcinomatosis. He was admitted for an etiological study, and an abdominal CT scan was repeated, which showed diffuse thickening of the stomach wall. Erythrocyte sedimentation rate of 14 mm/1 h and C-reactive protein of 1.24 mg/dL. Interferon-gamma release assay was positive. Acid-fast bacilli smear in sputum and blood and urine cultures in Loewenstein-Jensen medium were negative. Upper gastrointestinal endoscopy revealed Helicobacter Pylori infection and colonoscopy was normal. Positron emission tomography-CT confirmed the abdominal CT findings. Diagnostic laparoscopy was performed to clarify the etiology, and pathological anatomy revealed findings compatible with tuberculosis. Treatment with isoniazid, rifampicin, pyrazinamide, and ethambutolepyridoxine was started. Although abdominal TB continues to be a significant health problem in the developing world, recently, there has been an increase in the number of patients diagnosed with abdominal TB in parts of the world where TB generally was rare. This is partly a result of increasing travel and migration and also of the rising number of HIV patients who are susceptible to opportunistic infections.