Presentation
Abdominal distention for one month.
Patient Data
There are extensive compartmentalized ascites with thick enhanced peritoneum. Bilateral, almost symmetrical, enhancing adnexal lesions are seen.
There are multiple enhancing omental nodules. Minimal bilateral pleural effusion.
Both adrenals are unremarkable. The liver, spleen, both kidneys and pancreas appear normal. No definite pneumoperitoneum.
There is extensive compartmentalized ascites, with a thick enhanced peritoneum and bilateral convoluted tube-like structures inseparable from the uterus that show intense mucosal enhancement.
Multiple small enhancing omental nodules are noted.
The bowel loops appear matted to each other with edematous mesentery.
Both ovaries appear grossly unremarkable. The appendix measures about 0.6 cm and appears unremarkable. No apparent pelvic masses.
The uterus appears normal, with an endometrial thickness measuring about 0.4 cm.
The urinary bladder is unremarkable. The visualized skeleton appears normal.
Conclusion:
A large amount of ascites with enhanced peritoneum and bilateral salpingitis. The differential diagnosis includes tuberculous peritonitis or peritoneal carcinomatosis.
PATHOLOGY REPORT GROSS:
The specimen labeled with the patient's name, "Peritoneal biopsy," consists of a 2 x 1.5 x 0.3 cm whitish soft tissue piece. It is submitted all in one cassette.
The specimen fixed and labeled with the patient's name, "Omental biopsy," consists of 2 yellowish fatty tissue pieces, in aggregate measuring 3 x 3 x 0.5 cm. They are submitted all in 2 cassettes.
MICROSCOPIC:
Peritoneal and omental biopsies reveal similar findings, with infiltration by multiple, variably sized caseating and non-caseating epithelioid granulomas and scattered Langhans-type multinucleated giant cells. Z.N stain for acid-fast bacilli is negative. No malignancy was seen in the levels examined.
DIAGNOSIS: (1&2) Peritoneal and omental biopsy:
Granulomatous inflammation, including caseating epithelioid granulomas, is most in keeping with tuberculosis.
Case Discussion
Tuberculous peritonitis is one of the extrapulmonary manifestations of tuberculosis. There are two types: wet (as in this case) and dry (characterized by multiple necrotic lymph nodes).
It has been challenging to differentiate radiologically between tuberculous peritonitis and another disease affecting the peritoneum.
CA-125, often used as an ovarian cancer marker, is also elevated in patients with tuberculosis, both pulmonary and extrapulmonary.
The most useful CT finding in the differentiation of tuberculous peritonitis and peritonitis carcinomatosis is the appearance of the parietal peritoneum. While smooth minimal thickening and significant enhancement in the peritoneum support tuberculous peritonitis, nodular implants, and irregular peritoneal thickening suggest the diagnosis of peritonitis carcinomatosis.
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