華山論劍-專業案例挑戰/Case 2015-002

Date: 5 Apr. posted by 蔡英楠/曾兆明/陳志城/湯道謙/張吉仰/牟聯瑞醫師學術天地

Answer of Case 2015-002

Clinical Course:

After admission, paracentesis was performed, and the ascites showed WBC 3520/cmm, lymphocyte 54 % , albumin 3.0 g/dL and AFS(-). SAAG is 1.1(serum albumin 4.1 g/dL). Cytology was negative. Abdomen CT showed peritoneal thickening (omental caking) and one heterogenous soft tissue at pelvic area (doughy abdomen). Due to the possibility of carcinomatosis of unknown origin, we arranged EGD and colonoscopy that showed gastric ulcers at antrum and lower body and diverticula at ascending and sigmoid colon. However, gastric biopsies showed chronic gastritis with intestinal metaplasia and no evidence of H. pylori infection. Laparoscopy showed peritoneum studded with multiple whitish nodules and so-called "Violin-string" fibrinous strands. Peritoneal biopsies showed granulomatous inflammation. We also arranged thoracentesis that demonstrated exudative effusion. Acid-fast stains of ascites and peritoneal biopsy were negative. However, tuberculous peritonitis still could not be ruled out. Hence, we started HERZ therapy. Culture grew Mycobacterium tuberculosis one month later.

Final Diagnosis:

Tuberculous peritonitis

Suspect peritoneal carcinomatosis with omental cake