Description

The patient was a 77-year-old woman who had undergone surgery for gastric cancer, and who had periodically received CT of the chest and abdomen. At 7 years after the operation, CT revealed ascites with uniform peritoneal thickening and a small amount of unilateral pleural effusion (figure 1). Based on these CT findings, the attending surgeon suspected a recurrence of gastric cancer with systemic dissemination, including carcinomatous peritonitis. Exploratory laparoscopy revealed tiny yellow/white nodules diffusely covering the surface of anterior peritonea (figure 2) and small bowel. Histology was negative for malignancy but Ziehl-Neelsen staining was positive for acid-fast bacilli in non-caseating granulomas. Furthermore, the pleural fluid showed lymphocytosis with elevated levels of adenosin deaminase. An interferon-gamma release assay was positive. Based on these findings, although the patient did not have a distinct history of tuberculosis, we diagnosed her with miliary tuberculosis, including tuberculous peritonitis.

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Figure 1

CT showing ascites with uniform peritoneal thickening and a small amount of right pleural effusion.

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Figure 2

A laparoscopic photograph, showing tiny yellow/white nodules diffusely covering the surface of the anterior peritoneum.

Tuberculous peritonitis is a rare form of tuberculosis that involves the parietal and visceral peritoneum, omentum and intestinal mesentery.1 The possibility of miliary tuberculosis should be considered when ascites with peritoneal thickening is present along with pleural effusion.2 A delay in the diagnosis and treatment of tuberculosis increases patient mortality, suggesting that an early diagnosis by laparoscopic biopsy is very important for a prompt diagnosis and initiation of treatment.3