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Peritonitis, Tuberculous

For further information, see CMDT Part 15-09: Spontaneous Bacterial Peritonitis

Key Features

  • Tuberculous involvement of the peritoneum

  • Accounts for < 2% of all causes of ascites in the United States

  • Incidence higher among those with HIV disease, urban poor, nursing home residents, and immigrants from underdeveloped countries

  • In the United States, half have underlying cirrhosis and ascites from portal hypertension

Clinical Findings

  • Low-grade fever

  • Anorexia, weight loss

  • Abdominal distention and tenderness

  • Clinically apparent ascites or suggestion of abdominal mass

Diagnosis

  • Tuberculin skin tests positive in less than half (Table 9–13)

  • Chest radiographs abnormal in > 70%

  • Active pulmonary tuberculosis disease in < 20%

  • Ultrasonography or CT imaging of the abdomen

    • Reveals free or loculated ascites in > 80% of patients

    • May demonstrate lymphadenopathy or peritoneal, mesenteric, or omental thickening

  • Ascitic fluid total protein > 3.0 g/dL, lactate dehydrogenase > 90 units/L, or mononuclear cell-predominant leukocytosis > 500/mcL (0.5 × 109/L); each has a sensitivity of 70–80% but limited specificity

  • Ascitic fluid smears for acid-fast bacilli are usually negative; cultures are positive in only 35%

  • Ascitic fluid adenosine deaminase activity ≥ 36–40 international units/L has sensitivity > 100% and specificity of 97%, but limited predictive value in cirrhotic ascites or HIV disease

  • Laparoscopy establishes diagnosis

  • Characteristic peritoneal nodules are visible in > 90%

  • Peritoneal biopsy reveals granulomas

  • Peritoneal biopsy cultures are positive in < 66% and require at least 4–6 weeks

Table 9–13.Classification of positive tuberculin skin test reactions.1
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Table 9–13. Classification of positive tuberculin skin test reactions.1
Induration Size Group
≥ 5 mm

  1. HIV-positive persons.

  2. Recent contacts of a person with infectious tuberculosis.

  3. Persons with fibrotic changes on chest radiographs suggestive of prior tuberculosis.

  4. Patients with organ transplants and other immunosuppressed patients (receiving the equivalent of > 15 mg/day of prednisone for 1 month or more, or those taking TNF-alpha antagonists).
≥ 10 mm

  1. Recent immigrants (< 5 years) from countries with a high prevalence of tuberculosis (eg, Asia, Africa, Latin America).

  2. HIV-negative injection drug users.

  3. Mycobacteriology laboratory personnel.

  4. Residents of and employees in high-risk congregate settings: correctional institutions; long-term care facilities; hospitals and other health care facilities; residential facilities for HIV/AIDS patients; and homeless shelters.

  5. Persons with medical conditions that increase the risk of progression to tuberculosis disease: gastrectomy, weight loss to ≥ 10% below ideal body weight, jejunoileal bypass, diabetes mellitus, silicosis, advanced chronic kidney disease, some hematologic disorders (eg, leukemias, lymphomas), and other specific malignancies (eg, carcinoma of the head or neck and lung).

  6. Children younger than 4 years or infants, children, and adolescents exposed to adults at high risk.
≥ 15 mm

  1. Persons with no known risk factors for tuberculosis.

1A tuberculin skin test reaction is considered positive if the transverse diameter of the indurated area reaches the size required for the specific group. All other reactions ...

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