CHYLOUS ASCITES IN DISSEMINATED TB

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Chylous ascites (CA) is the peritoneal accumulation of lipid-rich fluid due to lymphatic disruption. Etiologies encompass portal and non-portal causes (1), with the latter including peritoneal tuberculosis (PTB), which accounts for 0.1–0.7% of TB cases (2). Mycobacteria enter the peritoneum via either bowel translocation or hematogenous spread from a pulmonary focus. Risk factors consist of cirrhosis, human immunodeficiency virus (HIV), diabetes, cancer, and peritoneal dialysis (3). We present a patient with Acquired Immunodeficiency Syndrome (AIDS) and CA due to disseminated TB. CASE PRESENTATION: A 52-year-old man with AIDS, disseminated TB confirmed by bronchoalveolar lavage and mesenteric lymph node biopsy, and cryptogenic cirrhosis presented with abdominal distension. He had required frequent paracenteses over the prior five months. Vital signs were normal and physical exam showed temporal wasting, no jaundice, a distended abdomen, and a fluid wave. Labs revealed a normal complete blood count and creatinine, sodium 126 mmol/L, protein 6.0 g/dL, and albumin 2.3 g/dL. Liver function tests and alpha-fetoprotein were normal. CD4 count was 14 cells/µL. Paracentesis yielded cloudy white fluid (Figure 1, 2) with 852 white blood cells (WBC)/µL and 6% neutrophils, 1,210 mg/dL triglycerides, and normal adenosine deaminase (ADA). Gram stain showed no organisms but culture speciated Enterococcus faecium. Acid-fast smear and culture, cytology, and flow cytometry were negative. Imaging showed no concerning hepatic lesions. He was treated with vancomycin for bacterascites, rifabutin and ethambutol for TB, and prednisone for TB-immune reconstitution inflammatory syndrome. Repeat paracentesis showed a decrease in ascitic fluid WBC and negative bacterial culture. DISCUSSION: The diagnosis of PTB starts with serum-ascites albumin gradient (SAAG). SAAG > 1.1 g/dL indicates portal hypertension with a high sensitivity, although elevation has been reported in case reports of CA due to PTB (4). The sensitivity of ascitic fluid AFB smear is 0–6%, while that of MTB culture is 2–50%. ADA has both a high sensitivity and specificity, but sensitivity decreases in areas of low TB prevalence and in patients with cirrhosis (5). Laparoscopy with biopsy remains the gold standard for diagnosis with sensitivity and specificity of 84% and 100%, respectively, for PTB (1, 6). CONCLUSIONS: In the US, CA is most commonly secondary to malignancy, cirrhosis, and iatrogenic lymphatic injury (7). In countries with a high prevalence of endemic TB, mycobacterial infection remains an important cause (8). Workup for the etiology of CA can be challenging as testing relies on low-sensitivity analysis of ascitic fluid. We present a complex case of CA secondary to biopsy-proven peritoneal TB, with potential contribution from cirrhosis or IRIS. The patient is currently improving clinically with antitubercular and steroid treatments. REFERENCE #1: 1. Bhardwaj R, Vaziri H, Gautam A, et al. Chylous ascites: A review of pathogenesis, diagnosis and treatment. J Clin Transl Hepatol. 2018; 6(1): 105–113. doi: 10.14218/JCTH.2017.00035 REFERENCE #2: 2. Mohammad L, Ibrahim A, Ibrahim A. Transudative chylothorax and chylous ascites in a child with peritoneal tuberculosis. Oxf Med Case Reports. 2019; 2019(3). doi: 10.1093/omcr/omz008 REFERENCE #3: 3. Terras Alexandre A, Raimundo S, Pinto C. Peritoneal tuberculosis: A rare diagnosis. Rev Port Pneumol. 2017;23(3):172-173. doi: 10.1016/j.rppnen.2017.02.0024. Wu UI, Chen MY, Hu RH, et al. Peritonitis due to Mycobacterium avium complex in patients with AIDS: report of five cases and review of the literature. Int J Infect Dis. 2009;13(2):285—290. doi: 10.1016/j.ijid.2008.07.0165. Ascitic fluid adenosine deaminase insensitivity in detecting tuberculous peritonitis in the United States. Hepatology. 1996;24(6):1408-12. doi: 10.1002/hep.510240617.6. Yousef F, Khan A. Peritoneal tuberculosis: Advances and controversies. Libyan J Med Sci. 2018;2(1): 3-7. doi: 10.4103/LJMS.LJMS_35_177. Press OW, Press NO, Kaufman SD. Evaluation and management of chylous ascites. Ann Intern Med. 1982;96(3):358. doi: 10.7326/0003-4819-96-3-358 8. Steinemann DC, Dindo D, Clavien PA, Nocito A. Atraumatic chylous ascites: systematic review on symptoms and causes. JAm Coll Surg. 2011;212(5):899. doi: 10.1016/j.jamcollsurg.2011.01.010 DISCLOSURES: No relevant relationships by David Ashkin, source=Web Response No relevant relationships by Robert Flowers, source=Web Response No relevant relationships by Megan Ninneman, source=Web Response No relevant relationships by Rene Rico, source=Web Response No relevant relationships by Christian Trujillo, source=Web Response