1. Disseminated Granulomatous disease of the peritoneum presenting as carcinomatosis: A Case Report
J. Khan, MD, Y. Baraki, MD, J. Mallalieu, DO, MD, M. Meyer, MD, Department Of Surgery, St. Agnes Hospital, Baltimore, MD
Case Report
We present the case of a 50 year-old African American who presented to the emergency department with a two week history of worsening abdominal bloating accompanied by moderate abdominal pain. He noted a 20 pound weight loss over the past 2 months and reported significant anorexia. Bowel habits were unchanged. On physical exam his abdomen was moderately distended with an incarcerated umbilical hernia, which the patient stated was unchanged for years. Initial laboratory showed normal white blood count and metabolic panel. A CT scan was obtained which showed considerable ascites and edema involving the bowel mesentery. The patient was brought to the operating room for hernia repair. In the operating room, a small peri-umbilical incision was made and incarcerated omentum was noted in the hernia defect. The omentum showed multiple small nodules consistent with carcinomatosis.
Abstract
Disseminated Granulomatous disease of the peritoneum presenting as carcinomatosis is a rare finding in the Western World. We present the case of a 50 year-old African American who present to the emergency department with two week history of worsening abdominal bloating accompanied by moderate abdominal pain and recent weight loss of 20 pounds.
He was taken to the operating room with diagnosis of umbilical hernia and found to have disseminated disease throughout the abdomen. Pathology was consistent with caseating granulomas.
Subsequently the patient admitted to being exposed to tuberculosis within the last 6 months and that 12 acquaintances had developed pulmonary tuberculosis after being exposed to the same contact.
Abdominal tuberculosis mimics common diseases and it’s diagnosis is often difficult to make.
Case Report
Multiple biopsies of the omentum were obtained. Pathologic evaluation of the omental biopsy revealed caseating and non-caseating granulomatous inflammation. There was no evidence of malignancy and stains for fungal and acid fast microorganisms were negative. In light of these results, an infectious disease consultation was requested. Upon questioning, the patient noted to have a relative with tuberculosis, and that subsequent to being in contact with his relative he was given a Mantoux PPD which was positive. In fact 12 other acquaintances were infected after coming into contact with the patient’s relative. Chest radiograph was negative for any active disease.
Discharge therapy included standard 6 month therapy with isoniazid, ethambutol, pyrazinamide, and rifampicin via state mandated Direct Observation Therapy.
Discussion
Cases of extra pulmonary tuberculosis account for approximately one-eighth of all tuberculosis infection worldwide. Of these, between 11-16% are abdominal in nature. The etiology of abdominal TB is either from reactivation of latent disease or secondary disease. In the later subset, infection spreads via swallow sputum, ingesting unpasteurized milk, or hematogenous spread. Lesions are characterized as hyperplastic, ulcerative or combined and can involve any organ or surface. Infections has been noted to affect the peritoneum, lymph nodes, solid organs, and more rarely combinations of all these.
Diagnosing abdominal TB is often challenging as mycobacterium culture has a low yield and imaging studies are of little use. Clinical exam is also unreliable and non-specific. Abdominal TB mimics more common diseases, including Crohn’s disease, lymphoma, and malignancy.
Low power view showing caseating granuloma
CT Scan showing ascites and inflammatory changes
CT Scan showing incarcerated omentum
High power view showing giant cell