Two months profound weight loss, fevers, cough and several weeks of abdominal distension.
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Enlarged mediastinal nodes in the right paratracheal and pretracheal regions.
Cluster of centrilobular nodules in the antero-inferior right middle lobe with branching opacities consistent with tree-in-bud pattern. Several other small scattered subpleural nodules in the medial right upper lobe and lateral right middle lobe.
Left lung is clear.
Extensive ascites with enhancing wall. Stranding within the adjacent fat most noticeable in the left abdomen.
No small or large bowel obstruction. No bowel wall thickening. Normal appendix. Unremarkable appearances of the solid organs.
No intra-abdominal lymphadenopathy.
Favored diagnosis of tuberculous peritonitis with evidence of active infection in the right lung.
The enhancing peritoneum and stranding is suggestive of TB peritonitis, wet type. Intra-abdominal TB is the most common site of extra-pulmonary TB.
Differentials for the abdominal findings include peritoneal carcinomatosis. This is most commonly due to ovarian and GI adenocarcinoma (including gastric, CRC, pancreas, appendix and gallbladder).
Patient went on have an ascitic tap. The fluid results were negative for acid fast bacilli and malignancy.
Sputum acid fast bacilli, blood cultures and serology were all negative.
Patient then went on to have a bronchoscopy with bronchoalveolar lavage. This was positive (Genexpert testing) PCR for mycobacterium tuberculosis.
He was commenced on appropriate antibiotic therapy.