166LU TB Lungs Liver Peritoneum

    • 40 yo man with PMHx of
      • latent TB
Patient presented with abdominal distention, RUQ pain and subjective fever/chills for the past 2 weeks. Tmax 102.6 this hospitalization. Ascites fluid tap consistent with SBP (even when correcting for RBCs) however cultures remained negative.
CT abd/pelvis  revealed new ascites, with abnormal peritoneal and greater omental soft tissue thickening and enhancement, splenomegaly with numerous lesions 
Found to have R/L axillary LAD, R cervical LAD, R/L inguinal LAD. 
CT chest done which showed multiple nodular and tree-in-bud opacities in b/l upper and left lower lobe as well as diffuse lymphadenopathy.
3 AFB sputum smears negative and 1 MTB sputum PCR neg but 1 resulted positive 
Cytology from para with no evidence of carcinoma (reactive mesothelial cells seen)
AFB stain from ascitic fluid negative
Flow cytometry peripheral blood with normal phenotype
IR guided lymph node biopsy of the left supraclavicular node showing necrotizing granulomatous lymphadenitis
ID was consulted and patient was started on RIPE therapy with levofloxacin with concern for resistance. ID thinks he has disseminated TB and potentially ascites also 2/2 TB.
–MRI brain negative for CNS involvement
–Fungal work-up with fungitell, coccidioides antibody, aspergillus antigen, histo antigen; urine histoplasma pending but less likely
–treated for SBP with 5 days of IV ceftriaxone but culture with no growth, likely TB related peritonitis 
–s/p therapeutic paracentesiswith 2.5L removed

Presents with Abdominal Pain and fever

Splenomegaly with innumerable hypoattenuating foci throughout the spleen, for which differential diagnosis includes lymphoproliferative disorders, may be partially artifactual due to phase of contrast. In addition there is a new subcentimeter hypodense foci in the hepatic segment VI. Further characterization can be performed with MRI abdomen with nonemergently with and without contrast (liver mass protocol), if there are no contraindications.

2. New 1.3 cm left lower lobe basilar nodule.

3. New moderate to large volume intra-abdominal ascites and bilateral pleural effusions.

 

  • disseminated TB with
  • pulmonary TB,
  • lymphadenitis and
  • presumed peritoneal TB
  • liver lesions and elevated liver blood tests concerning for liver abscess,
  • Lymph Node Biopsy
    • SUPRACLAVICULAR LYMPH NODE BIOPSY:
      Needle core biopsies showing necrotizing granulomatous lymphadenitis.

      • AFB and GMS stains are negative for acid fast bacilli and fungal forms.