A 31 y.o. graduate student comes in with abdominal bloating. The CT results are shown

What is the differential for new onset ascites with peritoneal studding?

Our patient had peritoneal tuberculosis.  He was from India with no previous history of Tbc. Tuberculous peritonitis  is increasing in prevalence.  It is common in patients with immunocompromised states, chronic kidney disease, or cirrhosis of the liver  It is most often caused by spread from pulmonary foci but can be caused by direct invasion of the  bacillus through the bowel wall.

peritoneal thickening from adenocarcinoma

The differential for ascites with peritoneal studding includes:

METASTATIC NEOPLASMS

-Carcinomas of the GI tract and ovary( stomach,colon, appendix, gallbladder and pancreas)

-pseudomyxoma peritonei-is a more benign condition where thick gelantinous materil covers the surface of the peritoneal cavity. It is thought to be a low grade appendiceal tumor which can be debulked since the tumor does not invade abdominal organs.

- Lymphoma generally associated with herpes virus:  human herpes virus 8 (also associated with Kaposi’s) and Epstein Barr virus

-sarcoma

INFECTIOUS AND INFLAMMATORY LESIONS

-granulomatous peritonitis includes tuberculosis,Histoplasmosis, or pneumocystis.  It also  includes sarcoid, and foreign material such as talc or barium. 

-Sclerosing encapsulating peritonitis may occur in a patient on peritoneal dialysis; the cause is not known.

MISCELLANEOUS TUMORS AND TUMORLIKE LESIONS

-Endometriosis occurs in 10% of women of childbearing age

-Melanosis can be associated with cystic teratomas

- splenosis is heterotopic splenic tissue often occurring after trauma to the spleen

peritoneal pseudomyxoma

35 cases of bovine tuberculosis were reported in New York City  from 2001-4 and linked to fresh cheese (queso fresco) brought to NYC from Mexico where 17% of cattle being slaughtered are positive for M. bovis.  Pasteurized milk is free of the disease. Our patient had a positive omental biopsy showing tuberculosis.  His ascitic fluid  and pleural fluid cultures were negative.  He was treated with rifampin, INH, pyrazinamide and ethambutol.

difficult to see red bacilli in the peritoneal biopsy

Levy A, Shaw J, Sobin L.  Secondary tumors and tumorlike lesions of the peritoneal cavity: imaging features with pathologic correlation. Radiographics. 2009. 29:347-373.

Srivastava U, Almusa O, Tung K, Heller M. Tuberculous peritonitis. Radiol Case Rep 2014;9(3):971.

MMWR Human Tuberculosis Casued by Mycobacterium bovis, New York City, 2001-2004 June 2005 54(24):605-608.