Abstract
Unraveling the Mystery: A Unique Presentation of Ascites in a Patient with Concurrent Malignant Peritoneal Mesothelioma and Rifampicin-Resistant Tuberculous Peritonitis
Emerald T. Gersava, MD; Heherson B. Adriano, MD
Veterans Memorial Medical Center
Significance: Malignant peritoneal mesothelioma (MPM) is a rare and aggressive neoplasm that is frequently associated with asbestos exposure. Diagnostic pitfalls are encountered in this disease entity particularly in differentiating it from tuberculous peritonitis (TBP), which is more common in developing countries. We report a first case of MPM and rifampicin-resistant TBP coexisting in a patient without any history of environmental exposure or tuberculosis, with an unusual presentation of high serum-ascites albumin gradient (SAAG).
Clinical Presentation: A 58-year-old hypertensive male presented with a progressively enlarging abdomen and significant weight loss over three months. He had no history of hospitalizations, prior tuberculosis, or notable environmental exposure. Physical examination revealed abdominal distension with shifting dullness. Laboratory tests showed normal liver and renal function, negative viral hepatitis serology, and negative sputum AFB testing. Imaging studies revealed massive ascites and peritoneal nodular thickening.
Management: Paracentesis was performed, yielding a high SAAG and elevated protein levels. Endoscopic evaluations are unremarkable. Diagnostic laparoscopy revealed histopathologically-confirmed MPM concurrent with rifampicin-resistant TBP on Xpert MTB/RIF Assay, necessitating a multidisciplinary approach to treatment.
Recommendation: It is paramount to do a thorough work-up for patients presenting with ascites, as etiologies like malignancy and infection may present with similar findings and may co-exist, as in this case. This report highlights the need for early and appropriate work-up and management.
Important Dates to Remember
| JRRE Activities 2023-2024 |
Proposed Dates |
|---|---|
| Resumption of face-to-face Evidence-Based Medicine Workshop Venue to be announced once finalized. |
July 21, 2023 (Friday), 1-5pm |
| Monthly Critical Appraisal of Topics Conferences to be gaciliated by Research Coordinators per Institution | Monthly Critical Appraisal of Topics Conferences per Institution |
| CAT Plenary/Liver Con Dates: September 23, 2023 December 16, 2023 March 2024 (During the JAC) Resumption of face-to-face Quarterly Critical Appraisal of Topics facilitated by the JRRE |
2 Clinical scenarios and articles are to be sent to institutions each on August 2023, November 2023, and February 2024; |
| Hybrid Research Workshop 4 week asynchronous via Moodle, followed by a 1 day on-site Onsite Workshop Research Protocol Presentation for Level I GI Fellows-In-Training - Research Protocol Presentation: August 12, 2023 - Research Forums of the Tripartite Societies |
Week 1: July 15-21, 2023 Week 2: July 22-28, 2023 Week 3: July 29-August 4, 2023 Week 4: August 5-11, 2023 |
| Research Manuscript Workshop for level II GI Fellows-In-Training | January 6, 2024 |