Peritoneal tuberculosis is a rare extrapulmonary manifestation of tuberculosis. Considering the diagnosis of peritoneal tuberculosis in a low prevalence setting can be vital for further clinical management in selected patients. In a young male with migration background, presenting with generalised abdominal pain, computed tomography revealed ascites, omental and peritoneal thickening and enlarged mesentery lymph nodes. Computed tomography also revealed a distal ureteral calculus at the right vesico-ureteral junction. Diagnostic laparoscopy showed a nodular degeneration of the visceral and parietal peritoneum and adhesions in the upper peritoneal cavity. Tissue biopsy of peritoneal lesions and omentum was performed. Histological examination revealed granulomas with central caseating necrosis. The ureteral stone was removed by means of ureteroscopy. Prompt diagnosis of peritoneal TB made possible to start anti-tuberculous chemotherapy without significant delay. The low prevalence of peritoneal TB demands a high index of suspicion in patients at risk presenting with nonspecific abdominal complaints, ascites and constitutional symptoms. Diagnostic laparoscopy leads to a quick diagnosis by direct visualisation of the peritoneal cavity and tissue biopsy. When available, it is the diagnostic procedure of choice to confirm tuberculous peritonitis. The concomitant presentation of tuberculous peritonitis and ureteral calculus can be explained by hypercalciuria in granulomatous disease.

Abdominal tuberculosis (ATB) continues to pose a major diagnostic challenge for clinicians due to its nonspecific clinical presentation, variable anatomical location and lack of sensitive diagnostic tools. In spite of the development of several assays till date; no single test has proved to be adequate for ATB diagnosis. In this study, we for the first time report the detection of circulating cell-free Mycobacterium tuberculosis (M. tuberculosis) DNA (cfMTB-DNA) in ascitic fluid (AF) samples and its utility in ATB diagnosis. Sixty-five AF samples were included in the study and processed for liquid culture, cytological, biochemical and molecular assays. A composite reference standard (CRS) was formulated to categorize the patients into 'Definite ATB' (M. tuberculosis culture positive, n = 2), 'Probable ATB' (n = 16), 'Possible ATB' (n = 13) and 'Non-TB' category (n = 34). Two molecular assays were performed, namely, the novel cfMTB-DNA qPCR assay targeting M. tuberculosis devR gene and Xpert MTB/RIF assay (Xpert), and their diagnostic accuracy was assessed using CRS as reference standard. Clinical features such as fever, loss of weight, abdominal distension and positive Mantoux were found to be strongly associated with ATB disease (p<0.05). cfMTB-DNA qPCR had a sensitivity of 66.7% (95% CI:40.9,86.7) with 97.1% specificity (95% CI:84.7,99.9) in 'Definite ATB' and 'Probable ATB' group collectively. The sensitivity increased to 70.9% (95% CI:51.9,85.8) in the combined 'Definite', 'Probable' and 'Possible' ATB group with similar specificity. The cfMTB-DNA qPCR assay performed significantly better than the Xpert assay which demonstrated a poor sensitivity of ≤16.7% with 100% (95% CI:89.7,100) specificity (p<0.001). We conclude that cfMTB-DNA qPCR assay is an accurate molecular test that can provide direct evidence of M. tuberculosis etiology and has promise to pave the way for improving ATB diagnosis.

We present a case report of a young nulliparous woman that presented with progressive ascites, night sweats and weight loss. Clinical and para-clinical findings were not suggestive of pulmonary tuberculosis (TB) or other peritoneal conditions. A laparoscopy revealed important ascites and granulomatous peritoneal infiltration with normal genital anatomy. Tests for tuberculosis revealed primary peritoneal involvement in absence of pulmonary TB. This was a case of TB with primary and limited localization in the peritoneum. A strength of this report is that it has adequate illustration of the macroscopic and microscopic findings. In this brief report, we argue that the peritoneal localization of TB has been forgotten, but in countries with a high incidence of this condition, it should always be taken into consideration by doctors from all specialities when making differential diagnosis.

Peritoneal tuberculosis is an important problem in regions of the world where tuberculosis is still prevalent (Chest 1991; 99:1134). Atypical presentations such as portal vein thrombosis can delay diagnosis or result in misdiagnosis (Gut 1990; 31:1130, Acta ClinBelg 2012; 67(2):137-9, J Cytol Histol 2014; 5:278, Digestive Diseases and Sciences 1991; 36(1):112-115). A high index of suspicion is required for the diagnosis of peritoneal tuberculosis, as the analysis of peritoneal fluid for tuberculous bacillus is often ineffective, and may increase mortality due to delayed diagnosis. (Clin Effect Dis 2002;35: 409-13) In light of new evidence, peritoneal biopsy through laparoscopy or laparotomy has emerged as the gold standard for diagnosis (Clin Effect Dis 2002; 35: 409-13).

We report a case of a 35 year old Sri Lankan female employed in a Middle - Eastern country who presented with progressive abdominal distention and constitutional symptoms for four months duration. She had been investigated abroad and diagnosed with ascites with chronic portal vein thrombosis following which warfarin therapy had been commenced suspecting an underlying thrombophilia. Despite treatment her symptoms had worsened. Therefore she had decided to return to Sri Lanka for further evaluation. After ruling out inherited thrombophilic states and the antiphospholipid syndrome, further investigations revealed a transudative ascites and high inflammatory markers. The tuberculosis work up on peritoneal fluid was negative. Therefore, we proceeded with laparoscopy which showed multiple nodular deposits on abdominal wall, bowel and omentum and peritoneal biopsy revealed granulomatous inflammation with caseous type necrosis compatible with mycobacterium tuberculosis infection. This was confirmed by tuberculosis genome identification on the biopsy sample confirming a diagnosis of peritoneal tuberculosis with secondary portal vein thrombosis and cavernous formation due to local inflammation. The patient was started on anti-tuberculosis treatment and warfarin was discontinued, following which she made a remarkable recovery.

Peritoneal tuberculosis can present with unusual manifestations such as portal vein thrombosis and transudative ascites causing a diagnostic dilemma. Ascitic fluid analysis is generally not diagnostic. Under such circumstances peritoneal biopsy should be performed as it has a good diagnostic yield and accuracy.

Male, 26 FINAL DIAGNOSIS: Sarcoidosis Symptoms: Disseminated lung parenchymal changes Medication: - Clinical Procedure: - Specialty: Pulmonology.

Rare disease.

Sarcoidosis is a granulomatous inflammatory disease that is induced by unknown antigen(s) in a genetically susceptible host. Although the direct link between Mycobacterium tuberculosis (MTB) infection and sarcoidosis can be excluded on the basis of a current knowledge, the non-infectious mechanisms may explain the causative role of mycobacterial antigens. The co-incidence of tuberculosis (TB) and sarcoidosis, and higher incidence of mycobacterial DNA in biological samples of sarcoid patients, have been reported by many authors.

We present a case in which MTB infection in 1 family member triggered a sarcoid reaction in the infected subject and 2 other non-infected family members. We discuss different aspects of diagnosis and differentiation, as well as up-to-date hypotheses on the possible mechanisms leading to sarcoid inflammation in patients exposed to MTB.

This case series documents the possibility of familial spreading of sarcoidosis, and points to MTB as a potential etiological factor.