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Ezhuthachan College of Pharmaceutical Sciences, Marayamuttom, Neyyattinkara, Thiruvananthapuram, Kerala, India..
Peritoneal tuberculosis with granulomatous hepatitis is a rare and diagnostically challenging presentation of extrapulmonary tuberculosis, often mimicking chronic liver disease. Peritoneal tuberculosis typically presents with nonspecific abdominal symptoms and radiological findings, frequently leading to delayed diagnosis and increased risk of complications. A 19-year old female presented with nausea, vomiting, regurgitation of food, loss of appetite, and significant weight loss over two months. Initial ultrasonography suggested liver cirrhosis with portal hypertension, with repeat imaging showing mesenteric fat stranding. Contrast enhanced computed tomography (CECT) of the abdomen demonstrated diffuse peritoneal and mesenteric thickening, omental caking, and lymphadenopathy, raising suspicion for tubercular peritonitis.Extensive etiological evaluation for chronic liver disease, including viral markers, autoimmune profile, and ceruloplasmin levels, was negative. Ascitic fluid analysis revealed markedly elevated adenosine deaminase (ADA). Diagnostic laparoscopy showed omental caking, dense bowel adhesions, and multiple peritoneal nodules. Histopathological examination of liver, omental, and peritoneal biopsies demonstrated multiple granulomas composed of epithelioid cells, Langhans giant cells, and central caseous necrosis. Liver biopsy additionally revealed macro and microvesicular steatosis with granulomatous inflammation, consistent with granulomatous hepatitis.Based on clinical examination and histological results, a final diagnosis of granulomatous hepatitis and peritoneal tuberculosis was established. Gradual clinical improvement was achieved with hepatoprotective and supportive therapy in addition to a modified anti tubercular regimen.This case study emphasises the crucial function of histological assessment in making the diagnosis and the need of taking granulomatous hepatitis and peritoneal tuberculosis into consideration in patientsexhibiting symptoms suggestive of chronic liver disease.
Tuberculosis (TB) remains a major global health problem, with World Health Organization estimates indicating millions of new cases annually, particularly in developing countries such as India. Extrapulmonary tuberculosis (EPTB) accounts for approximately 15–20% of all TB cases in immunocompetent individuals and up to 50% in immunocompromised patients. Among these, abdominal tuberculosis constitutes about 5–10% of EPTB cases, with peritoneal tuberculosis being one of its less common but clinically significant forms.
Peritoneal tuberculosis typically results from hematogenous spread, lymphatic dissemination, or reactivation of latent infection. It often presents with nonspecific clinical features such as abdominal pain, ascites, fever, weight loss, and gastrointestinal disturbances, which can mimic other conditions including malignancy, cirrhosis, and inflammatory disorders. Radiological findings such as peritoneal thickening, omental caking, and lymphadenopathy further add to the diagnostic challenge due to their overlap with peritoneal carcinomatosis.
Granulomatous hepatitis is an uncommon hepatic manifestation characterized by the presence of granulomas within the liver parenchyma. Infectious causes, particularly tuberculosis, are among the leading etiologies in endemic regions, although autoimmune disorders, drug reactions, and systemic diseases may also contribute. The coexistence of peritoneal tuberculosis with granulomatous hepatitis is rare and may lead to diagnostic confusion, especially when initial imaging suggests chronic liver disease or cirrhosis.
Early diagnosis is often difficult due to the insidious onset and nonspecific presentation of the disease. Laboratory investigations, including elevated adenosine deaminase (ADA) levels in ascitic fluid, and imaging studies may provide supportive evidence however, definitive diagnosis frequently relies on histopathological confirmation demonstrating caseating granulomas with Langhans giant cells.
In this context, the present case highlights a rare presentation of peritoneal tuberculosis with granulomatous hepatitis in a young female, initially mimicking chronic liver disease, emphasizing the importance of maintaining a high index of suspicion and the crucial role of tissue diagnosis in guiding appropriate management.
In regions with a high burden of tuberculosis such as India, atypical and extrapulmonary presentations continue to pose significant diagnostic challenges for clinicians. The overlap of clinical, biochemical, and radiological features between peritoneal tuberculosis and chronic liver disease often leads to misdiagnosis or delayed diagnosis, potentially resulting in inappropriate management. Moreover, hepatic involvement in the form of granulomatous hepatitis further complicates the clinical picture, especially when routine etiological workup for liver disease remains inconclusive. Therefore, a multidisciplinary approach incorporating imaging, laboratory parameters, and, most importantly, histopathological evaluation is essential for accurate diagnosis and timely initiation of appropriate therapy, thereby improving patient outcomes.
CASE REPORT
A 19-year-old female presented with a 2-week history of nausea, vomiting, and postprandial regurgitation, associated with anorexia. She reported an unintentional weight loss of approximately 10 kg over the preceding 2 months.
On examination, she was conscious, alert, and oriented, with pallor. There was no icterus, clubbing, cyanosis, pedal oedema, or lymphadenopathy. Vital signs were stable: pulse rate 80 beats/min, blood pressure 120/80 mmHg, respiratory rate 18 breaths/min, and she was afebrile.
Initial ultrasonography (USG) of the abdomen revealed features suggestive of liver cirrhosis with portal hypertension. A repeat USG abdomen showed cirrhotic changes along with mesenteric fat stranding. Further evaluation with contrast enhanced computed tomography (CECT) of the abdomen demonstrated mild diffuse thickening and enhancement of the mesentery and peritoneum, omental caking, and multiple enlarged lymph nodes, raising suspicion of peritoneal tuberculosis. Hepatomegaly with gross fatty infiltration was also noted.
The patient underwent diagnostic laparoscopy, which revealed omental caking, severe adhesions of bowel loops, minimal ascites, and multiple nodules studding the peritoneum. Histopathological examination of liver core biopsy showed hepatocytes with macro and microvesicular steatosis along with granulomatous inflammation composed of epithelioid cells, macrophages, Langhans-type multinucleated giant cells, and surrounding lymphocytes. Omental and peritoneal biopsies demonstrated multiple discrete and confluent granulomas with central caseous necrosis.
Based on clinical, radiological, and histopathological findings, a diagnosis of peritoneal tuberculosis with granulomatous hepatitis was established.
The patient was initiated on a modified anti tubercular regimen along with supportive therapy due to underlying liver involvement. Treatment included injection pantoprazole 40 mg, injection N-acetylcysteine (1.2 g), tablet ursodeoxycholic acid 450 mg, injection ondansetron 4 mg, injection vitamin K1 10 mg, tablet hepatoprotective agents (Heptagon), injection streptomycin 750 mg, tablet levofloxacin 500 mg, and tablet ethambutol 800 mg.
The patient demonstrated gradual clinical improvement with reduction in gastrointestinal symptoms, improved appetite, and stabilization of general condition. She was discharged in stable condition with medications including injection streptomycin 750 mg intramuscularly once daily for 3 days, tablet levofloxacin 500 mg once daily, tablet ethambutol 800 mg once daily, tablet esomeprazole 40 mg, tablet ursodeoxycholic acid 300 mg, hepatoprotective agents, tablet N-acetylcysteine 600 mg, and ondansetron as needed.
Table 1. Investigations
|
Investigation |
Findings |
Interpretation |
|
USG Abdomen (Initial) |
Features of liver cirrhosis with portal hypertension |
Suggestive of chronic liver disease |
|
USG Abdomen (Repeat) |
Cirrhotic liver with mesenteric fat stranding |
Suspicious for inflammatory/infective pathology |
|
CECT Abdomen |
Diffuse peritoneal and mesenteric thickening, omental caking, multiple enlarged lymph nodes, hepatomegaly with fatty infiltration |
Suggestive of peritoneal tuberculosis |
|
Diagnostic laparoscopy |
Omental caking, dense adhesions, minimal ascites, peritoneum studded with nodules |
Strongly suggestive of tubercular peritonitis |
|
Liver biopsy |
Macro and microvesicular steatosis with granulomas (epithelioid cells, Langhans giant cells, Lymphocytes) |
Granulomatous hepatitis |
|
Omental & peritoneal biopsy |
Multiple granulomas with central caseous necrosis |
Confirmatory of tuberculosis |
|
Ascitic fluid ADA |
89 U/L |
Highly suggestive of tubercular etiology |
Table 2. Laboratory values
|
Parameters |
Values |
|
Hemoglobin |
8 g/dl |
|
CRP |
20.2 mg/dl |
|
Total bilirubin |
1.85 mg/dl |
|
Direct bilirubin |
1.36 mg/dl |
|
SGOT |
414 U/L |
|
SGPT |
161 U/L |
|
Alkaline phosphatase |
271 U/L |
|
Total protein |
6.2 g/dl |
|
Albumin |
2.05 g/dl |
|
Globulin |
4.1 g/dl |
|
Total IgG |
3320 mg/dl |
|
24 hr urinary copper |
65 µg |
Table 3. Treatment Chart
|
Sl no |
Drug |
Dose |
|
1 |
INJ. PANTOPRAZOLE |
40 mg |
|
2 |
INJ. N-ACETYLCYSTEINE |
1.2 g |
|
3 |
T. URSODEOXYCHOLIC ACID |
450 mg |
|
4 |
INJ. ONDANSETRON |
4 mg |
|
5 |
INJ. VITAMIN K1 |
10 mg |
|
6 |
T. HEPTAGON |
1 tab-0-1 tab |
|
7 |
INJ. STREPTOMYCIN |
750 mg |
|
8 |
T. ETHAMBUTOL |
800 mg |
|
9 |
T. LEVOFLOXACIN |
500 mg |
DISCUSSION
Peritoneal tuberculosis is an uncommon form of abdominal tuberculosis that often presents with vague and nonspecific symptoms, frequently mimicking conditions such as malignancy or chronic liver disease. This diagnostic overlap can lead to delays in recognition, particularly when initial imaging suggests cirrhosis or portal hypertension. In regions with a high burden of tuberculosis such as India, clinicians should maintain a high index of suspicion, especially in young patients presenting with weight loss, anorexia, and gastrointestinal symptoms. Radiological findings like peritoneal thickening, omental caking, and lymphadenopathy, although suggestive, are not definitive and require further evaluation.
An important feature of this case is the presence of granulomatous hepatitis, which is a relatively rare hepatic manifestation. While hepatic granulomas can arise from multiple causes, tuberculosis remains a key etiology in endemic settings. The histopathological findings of epithelioid granulomas with Langhans giant cells and caseous necrosis confirmed the tubercular origin and indicated a likely prolonged or disseminated disease process. The coexistence of peritoneal tuberculosis with granulomatous hepatitis can complicate the clinical picture and mimic chronic liver disease, as seen in this patient.
This case highlights the critical role of histopathological confirmation in establishing the diagnosis when clinical and imaging findings are inconclusive. Although supportive investigations such as elevated ascitic fluid ADA levels may suggest tuberculosis, definitive diagnosis relies on tissue biopsy. Early diagnosis and initiation of an appropriate, modified anti-tubercular regimen especially in the presence of liver involvement are essential for favourable outcomes. Recognizing such atypical presentations is important to avoid misdiagnosis and prevent disease progression.
COMPARISON WITH OTHER CASE REPORTS
Most reported cases of peritoneal tuberculosis describe patients presenting with abdominal pain, ascites, fever, and weight loss, often mimicking peritoneal carcinomatosis. Radiological features such as omental caking and peritoneal nodules are frequently reported and were also seen in this case. However, initial presentation as cirrhosis with portal hypertension is less commonly documented, making this case somewhat atypical and diagnostically challenging.
Another notable difference is the coexistence of granulomatous hepatitis, which is not routinely emphasized in many case reports focusing on peritoneal tuberculosis alone. While some studies mention hepatic involvement, it is often secondary and not highlighted as a key feature. In contrast, this case demonstrates clear histopathological evidence of both peritoneal and hepatic granulomatous disease, suggesting a more extensive disease spectrum.
Overall, similar to previously reported cases, the diagnosis was ultimately established through tissue biopsy, and the patient showed good clinical response to anti tubercular therapy. This reinforces the consistent finding across literature that, despite varied presentations, timely diagnosis and appropriate treatment lead to favourable outcomes.
PROGNOSIS
The prognosis in this case appears favourable, as the patient showed clear clinical improvement following initiation of anti tubercular therapy along with supportive hepatoprotective management. Symptoms such as nausea, vomiting, and poor appetite improved, and the overall condition stabilized before discharge. In general, peritoneal tuberculosis responds well to timely treatment, even in cases with atypical or advanced presentation. However, the presence of hepatic involvement, as seen with granulomatous hepatitis, requires careful monitoring due to the potential risk of drug-induced hepatotoxicity and underlying liver dysfunction. With adherence to therapy and regular follow-up, the long-term outcome is expected to be good, although delayed diagnosis in such cases can increase the risk of complications.
CONCLUSION
This case highlights an uncommon presentation of peritoneal tuberculosis with granulomatous hepatitis in a young patient, initially mimicking chronic liver disease. It underscores how easily such cases can be misinterpreted based on imaging alone, especially in the early stages. The diagnosis ultimately depended on histopathological findings, reinforcing the importance of tissue biopsy in unclear clinical scenarios.
It also emphasizes the need to consider tuberculosis in the differential diagnosis of patients presenting with unexplained gastrointestinal symptoms and features suggestive of liver disease, particularly in high-burden settings such as India. Early recognition and appropriate treatment can lead to good clinical outcomes, even in complex presentations like this.
PATIENT CONSENT
Written informed consent was obtained from the patient for publication of this case report and accompanying details.
REFERENCES
Jesmin G. X., Reshma Babu, Dr. Shaiju Dharan, A Rare Case of Peritoneal Tuberculosis with Granulomatous Hepatitis Mimicking Chronic Liver Disease: A Diagnostic Challenge , Int. J. of Pharm. Sci., 2026, Vol 4, Issue 5, 2745-2751, https://doi.org/10.5281/zenodo.20133056
10.5281/zenodo.20133056