Atypical Tuberculous Peritonitis Revealed by a Peritoneal Pseudocyst Without Prior Ventriculoperitoneal Shunting: Insights From a Case and Literature Review

Atypical Tuberculous Peritonitis Revealed by a Peritoneal Pseudocyst Without Prior Ventriculoperitoneal Shunting: Insights From a Case and Literature Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Atypical Tuberculous Peritonitis Revealed by a Peritoneal Pseudocyst Without Prior Ventriculoperitoneal Shunting: Insights From a Case and Literature Review Jimmy Minani Balibanga, Wani Bisimwa, Fabrice Gulimwentuga Cikomola, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4613912/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Sep, 2024 Read the published version in BMC Infectious Diseases → Version 1 posted 13 You are reading this latest preprint version Abstract Background Tuberculous peritonitis often presents with nonspecific symptoms that can lead to diagnostic challenges, particularly when manifesting as peritoneal pseudocysts. This study highlights the clinical complexity and diagnostic approach of tuberculous peritonitis presented as a pseudocyst in an immunocompetent adult, an atypical scenario that is rarely documented. Case presentation: We report a detailed case of a 41-year-old man presenting with abdominal distension, pain, and significant weight loss over four months. Abdominal CT showed an intraperitoneal pseudocyst, initially misdiagnosed due to its resemblance to more common abdominal pathologies. The diagnosis of tuberculous peritonitis was confirmed through histopathological analysis. Additionally, a systematic literature review was conducted to identify and analyse similar cases, focusing on clinical presentations, diagnostic methods, and patient outcomes. Our patient exhibited classic symptoms of abdominal TB but was unique due to the absence of prior ventriculoperitoneal shunting, a common factor in similar cases. Our literature review found that such presentations typically result in diagnostic delays averaging five months, complicating patient management and outcomes. This review also underscores the importance of considering tuberculosis in the differential diagnosis of intraperitoneal pseudocysts, particularly in TB-endemic regions. Conclusion This case and review emphasize the need for high clinical suspicion and prompt investigation of tuberculosis in patients presenting with atypical abdominal symptoms and pseudocysts. Improved diagnostic strategies, including early use of imaging and pathological evaluations, are essential for timely diagnosis and management, thereby improving patient outcomes in suspected cases of extrapulmonary tuberculosis. pseudocysts tuberculous peritonitis extrapulmonary tuberculosis diagnosis challenge ventriculoperitoneal shunt setting DR of the Congo Figures Figure 1 Figure 2 Figure 3 Figure 4 BACKGROUND Tuberculosis (TB) remains a significant public health challenge, especially in developing regions( 1 ) such as the Southeast Asia, the Western Pacific, and the Sub-Saharan Africa ( 2 ). While the most cases of TB are pulmonary, abdominal TB, including tuberculous peritonitis, represent a critical area of rising incidence. It ranks as the sixth most prevalent form of extrapulmonary TB ( 2 , 3 ). Peritoneal TB, which constitutes approximately 25–50% of abdominal TB cases( 2 ) and 5 to 16.6% of extrapulmonary TB cases ( 1 , 4 ), is often a result of reactivation of latent infections. The bacilli typically spread hematogenously to the mesenteric lymph nodes from active pulmonary infection or ingested with subsequent passage through Peyer’s patches ( 1 – 3 ). Rarely, the bacilli enter the peritoneal cavity transmurally from sites such as genitourinary tract ( 1 , 2 , 5 ). People with immunocompromised states, chronic kidney disease requiring continuous ambulatory peritoneal dialysis, cirrhosis or liver disease, living in endemic TB areas, prior TB infection and prior TB exposure are more likely to develop peritoneal TB ( 2 , 6 ). Despite its prevalence, this condition poses significant diagnostic challenges, particularly due to its insidious and non-specific symptoms like abdominal pain, weight loss, fever, and ascites ( 1 , 2 , 5 ). This diagnosis challenge is even more pronounced in atypical presentations of peritoneal TB, notably pseudotumoral forms, which can mimic other serious conditions, often leading to misdiagnoses and, consequently, delayed management. Among these, the pseudocystic form is exceptionally rare and predominantly documented post ventriculoperitoneal shunt operations, thus adding to the complexity of clinical evaluation and diagnosis ( 6 – 8 ). In this context, our study presents a unique case of tuberculous peritonitis manifesting as a peritoneal pseudocyst in an immunocompetent adult with no history of ventriculoperitoneal shunting. This case highlights the diagnostic dilemma associated with such rare presentations. Alongside the case report, we conducted a comprehensive review of the literature through Medline, covering publications up to March 2024, to gather additional insights into similar cases. Our analysis focused on the clinical presentations, demographic characteristics, diagnostic strategies, and progression of the disease, aiming to enhance understanding and improve the diagnostic accuracy for such atypical presentations of peritoneal TB. METHODS Case report description Our study begins with a detailed case report of tuberculous peritonitis manifesting as a peritoneal pseudocyst. We provide an in-depth look at the clinical manifestations, diagnostic processes, therapeutic interventions, and outcomes for this patient. Informed consent was secured prior to the study's initiation, ensuring ethical compliance. Subsequently, we extend our analysis to encompass sociodemographic factors, diagnostic methodologies, and disease trajectories of comparable cases documented in the literature. Literature review and search strategy To identify additional cases of tuberculous peritonitis presenting as peritoneal pseudocysts, we conducted a literature search using Medline. This search utilized both keywords and predefined MeSH terms: "peritoneal tuberculosis OR abdominal tuberculosis OR 'Peritonitis, Tuberculous'[Mesh]" AND "pseudocyst OR 'Mesenteric Cyst'[Mesh]". The review spanned from the inception of the database until March 2024, and included articles published in both English and French. Inclusion criteria and data analysis The inclusion criteria were strict, focusing on studies where tuberculous peritonitis was definitively confirmed via histopathological analysis following surgical resection or through culture of aspirated pseudocyst fluid. Of the initial 20 articles identified, 14 were excluded due to non-tuberculous diagnoses, 2 due to pseudocyst localization outside the peritoneal cavity, and 1 for lack of accessible abstracts or full texts. The remaining three case reports were examined thoroughly (Figure 1). Data extracted included age at diagnosis, sex, nationality, clinical symptoms, presence of a ventriculoperitoneal shunt, time to diagnosis, findings from CT scans and other imaging techniques, surgical and pathological results, and patient outcomes. The time to diagnosis was specifically noted from the onset of symptoms to confirmed diagnosis. Descriptive statistics were employed to synthesize the data, using Epi Info version 7.2 for data encoding and analysis. Categorical variables were presented as proportions, while continuous variables were depicted as means. RESULTS Case report: Patient presentation A 41-year-old man was seen as an outpatient for severe abdominal distension, abdominal pain, and significant weight loss (62 to 47Kg) over four months. He had no history of smoking, immunocompromising disease, or familial history of neoplasia. Initially treated for suspected poisoning with traditional methods, he showed no symptom improvement. Medical examination revealed generalized abdominal distension, diffuse abdominal tenderness and bilateral oedema of the lower limbs. There was no adenopathy or organomegaly, and the chest examination was normal. Blood tests showed a normal white blood cell count, an inflammatory syndrome with 82 mg/L C-reactive protein, a sedimentation rate of 70 mm in the first hour, hypoalbuminemia at 2.6 g/dl, a normal total serum protein of 7.8 g/dL, a biological cholestasis syndrome with an elevated gamma-glytamyltransferase rate at 266 IU/L and a phosphatase alkaline at 268 IU/L. HIV, hepatitis B and hepatitis C serologies were all negative. Imaging studies including ultrasonography and a CT scan suggested an intraperitoneal pseudocyst associated with multiple adenopathies and bilateral pleural effusion, predominantly on the right, raising initial differential diagnoses of lymphoma or dysembryoma (Fig. 2 ). Laparotomy was indicated to explore and remove the intraperitoneal pseudocyst to relieve the compression of the abdominal viscera. Surgical procedure A xyphopubic laparotomy exposed a thickened parietal peritoneum and intestinal membranes encased in a fibrous matrix, containing a yellow-citrine liquid (Fig. 3 ). Approximately 6.5 litters of fluid were removed, followed by thorough cleansing of the peritoneal cavity. Analysis of the peritoneal fluid showed normal cytology, normal direct examination, and negative bacteriological tests. Histological examination of the peritoneal biopsy revealed fibro- collagenized tissue with granulomatous formations and caseous necrosis, confirming tuberculous peritonitis. Postoperative care involved intensive monitoring and initiation of a six-month course of antituberculosis therapy (Fig. 4 ). Patient evolution Post-surgery, the patient experienced initial weight loss (47 to 38 Kg) but showed significant clinical improvement under antituberculosis treatment, including the resolution of abdominal symptoms and oedema. He was discharged after a week and continued to recover, regaining weight (52.7 Kg), and showing no treatment-related side effects. Review of literature cases Our literature search yielded three additional cases of peritoneal tuberculosis presenting as pseudocysts, providing valuable insights into the demographic characteristics, clinical manifestations, diagnostic approaches, and therapeutic outcomes of these rare instances (Table 1 ). All reported cases involved male patients, with a mean age of 15.6 years, indicating a possible demographic trend in the occurrence of this atypical presentation. The geographical distribution included two cases from high-income countries and one from a low-income country, suggesting that the incidence is not confined to regions traditionally associated with high TB prevalence. Clinical presentations and diagnosis The clinical presentations were consistently marked by abdominal pain and distension, accompanied by significant weight loss. These symptoms align with typical manifestations of peritoneal tuberculosis but are complicated by the presence of pseudocysts, which can mimic other abdominal pathologies, thereby complicating the clinical diagnosis. The average time from symptom onset to diagnosis was approximately five months, reflecting the challenges in recognizing this atypical form of TB. Imaging studies played a crucial role in these cases, with CT scans frequently revealing cystic masses associated with ventriculoperitoneal shunt catheters, a common feature in these patients. This specific finding guided the diagnostic process towards considering tuberculous aetiology alongside other differential diagnoses. Histopathological confirmation and treatment Definitive diagnosis was established through histopathological analysis in most cases, where tissue samples exhibited characteristic epithelioid granulomas with caseous necrosis. In one instance, Mycobacterium tuberculosis was isolated from the aspirate of a pseudocyst, providing direct microbiological confirmation of the infection. Treatment regimens typically followed standard anti-tuberculosis protocols, but the presence of ventriculoperitoneal shunts introduced additional complexities. One patient experienced a relapse of symptoms two years post-treatment, necessitating the removal of the shunt via thoracoscopic surgery and a renewed course of anti-tuberculosis medication. Outcomes and prognosis Outcomes varied among the cases, with most patients showing clinical improvement and stabilization of symptoms following the initiation of treatment. However, the case with relapse highlights the potential for long-term complications and the need for ongoing surveillance in patients with peritoneal TB, especially those with complicating factors such as ventriculoperitoneal shunts. DISCUSSION Our study has shown the challenges of diagnosing and managing tuberculous peritonitis, particularly when it presents as a peritoneal pseudocyst. We described a unique case of an immunocompetent adult with this condition, who had no prior history of ventriculoperitoneal shunting, contrasting with other cases in the literature where such a history was prevalent. The patient presented with significant abdominal symptoms, which were initially mistaken for other abdominal pathologies. This highlights the critical need for heightened awareness and clinical suspicion, especially in regions where tuberculosis is endemic. Diagnostic efforts were compounded by the pseudocyst’s atypical presentation, which commonly led to a delay in reaching the correct diagnosis. The literature reveals that tuberculous peritonitis presenting as a pseudocyst is an infrequent Table 1 Comprehensive overview of reported cases of tuberculous peritonitis revealed by an intraperitoneal pseudocyst Reference and Year Age Sex Country Clinical Presentation Ventriculo-Peritoneal Shunts Abdomen CT-Scan Findings Time to Diagnosis Microbiological and Pathology Findings Findings During Surgery Patient Evolution Narasimharao KL et al., 1984 8 years M India Abdominal pain, enlarging mass Yes NS 8 months Epithelioid granuloma composed of epithelioid cells, Langhan’s giant cells, and lymphocytes characteristic of tuberculosis Pseudocyst formation in the supracolic compartment, extensive tubercles noted all over the omentum, peritoneum, and bowel wall with blood-stained ascites NS Hajime Takase et al., 2014 21 years M Japan Abdominal pain, nausea, abdominal distention Yes Enormous peritoneal cyst surrounding the distal end of the peritoneal tube, and fluid in the sheath surrounding the peritoneal tube. No chest CT abnormalities 2 months Mycobacterium tuberculosis in the xanthochromic fluid from the left knee No membrane surrounding the abdominal cyst, no malignancy within the omentum, no ascites within the abdominal cavity Relapse of peritoneal inflammation after 2 years, treated with antituberculosis agents. Symptoms improved after removal of the CP shunt by thoracoscopic surgery. Manzoor Ahmed et al., 2019 18 years M United Arab Emirates Headache, fever, change in mental status Yes CT: cystic mass to the tip of the VPS catheter NS Mycobacterium tuberculosis isolated in culture from the cyst aspirates and a CSF shunt tap Large pseudocyst with local inflammatory change Slow clinical improvement, stable appearance with no new disease signs. Our case, current study 41 years M Democratic Republic of Congo Abdominal distension, abdominal pain, and weight loss No Large, 3 mm-thick oval intraperitoneal cystic mass from right hypochondrium to pelvis, displacing bowel and bladder. Notable for multiple adenopathies and bilateral pleural effusion, predominantly right. 4 months Epithelio-gigantocellular granulomatous formations with large patches of caseous necrosis Thickening of the parietal peritoneum, surface of the intestinal ansae covered by a thick membrane, forming a magma Significant weight gain and improved general condition post-treatment. Disappearance of abdominal pain and distention. CSF: cerebrospinal fluid, CP: Cysto-peritoneal, CT: Computed Tomography, NS: not specified., VPS : Ventriculoperitoneal shunt but clinically significant manifestation, particularly because it mimics more common abdominal disorders, leading to diagnostic complexities ( 9 ). This is evident in the cases reviewed, where pseudocysts were initially mistaken for neoplastic or other inflammatory abdominal conditions. Such misdiagnoses underscore the subtlety of tuberculous peritonitis's symptoms and the necessity for differential diagnosis in abdominal pathology. Additionally, the reviewed literature highlights a consistent pattern of delayed diagnosis, averaging five months, primarily due to the atypical presentation of the disease and a low initial suspicion of tuberculosis ( 10 ). This delay is problematic, as it can lead to worsening of the condition and highlights the need for improved diagnostic protocols that incorporate the possibility of tuberculosis more readily. The cases from the literature also emphasize the variability in clinical presentations and outcomes associated with tuberculous peritonitis presenting as a pseudocyst. In most documented instances, patients exhibited classical symptoms such as abdominal pain and distention, which were compounded by additional complications from associated conditions like ventriculoperitoneal shunts ( 6 – 8 ). These presentations stress the importance of considering a comprehensive diagnostic approach, including the use of advanced imaging techniques and definitive microbiological and histopathological examinations, to differentiate tuberculous peritonitis from other similar clinical conditions ( 3 , 9 ). The need for such detailed diagnostic strategies becomes even more critical in areas with high tuberculosis prevalence, suggesting that healthcare systems in these regions should prioritize access to and training in the use of these diagnostic technologies. The challenges highlighted by these cases have important implications for both public health policy and clinical practice. Given the potential for diagnostic delays and their associated morbidity, there is a clear need for policy makers to strengthen diagnostic capabilities in endemic regions, possibly through better access to advanced imaging and microbiological testing. Clinically, the findings advocate for the development of guidelines that prompt earlier consideration of tuberculosis in patients presenting with nonspecific abdominal symptoms and pseudocysts, irrespective of their immune status or history of prior tuberculosis exposure. This approach can facilitate earlier intervention, potentially improving patient outcomes and decreasing the spread of tuberculosis within communities. This study's strength lies in its detailed case description and comprehensive review of similar cases, which provide a deep insight into a rare presentation of a common global health issue. However, the study is limited by the small number of similar cases available for review, which might not fully represent the spectrum of presentations of tuberculous peritonitis as a pseudocyst. Additionally, the retrospective nature of the case reviews limits the ability to draw causal inferences from the data collected. The impact of different treatment regimens could also not be robustly assessed due to the variability in clinical management across the cases. CONCLUSION Our study exemplifies a very rare scenario of tuberculous peritonitis revealed by an intraperitoneal pseudocyst and highlights the diagnostic and therapeutic challenges of this atypical presentation. It calls for a critical evaluation of both clinical and policy approaches to managing tuberculosis, particularly in its less common forms. If diagnostic is improved and system delay is reduced in treatment, healthcare providers can significantly improve outcomes for patients suffering from this severe form of extrapulmonary tuberculosis. The insights gained from this study and similar cases in the literature should inform future strategies in both local and global tuberculosis management efforts. Abbreviations CT: Computed Tomography, CSF: cerebrospinal fluid, CP: Cysto-peritoneal, NS: not specified, TB: Tuberculosis. Declarations AUTHORS’ CONTRIBUTION JMB: drafted the manuscript, reviewed the literature, followed up the patient and edited the final manuscript. JMB, WB and FGC followed-up the patient. AB, GMB, GQM, DLM, PMK, MB, PM, PDMK and TAS edited and revised the manuscript. All the authors approved the final version of the manuscript. FUNDING This work received no funding. AVAILABILITY OF DATA AND MATERIALS Materials and data provided in this case study and literature review are available from the corresponding author on reasonable request. ETHICS APPROVAL AND CONSENT TO PARTICIPATE The publication of the case was approved by the Ethics committee of the Catholic University of Bukavu, DRC. Informed consent to participate was obtained from all study participants. CONSENT FOR PUBLICATION Consent for publication of the clinical details and/or laboratory results was obtained from the patient. CONFLITCT OF INTEREST All authors declare that they have no conflicts of interest. References Vaid U, Kane GC. Tuberculous Peritonitis. Microbiology Spetrum [Internet]. 2017;5(1). Available from: www.asmscience.org Wu DC, Averbukh LD, Wu GY. Diagnostic and therapeutic strategies for peritoneal tuberculosis: A review. Vol. 7, Journal of Clinical and Translational Hepatology. Xia and He Publishing Inc.; 2019. p. 140–8. Koff A, Azar MM. Diagnosing peritoneal tuberculosis. BMJ Case Rep. 2020 Feb 6;13(2). Ozturk NB, Tsagkaris C, Dolek N, Iliaz R. Clinical presentation of peritoneal tuberculosis. Baylor University Medical Center Proceedings. 2023;36(2):259–60. Abi El Hessen T, Saleem S, Hani RH, Chadli FZ, Makarem JA. Peritoneal Tuberculosis Mimicking Peritoneal Carcinomatosis in an Immunocompetent Patient. Cureus. 2022 Nov 14; Ahmed M, ElGamal EA, Ahmad A, Zaman MB. TB Meningitis and TB Peritonitis: Abdominal Pseudocyst and VP-Shunt Link. Case Rep Radiol. 2019 Apr 28;2019:1–6. Takase H, Tatezuki J, Ikegaya N, Yamamoto D, Hashimoto M, Takagi M, et al. Critical ventriculo-peritoneal shunt failure due to peritoneal tuberculosis: Case report and diagnostic suggestions for abdominal pseudocyst. Surg Neurol Int. 2014;5(Supplement). Narasimharao KL, Purohit A, Yadav K, Pathak IC, Narasimharao L. Recurrent abdominal pseudocyst after ventriculoperitoneal shunt Chandigarh-160 012 India K L Narasimharao MB MS MCh Senior Resident A Purohit M B MS MCh Senior Resident K Yadav MB MS FRACS Assistant Professor I C Pathak. Vol. 20, Aust. Paediatr. J. 1984. Divya Shetty et al. Intriguing case of giant intra-abdominal pseudocyst: Diagnostic dilemma. 2020. Grira M, Boulvain M, Janssens JP. Inflammatory Syndrome as the Initial Manifestation of Retroperitoneal Tuberculosis in a Pregnant Woman. Eur J Case Rep Intern Med. 2018 May 24;(LATEST ONLINE):1. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 30 Sep, 2024 Read the published version in BMC Infectious Diseases → Version 1 posted Editorial decision: Revision requested 20 Aug, 2024 Reviews received at journal 17 Aug, 2024 Reviews received at journal 09 Aug, 2024 Reviewers agreed at journal 09 Aug, 2024 Reviews received at journal 07 Aug, 2024 Reviewers agreed at journal 07 Aug, 2024 Reviewers agreed at journal 01 Aug, 2024 Reviewers agreed at journal 31 Jul, 2024 Reviewers invited by journal 25 Jul, 2024 Editor invited by journal 24 Jun, 2024 Editor assigned by journal 23 Jun, 2024 Submission checks completed at journal 23 Jun, 2024 First submitted to journal 20 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4613912","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":319308820,"identity":"cd24b332-db5c-408a-ba9a-94f4763ed4bc","order_by":0,"name":"Jimmy Minani 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2024\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4613912/v1/eec30a70c5e072fd83f798c6.png"},{"id":60619881,"identity":"86083a7a-0d86-4da5-919a-e9ce5e1f4eff","added_by":"auto","created_at":"2024-07-18 20:47:21","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1001692,"visible":true,"origin":"","legend":"\u003cp\u003eAbdominal CT scan showing a large intraperitoneal cystic mass (blue arrows), 3 mm-thick (white arrows) and measuring 203x266x248 mm associated with multiple adenopathies and bilateral pleural effusion, predominantly on the right (red arrow).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4613912/v1/06c5a095e80327250ed1d30d.png"},{"id":60619882,"identity":"3ece3aba-e8d7-458c-884e-00b960d7acd1","added_by":"auto","created_at":"2024-07-18 20:47:21","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":650673,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative photograph showing thickening of the parietal peritoneum (white arrow) and the surface of the intestinal ansae covered by a thick membrane, forming a magma (blue arrow).\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4613912/v1/6e91adab36a967a4ab91b573.png"},{"id":60620848,"identity":"ef78d07c-94cb-40be-945c-db4b21a7e1f9","added_by":"auto","created_at":"2024-07-18 20:55:22","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":3354427,"visible":true,"origin":"","legend":"\u003cp\u003ePeritoneal biopsy showing a fibro-collagenized and fatty tissue containing epithelio-gigantocellular granulomatous formations with large patches of caseous necrosis.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-4613912/v1/75d4d1f0ac4ae66971f1e316.png"},{"id":66096909,"identity":"581e7557-05cd-40a1-94ae-e713286d4f0e","added_by":"auto","created_at":"2024-10-07 16:11:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":9456463,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4613912/v1/557c5897-05b5-4014-9ee8-2be3d35d4f74.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eAtypical Tuberculous Peritonitis Revealed by a Peritoneal Pseudocyst Without Prior Ventriculoperitoneal Shunting: Insights From a Case and Literature Review\u003c/p\u003e","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eTuberculosis (TB) remains a significant public health challenge, especially in developing regions(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) such as the Southeast Asia, the Western Pacific, and the Sub-Saharan Africa (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). While the most cases of TB are pulmonary, abdominal TB, including tuberculous peritonitis, represent a critical area of rising incidence. It ranks as the sixth most prevalent form of extrapulmonary TB (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Peritoneal TB, which constitutes approximately 25\u0026ndash;50% of abdominal TB cases(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) and 5 to 16.6% of extrapulmonary TB cases (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), is often a result of reactivation of latent infections. The bacilli typically spread hematogenously to the mesenteric lymph nodes from active pulmonary infection or ingested with subsequent passage through Peyer\u0026rsquo;s patches (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Rarely, the bacilli enter the peritoneal cavity transmurally from sites such as genitourinary tract (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). People with immunocompromised states, chronic kidney disease requiring continuous ambulatory peritoneal dialysis, cirrhosis or liver disease, living in endemic TB areas, prior TB infection and prior TB exposure are more likely to develop peritoneal TB (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite its prevalence, this condition poses significant diagnostic challenges, particularly due to its insidious and non-specific symptoms like abdominal pain, weight loss, fever, and ascites (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). This diagnosis challenge is even more pronounced in atypical presentations of peritoneal TB, notably pseudotumoral forms, which can mimic other serious conditions, often leading to misdiagnoses and, consequently, delayed management. Among these, the pseudocystic form is exceptionally rare and predominantly documented post ventriculoperitoneal shunt operations, thus adding to the complexity of clinical evaluation and diagnosis (\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn this context, our study presents a unique case of tuberculous peritonitis manifesting as a peritoneal pseudocyst in an immunocompetent adult with no history of ventriculoperitoneal shunting. This case highlights the diagnostic dilemma associated with such rare presentations. Alongside the case report, we conducted a comprehensive review of the literature through Medline, covering publications up to March 2024, to gather additional insights into similar cases. Our analysis focused on the clinical presentations, demographic characteristics, diagnostic strategies, and progression of the disease, aiming to enhance understanding and improve the diagnostic accuracy for such atypical presentations of peritoneal TB.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eCase report description\u003c/h2\u003e \u003cp\u003eOur study begins with a detailed case report of tuberculous peritonitis manifesting as a peritoneal pseudocyst. We provide an in-depth look at the clinical manifestations, diagnostic processes, therapeutic interventions, and outcomes for this patient. Informed consent was secured prior to the study's initiation, ensuring ethical compliance. Subsequently, we extend our analysis to encompass sociodemographic factors, diagnostic methodologies, and disease trajectories of comparable cases documented in the literature.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eLiterature review and search strategy\u003c/h2\u003e \u003cp\u003eTo identify additional cases of tuberculous peritonitis presenting as peritoneal pseudocysts, we conducted a literature search using Medline. This search utilized both keywords and predefined MeSH terms: \"peritoneal tuberculosis OR abdominal tuberculosis OR 'Peritonitis, Tuberculous'[Mesh]\" AND \"pseudocyst OR 'Mesenteric Cyst'[Mesh]\". The review spanned from the inception of the database until March 2024, and included articles published in both English and French.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eInclusion criteria and data analysis\u003c/h2\u003e \u003cp\u003eThe inclusion criteria were strict, focusing on studies where tuberculous peritonitis was\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003edefinitively confirmed via histopathological analysis following surgical resection or through culture of aspirated pseudocyst fluid. Of the initial 20 articles identified, 14 were excluded due to non-tuberculous diagnoses, 2 due to pseudocyst localization outside the peritoneal cavity, and 1 for lack of accessible abstracts or full texts. The remaining three case reports were examined thoroughly (Figure 1). Data extracted included age at diagnosis, sex, nationality, clinical symptoms, presence of a ventriculoperitoneal shunt, time to diagnosis, findings from CT scans and other imaging techniques, surgical and pathological results, and patient outcomes. The time to diagnosis was specifically noted from the onset of symptoms to confirmed diagnosis. Descriptive statistics were employed to synthesize the data, using Epi Info version 7.2 for data encoding and analysis. Categorical variables were presented as proportions, while continuous variables were depicted as means.\u003c/p\u003e\u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eCase report:\u003c/h2\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003ePatient presentation\u003c/h2\u003e \u003cp\u003eA 41-year-old man was seen as an outpatient for severe abdominal distension, abdominal pain, and significant weight loss (62 to 47Kg) over four months. He had no history of smoking, immunocompromising disease, or familial history of neoplasia. Initially treated for suspected poisoning with traditional methods, he showed no symptom improvement. Medical examination revealed generalized abdominal distension, diffuse abdominal tenderness and bilateral oedema of the lower limbs. There was no adenopathy or organomegaly, and the chest examination was normal. Blood tests showed a normal white blood cell count, an inflammatory syndrome with 82 mg/L C-reactive protein, a sedimentation rate of 70 mm in the first hour, hypoalbuminemia at 2.6 g/dl, a normal total serum protein of 7.8 g/dL, a biological cholestasis syndrome with an elevated gamma-glytamyltransferase rate at 266 IU/L and a phosphatase alkaline at 268 IU/L. HIV, hepatitis B and hepatitis C serologies were all negative. Imaging studies including ultrasonography and a CT scan suggested an intraperitoneal pseudocyst associated with multiple adenopathies and bilateral pleural effusion, predominantly on the right, raising initial differential diagnoses of lymphoma or dysembryoma (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Laparotomy was indicated to explore and remove the intraperitoneal pseudocyst to relieve the compression of the abdominal viscera.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eSurgical procedure\u003c/h2\u003e \u003cp\u003eA xyphopubic laparotomy exposed a thickened parietal peritoneum and intestinal membranes encased in a fibrous matrix, containing a yellow-citrine liquid (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Approximately 6.5 litters of fluid were removed, followed by thorough cleansing of the peritoneal cavity. Analysis of the peritoneal fluid showed normal cytology, normal direct examination, and negative bacteriological tests. Histological examination of the peritoneal biopsy revealed fibro-\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ecollagenized tissue with granulomatous formations and caseous necrosis, confirming tuberculous peritonitis. Postoperative care involved intensive monitoring and initiation of a six-month course of antituberculosis therapy (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003ePatient evolution\u003c/h2\u003e \u003cp\u003ePost-surgery, the patient experienced initial weight loss (47 to 38 Kg) but showed significant clinical improvement under antituberculosis treatment, including the resolution of abdominal symptoms and oedema. He was discharged after a week and continued to recover, regaining weight (52.7 Kg), and showing no treatment-related side effects.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eReview of literature cases\u003c/h2\u003e \u003cp\u003eOur literature search yielded three additional cases of peritoneal tuberculosis presenting as pseudocysts, providing valuable insights into the demographic characteristics, clinical manifestations, diagnostic approaches, and therapeutic outcomes of these rare instances (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). All reported cases involved male patients, with a mean age of 15.6 years, indicating a possible demographic trend in the occurrence of this atypical presentation. The geographical distribution included two cases from high-income countries and one from a low-income country, suggesting that the incidence is not confined to regions traditionally associated with high TB prevalence.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eClinical presentations and diagnosis\u003c/h2\u003e \u003cp\u003eThe clinical presentations were consistently marked by abdominal pain and distension, accompanied by significant weight loss. These symptoms align with typical manifestations of peritoneal tuberculosis but are complicated by the presence of pseudocysts, which can mimic other abdominal pathologies, thereby complicating the clinical diagnosis. The average time from symptom onset to diagnosis was approximately five months, reflecting the challenges in recognizing this atypical form of TB. Imaging studies played a crucial role in these cases, with CT scans frequently revealing cystic masses associated with ventriculoperitoneal shunt catheters, a common feature in these patients. This specific finding guided the diagnostic process towards considering tuberculous aetiology alongside other differential diagnoses.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eHistopathological confirmation and treatment\u003c/h2\u003e \u003cp\u003eDefinitive diagnosis was established through histopathological analysis in most cases, where tissue samples exhibited characteristic epithelioid granulomas with caseous necrosis. In one instance, \u003cem\u003eMycobacterium tuberculosis\u003c/em\u003e was isolated from the aspirate of a pseudocyst, providing direct microbiological confirmation of the infection. Treatment regimens typically followed standard anti-tuberculosis protocols, but the presence of ventriculoperitoneal shunts introduced additional complexities. One patient experienced a relapse of symptoms two years post-treatment, necessitating the removal of the shunt via thoracoscopic surgery and a renewed course of anti-tuberculosis medication.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eOutcomes and prognosis\u003c/h2\u003e \u003cp\u003eOutcomes varied among the cases, with most patients showing clinical improvement and stabilization of symptoms following the initiation of treatment. However, the case with relapse highlights the potential for long-term complications and the need for ongoing surveillance in patients with peritoneal TB, especially those with complicating factors such as ventriculoperitoneal shunts.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eOur study has shown the challenges of diagnosing and managing tuberculous peritonitis, particularly when it presents as a peritoneal pseudocyst. We described a unique case of an immunocompetent adult with this condition, who had no prior history of ventriculoperitoneal shunting, contrasting with other cases in the literature where such a history was prevalent. The patient presented with significant abdominal symptoms, which were initially mistaken for other abdominal pathologies. This highlights the critical need for heightened awareness and clinical suspicion, especially in regions where tuberculosis is endemic. Diagnostic efforts were compounded by the pseudocyst\u0026rsquo;s atypical presentation, which commonly led to a delay in reaching the correct diagnosis.\u003c/p\u003e \u003cp\u003eThe literature reveals that tuberculous peritonitis presenting as a pseudocyst is an infrequent\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComprehensive overview of reported cases of tuberculous peritonitis revealed by an intraperitoneal pseudocyst\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReference and Year\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCountry\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eClinical Presentation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eVentriculo-Peritoneal Shunts\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAbdomen CT-Scan Findings\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eTime to Diagnosis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eMicrobiological and Pathology Findings\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eFindings During Surgery\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003ePatient Evolution\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNarasimharao KL et al., 1984\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIndia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAbdominal pain, enlarging mass\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e8 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eEpithelioid granuloma composed of epithelioid cells, Langhan\u0026rsquo;s giant cells, and lymphocytes characteristic of tuberculosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePseudocyst formation in the supracolic compartment, extensive tubercles noted all over the omentum, peritoneum, and bowel wall with blood-stained ascites\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHajime Takase et al., 2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eJapan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAbdominal pain, nausea, abdominal distention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eEnormous peritoneal cyst surrounding the distal end of the peritoneal tube, and fluid in the sheath surrounding the peritoneal tube. No chest CT abnormalities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eMycobacterium tuberculosis in the xanthochromic fluid from the left knee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNo membrane surrounding the abdominal cyst, no malignancy within the omentum, no ascites within the abdominal cavity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eRelapse of peritoneal inflammation after 2 years, treated with antituberculosis agents. Symptoms improved after removal of the CP shunt by thoracoscopic surgery.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eManzoor Ahmed et al., 2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUnited Arab Emirates\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHeadache, fever, change in mental status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCT: cystic mass to the tip of the VPS catheter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eMycobacterium tuberculosis isolated in culture from the cyst aspirates and a CSF shunt tap\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eLarge pseudocyst with local inflammatory change\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eSlow clinical improvement, stable appearance with no new disease signs.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOur case, current study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDemocratic Republic of Congo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAbdominal distension, abdominal pain, and weight loss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLarge, 3 mm-thick oval intraperitoneal cystic mass from right hypochondrium to pelvis, displacing bowel and bladder. Notable for multiple adenopathies and bilateral pleural effusion, predominantly right.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eEpithelio-gigantocellular granulomatous formations with large patches of caseous necrosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eThickening of the parietal peritoneum, surface of the intestinal ansae covered by a thick membrane, forming a magma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eSignificant weight gain and improved general condition post-treatment. Disappearance of abdominal pain and distention.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eCSF: cerebrospinal fluid, CP: Cysto-peritoneal, CT: Computed Tomography, NS: not specified., VPS : Ventriculoperitoneal shunt\u003c/p\u003e \u003cp\u003ebut clinically significant manifestation, particularly because it mimics more common abdominal disorders, leading to diagnostic complexities (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). This is evident in the cases reviewed, where pseudocysts were initially mistaken for neoplastic or other inflammatory abdominal conditions. Such misdiagnoses underscore the subtlety of tuberculous peritonitis's symptoms and the necessity for differential diagnosis in abdominal pathology. Additionally, the reviewed literature highlights a consistent pattern of delayed diagnosis, averaging five months, primarily due to the atypical presentation of the disease and a low initial suspicion of tuberculosis (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). This delay is problematic, as it can lead to worsening of the condition and highlights the need for improved diagnostic protocols that incorporate the possibility of tuberculosis more readily.\u003c/p\u003e \u003cp\u003eThe cases from the literature also emphasize the variability in clinical presentations and outcomes associated with tuberculous peritonitis presenting as a pseudocyst. In most documented instances, patients exhibited classical symptoms such as abdominal pain and distention, which were compounded by additional complications from associated conditions like ventriculoperitoneal shunts (\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). These presentations stress the importance of considering a comprehensive diagnostic approach, including the use of advanced imaging techniques and definitive microbiological and histopathological examinations, to differentiate tuberculous peritonitis from other similar clinical conditions (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The need for such detailed diagnostic strategies becomes even more critical in areas with high tuberculosis prevalence, suggesting that healthcare systems in these regions should prioritize access to and training in the use of these diagnostic technologies.\u003c/p\u003e \u003cp\u003eThe challenges highlighted by these cases have important implications for both public health policy and clinical practice. Given the potential for diagnostic delays and their associated morbidity, there is a clear need for policy makers to strengthen diagnostic capabilities in endemic regions, possibly through better access to advanced imaging and microbiological testing. Clinically, the findings advocate for the development of guidelines that prompt earlier consideration of tuberculosis in patients presenting with nonspecific abdominal symptoms and pseudocysts, irrespective of their immune status or history of prior tuberculosis exposure. This approach can facilitate earlier intervention, potentially improving patient outcomes and decreasing the spread of tuberculosis within communities.\u003c/p\u003e \u003cp\u003eThis study's strength lies in its detailed case description and comprehensive review of similar cases, which provide a deep insight into a rare presentation of a common global health issue. However, the study is limited by the small number of similar cases available for review, which might not fully represent the spectrum of presentations of tuberculous peritonitis as a pseudocyst. Additionally, the retrospective nature of the case reviews limits the ability to draw causal inferences from the data collected. The impact of different treatment regimens could also not be robustly assessed due to the variability in clinical management across the cases.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eOur study exemplifies a very rare scenario of tuberculous peritonitis revealed by an intraperitoneal pseudocyst and highlights the diagnostic and therapeutic challenges of this atypical presentation. It calls for a critical evaluation of both clinical and policy approaches to managing tuberculosis, particularly in its less common forms. If diagnostic is improved and system delay is reduced in treatment, healthcare providers can significantly improve outcomes for patients suffering from this severe form of extrapulmonary tuberculosis. The insights gained from this study and similar cases in the literature should inform future strategies in both local and global tuberculosis management efforts.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCT: Computed Tomography, CSF: cerebrospinal fluid, CP: Cysto-peritoneal, NS: not specified, TB: Tuberculosis.\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAUTHORS\u0026rsquo; CONTRIBUTION\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJMB: drafted the manuscript, reviewed the literature, followed up the patient and edited the final manuscript.\u0026nbsp;JMB, WB and FGC followed-up the patient. AB, GMB, GQM, DLM, PMK, MB, PM, PDMK\u0026nbsp;and\u0026nbsp;TAS\u0026nbsp;edited and revised the manuscript. All the authors approved the final version of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFUNDING\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work received no funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAVAILABILITY OF DATA AND MATERIALS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMaterials and data provided in this case study and literature review are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eETHICS APPROVAL AND CONSENT TO PARTICIPATE\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe publication of the case was approved by the Ethics committee of the Catholic University of Bukavu, DRC. Informed consent to participate was obtained from all\u0026nbsp;study\u0026nbsp;participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONSENT FOR PUBLICATION\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsent for publication of the clinical details and/or laboratory results was obtained from the patient.\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONFLITCT OF INTEREST\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors declare that they have no conflicts of interest.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eVaid U, Kane GC. Tuberculous Peritonitis. Microbiology Spetrum [Internet]. 2017;5(1). Available from: www.asmscience.org\u003c/li\u003e\n\u003cli\u003eWu DC, Averbukh LD, Wu GY. Diagnostic and therapeutic strategies for peritoneal tuberculosis: A review. Vol. 7, Journal of Clinical and Translational Hepatology. Xia and He Publishing Inc.; 2019. p. 140\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eKoff A, Azar MM. Diagnosing peritoneal tuberculosis. BMJ Case Rep. 2020 Feb 6;13(2). \u003c/li\u003e\n\u003cli\u003eOzturk NB, Tsagkaris C, Dolek N, Iliaz R. Clinical presentation of peritoneal tuberculosis. Baylor University Medical Center Proceedings. 2023;36(2):259\u0026ndash;60. \u003c/li\u003e\n\u003cli\u003eAbi El Hessen T, Saleem S, Hani RH, Chadli FZ, Makarem JA. Peritoneal Tuberculosis Mimicking Peritoneal Carcinomatosis in an Immunocompetent Patient. Cureus. 2022 Nov 14; \u003c/li\u003e\n\u003cli\u003eAhmed M, ElGamal EA, Ahmad A, Zaman MB. TB Meningitis and TB Peritonitis: Abdominal Pseudocyst and VP-Shunt Link. Case Rep Radiol. 2019 Apr 28;2019:1\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eTakase H, Tatezuki J, Ikegaya N, Yamamoto D, Hashimoto M, Takagi M, et al. Critical ventriculo-peritoneal shunt failure due to peritoneal tuberculosis: Case report and diagnostic suggestions for abdominal pseudocyst. Surg Neurol Int. 2014;5(Supplement). \u003c/li\u003e\n\u003cli\u003eNarasimharao KL, Purohit A, Yadav K, Pathak IC, Narasimharao L. Recurrent abdominal pseudocyst after ventriculoperitoneal shunt Chandigarh-160 012 India K L Narasimharao MB MS MCh Senior Resident A Purohit M B MS MCh Senior Resident K Yadav MB MS FRACS Assistant Professor I C Pathak. Vol. 20, Aust. Paediatr. J. 1984. \u003c/li\u003e\n\u003cli\u003eDivya Shetty et al. Intriguing case of giant intra-abdominal pseudocyst: Diagnostic dilemma. 2020. \u003c/li\u003e\n\u003cli\u003eGrira M, Boulvain M, Janssens JP. Inflammatory Syndrome as the Initial Manifestation of Retroperitoneal Tuberculosis in a Pregnant Woman. Eur J Case Rep Intern Med. 2018 May 24;(LATEST ONLINE):1. \u003c/li\u003e\n\u003c/ol\u003e "}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"pseudocysts, tuberculous peritonitis, extrapulmonary tuberculosis, diagnosis challenge, ventriculoperitoneal shunt setting, DR of the Congo","lastPublishedDoi":"10.21203/rs.3.rs-4613912/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4613912/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eTuberculous peritonitis often presents with nonspecific symptoms that can lead to diagnostic challenges, particularly when manifesting as peritoneal pseudocysts. This study highlights the clinical complexity and diagnostic approach of tuberculous peritonitis presented as a pseudocyst in an immunocompetent adult, an atypical scenario that is rarely documented.\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e \u003cp\u003eWe report a detailed case of a 41-year-old man presenting with abdominal distension, pain, and significant weight loss over four months. Abdominal CT showed an intraperitoneal pseudocyst, initially misdiagnosed due to its resemblance to more common abdominal pathologies. The diagnosis of tuberculous peritonitis was confirmed through histopathological analysis. Additionally, a systematic literature review was conducted to identify and analyse similar cases, focusing on clinical presentations, diagnostic methods, and patient outcomes. Our patient exhibited classic symptoms of abdominal TB but was unique due to the absence of prior ventriculoperitoneal shunting, a common factor in similar cases. Our literature review found that such presentations typically result in diagnostic delays averaging five months, complicating patient management and outcomes. This review also underscores the importance of considering tuberculosis in the differential diagnosis of intraperitoneal pseudocysts, particularly in TB-endemic regions.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis case and review emphasize the need for high clinical suspicion and prompt investigation of tuberculosis in patients presenting with atypical abdominal symptoms and pseudocysts. Improved diagnostic strategies, including early use of imaging and pathological evaluations, are essential for timely diagnosis and management, thereby improving patient outcomes in suspected cases of extrapulmonary tuberculosis.\u003c/p\u003e","manuscriptTitle":"Atypical Tuberculous Peritonitis Revealed by a Peritoneal Pseudocyst Without Prior Ventriculoperitoneal Shunting: Insights From a Case and Literature Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-18 20:47:17","doi":"10.21203/rs.3.rs-4613912/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-20T13:28:58+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-17T13:46:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-09T15:16:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"338484641119964913920764931409592849327","date":"2024-08-09T12:04:58+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-08T01:31:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"330743516832378685993451389834840974580","date":"2024-08-07T11:17:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"320383525765334888887554838747084384013","date":"2024-08-01T17:15:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"146187762966940611398198461027119537087","date":"2024-07-31T11:58:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-25T13:49:26+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-06-24T10:45:45+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-24T01:58:11+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-24T01:56:59+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Infectious Diseases","date":"2024-06-20T22:07:54+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d8b526e5-ccf0-486a-95b3-10328cda9efa","owner":[],"postedDate":"July 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-10-07T16:03:06+00:00","versionOfRecord":{"articleIdentity":"rs-4613912","link":"https://doi.org/10.1186/s12879-024-09955-0","journal":{"identity":"bmc-infectious-diseases","isVorOnly":false,"title":"BMC Infectious Diseases"},"publishedOn":"2024-09-30 15:57:48","publishedOnDateReadable":"September 30th, 2024"},"versionCreatedAt":"2024-07-18 20:47:17","video":"","vorDoi":"10.1186/s12879-024-09955-0","vorDoiUrl":"https://doi.org/10.1186/s12879-024-09955-0","workflowStages":[]},"version":"v1","identity":"rs-4613912","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4613912","identity":"rs-4613912","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}