ATYPICAL MANIFESTATION OF TUBERCULOSIS IN HEMODIALYSIS

Peritonitis related to Mycobacterium tuberculosis infection constitutes 11% of all forms of tuberculosis affecting humans. This infection is most prevalent between the fourth and fifth decades of life, particularly in females. Tuberculosis of the digestive system correlates with various conditions such as low socioeconomic status, immunosuppression, HIV infections, alcoholism, drug addiction, chronic kidney disease, and peritoneal dialysis. Symptoms are nonspecific, requiring histopathological examination as the diagnostic gold standard, in addition to culture. Approximately a quarter of the global population is estimated to be infected with the tuberculosis bacillus, with 5-10% developing symptoms and progressing to tuberculosis.

 There are no clear records regarding the incidence of tuberculosis in patients with chronic kidney disease, let alone exclusive cases of peritoneal tuberculosis.

Tuberculosis represents a globally significant infectious disease and a substantial health challenge. Its incidence has shown an increase in recent years. It stands as one of the chronic infectious diseases with high mortality rates and challenging diagnostic complexities. Nevertheless, it is a preventable condition, amenable to cure with timely and appropriate treatment.

Microbiological confirmation of tubercular infection is essential, often necessitating invasive diagnostic methods such as laparotomy and peritoneal biopsy, with options for direct staining using Ziehl-Neelsen, rapid detection tests on tissues such as XPert, and tissue culturing. Culturing typically entails periods of up to 45 days for infection detection, leading to diagnostic and treatment delays in the absence of other positive tests, resulting in severe disease manifestations with high mortality.  In this specific case, tuberculosis infection exclusively affected the peritoneum, with no pulmonary or digestive involvement. The diagnosis required invasive studies such as endoscopies, laparotomy, and peritoneal biopsy, yet even then, the results were inconclusive, preventing the initiation of early treatment. The definitive diagnosis emerged from ascitic fluid culture 45 days after sample collection and XPert analysis of the peritoneal biopsy several months after the onset of the disease, coinciding with severe deterioration in the patient's health.

Therefore, the study of immunosuppressed patients or those with a history of chronic kidney disease, renal transplant, presenting with a febrile syndrome, associated weight loss, and ascitic syndrome, especially when commonly assumed to be fluid overload, inadequate dialysis-subdialysis, or heart failure as the most frequent causes of ascites in dialysis patients, should be systematized. This systematic approach would optimize resources and diagnostic time, facilitating early treatment initiation and patient recovery, thereby reducing morbidity and mortality.

The diagnosis required invasive studies such as endoscopies, laparotomy, and peritoneal biopsy, yet even then, the results were inconclusive, preventing the initiation of early treatment. The definitive diagnosis emerged from ascitic fluid culture 45 days after sample collection and XPert analysis of the peritoneal biopsy several months after the onset of the disease, coinciding with severe deterioration in the patient's health.

Therefore, the study of immunosuppressed patients or those with a history of chronic kidney disease, renal transplant, presenting with a febrile syndrome, associated weight loss, and ascitic syndrome, especially when commonly assumed to be fluid overload, inadequate dialysis-subdialysis, or heart failure as the most frequent causes of ascites in dialysis patients, should be systematized. This systematic approach would optimize resources and diagnostic time, facilitating early treatment initiation and patient recovery, thereby reducing morbidity and mortality.

A 44-year-old patient with a history of chronic kidney disease due to IgA nephropathy underwent renal transplant from a related live donor. Subsequently, there was a re-entry into dialysis due to the loss of renal graft function secondary to mixed rejection and BK virus nephropathy. At the time of presentation, the patient had been undergoing thrice-weekly hemodialysis for the past 2 years and reported the onset of evening fevers, approximately 10 kilograms of weight loss over the last 2 months, associated with an increase in abdominal girth, swelling of the lower limbs, and an intermittent non-productive cough. Physical examination revealed cutaneous-mucosal pallor, good respiratory mechanics, bibasal hypoventilation without added sounds. The abdomen was distended and globular, soft, depressible, with ascites, edema of lower limbs, and non-painful erythematous hyperpigmented, desquamative, and crusted lesions on the lower limbs. No axillary or inguinal lymphadenopathy was noted. Laboratory tests, chest X-ray, abdominal ultrasound, serologies for Hepatitis B negative, Hepatitis C negative, HIV negative, negative ANA, negative Anti-DNA, skin biopsy, 0-millimeter Mantoux test, Doppler echocardiogram, chest, abdomen, and pelvic CT scan, blood cultures, direct and sputum cultures were requested.

Concentric left ventricular hypertrophy, mild deterioration of systolic function. Estimated ejection fraction (EF) of 51%.

Paracentesis of ascitic fluid was performed, and the physical-chemical study, direct for acid-fast bacilli (BAAR). Mononuclear predominance was observed in the physical-chemical study of ascitic fluid. Despite daily dialysis sessions, the persistence of ascites led to an exploratory laparotomy with biopsy, direct culture for BAAR, and Xpert. Chest CT reported no significant pulmonary lesions, bilateral laminar pleural effusion predominantly on the left, and pericardial effusion. Abdomen and pelvic CT revealed significant homogeneous free fluid in the abdominal cavity. A skin biopsy indicated leukocytoclastic vasculitis.

Upper gastrointestinal endoscopy revealed a normal esophageal mucosa and no lesions in the esophagus, body, or antrum. The duodenum showed no lesions or pathological findings. Colonoscopy indicated no lesions.

Pathological anatomy findings suggested interstitial histiocytic lymphoplasmacytic infiltration, an active chronic inflammatory process. Culture for acid-fast bacilli returned positive after 45 days. Xpert from the peritoneal biopsy was positive for tuberculosis.

The development of peritoneal tuberculosis is associated with comorbidities such as immunosuppression, HIV, chronic kidney disease, and peritoneal dialysis, with no reports in hemodialysis patients. Approximately 70 percent of patients exhibit symptoms for more than 4 months before a definitive diagnosis. This delay is partly attributed to the insidious onset of the disease, and its diagnosis is often not suspected. Peritoneal infection is typically secondary to hematogenous dissemination of bacteria from a pulmonary focus, rarely coexisting with active pulmonary disease.

More than 90% of these patients present with ascites at the time of diagnosis, with few cases progressing to an advanced stage known as tuberculous dry peritonitis, characterized by fibrous adhesions. Tuberculous peritonitis should be considered in the differential diagnosis of any immunosuppressed patient presenting with abdominal pain, fever, and weight loss over several weeks.

The incidence of tuberculosis and chronic kidney disease is on the rise worldwide. Patients with kidney disease constitute a vulnerable population to tuberculosis, likely due to chronic inflammation and immunosuppression from nephropathies, glomerular diseases, or transplantation.

Peritoneal tuberculosis is a rare manifestation of extrapulmonary tuberculosis, typically occurring between 20 to 50 years of age. The clinical presentation is often oligosymptomatic initially, with weight loss and a febrile syndrome, which is sometimes underestimated until reaching advanced stages, manifesting as diarrhea and ascites unresponsive to hemodialysis sessions. Due to the potential confusion of ascites with volume overload, subdialysis, or heart failure, which commonly occurs in this patient population, diagnosis can be delayed or even overlooked.

Clinical suspicion of tuberculosis is fundamental for diagnosis, requiring invasive studies such as laparoscopy and biopsy for cultures and high-cost rapid tests. Early initiation of treatment is crucial to reduce morbidity and mortality, as tuberculous peritonitis responds well to conventional treatment.