Why does this matter?
Chronic Kidney Disease (CKD) is a condition that affects over 800 million people worldwide. It is characterised by the gradual loss of kidney function over time. One complication is nephrogenic ascites, the accumulation of fluid in the peritoneal cavity due to impaired kidney function. However, in some cases, the symptoms of nephrogenic ascites may mimic other conditions, leading to misdiagnosis and delayed appropriate treatment.
What happened in this case?
A 45 year old male with a history of end-stage kidney disease, presented to A&E for routine haemodialysis and abdominal swelling (Crossman et al., 2023). He was from a region with endemic tuberculosis.
The medical team initially suspected nephrogenic ascites. But he was found to have clinical findings consistent with a systemic illness; including fever, night sweats, hypercalcemia, lymphadenopathy and pleural effusions. Ascitic fluid showed a serum albumin of less than 1.1 g/L. The patient was not improving on conventional therapy. So the team considered alternative diagnoses including haematological malignancy (with disseminated infection less likely).
Computed tomography of the abdomen and pelvis demonstrated a large volume of abdominopelvic ascites with peritoneal thickening, and nodularity throughout the omentum. MRI of the abdomen/pelvis showed enhancing soft tissue thickening throughout the greater omentum. These are the scans.
Bronchoscopy was normal. Core biopsy of cervical lymph node revealed granulomatous inflammation with central necrosis but with a negative AFB stain. But AFB stain and TB PCR were positive on a sputum sample, eventually growing Mycobacterium tuberculosis. The patient was therefore initiated on RIPE therapy (i.e., rifamycin, isoniazid, pyrazinamide, and ethambutol).
How does it affect you?
It does not unless you are on haemodialysis, and develop abdominal swelling. But misdiagnosing peritoneal tuberculosis as nephrogenic ascites in this case, highlights the challenges in differentiating between similar clinical presentations in complex patients. In cases of CKD patients presenting with ascites, it is crucial to consider alternative diagnoses, especially in regions with a high prevalence of tuberculosis.
Reference
Crossman, L. et al. (2023) ‘Disseminated peritoneal tuberculosis initially misdiagnosed as nephrogenic ascites’, Case Reports in Nephrology, 2023, pp. 1–4. doi:10.1155/2023/4240423.
Last Reviewed on 21 September 2023