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Resumen:
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Aim: Type 2 Diabetes mellitus is a disease that may compromise several organs and systems, including the host defenses. Infectious causes of abdominal pain need to be studied. Methods: A 52 year-old compliant diabetic woman presents to the emergency department with night sweats, diff use abdominal pain and progressive abdominal distention for the past 2 months. Significant weight loss (16 lb) was also noted during this time. A PPD test was negative 3 months ago. On physical examination, vitals were: T= 37.5ºC, BP: 140/85, HR: 89 bpm, RR: 24/min and SO2: 97% on room air. Physical evaluation of the abdomen revealed a distended abdomen with diff use tenderness. A positive fl uid wave and shift ing dullness were also noted. Th e rest of the physical examination is normal. Results: Blood test revealed a WBC: 3.2 x 103cells/mm3 (N: 81.4% B: 0.1% L: 1% E: 0%) and Hb: 12.1 mg/dL. In terms of biochemical panel: Glu: 182, Urea: 202 mg/dL, Cr: 1.2 mg/dL, Na: 135mmol/L, K: 3.9mmol/L and Cl: 107mmol/L. In addition, serum protein: 6.2 mg/dL, Alb: 3.5 mg/dL and LDH: 340 U/L. Liver function tests and coagulation tests were within normal limits. The hepatitis and HIV serology was also negative. Th e abdominal U/S revealed free liquid in the four pockets and no signs of chronic liver disease. A CT scan of the abdomen showed diff use thickening of the omentum along to infl ammatory changes, rising suspicious of a malignant versus infectious etiology. After this, a diagnostic paracentesis was planned and yielded a turbid yellow fl uid with WBC: 4500, PMN 70%, LMN: 30%, Glu: 182 mg/dL, with a SAAG level at 1; consistent for a non-hypertensive ascites. Ascites fluid samples were sent for gram stain as well as bacterial and fungal cultures (including TB), all which came back negative. Cytological studies of the ascitic fl uid were also negative for malignant cells. An exploratory laparoscopy was performed and the omentum and peritoneum were found to have multiple pearl color lesions. Histological studies revealed caseous granulomas with scattered multinucleated giant cells. Culture of peritoneal tissue samples demonstrated Mycobacterium tuberculosis aft er 4 weeks of the procedure. Th e patient was started on quadruple therapy with subsequent improvement during the follow up. Discussion: Mycobacterium tuberculosis is an ubiquitous agent that may be diffi cult to isolate on a regular basis. Extensive evaluation of this possibility should be attempted despite negative work-up.
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