A 26-Year-Old Woman With Pleural Effusion, Hydronephrosis, and Ascites

Kaleem Ullah Toori, MB BS; Sumaira Nabi, MB BS; Sadaf Khattak, MB BS; Herbert S Diamond, MD

Disclosures

August 16, 2018

Physical Examination and Workup

Upon physical examination, the patient appears toxic. Her oral temperature is 100°F (37.8°C). Her pulse is regular with a rate of 100 beats/min. Her blood pressure is 160/100 mm Hg. She is noted to have generalized pallor, but no clubbing, jaundice, or cyanosis is detected. Her abdominal examination reveals distention with mild generalized tenderness. A mild-to-moderate amount of ascites are noted. The chest examination is suggestive of bilateral basal pleural effusion that is greater on the left. The remainder of the physical examination is unremarkable.

The patient’s initial laboratory investigations reveal a normocytic, normochromic anemia with a hemoglobin of 8 mg/dL, an elevated erythrocyte sedimentation rate (ESR) of 65 mm/h, normal liver and renal functioning, and a urinalysis that is positive for red blood cells (RBCs), white blood cells (WBCs), and protein. A chest x-ray confirms the finding of bilateral basilar pleural effusions (that are greater on the left). Mantoux skin testing is negative. Ultrasonography of the abdomen and pelvis demonstrates bilateral hydronephrosis (Figure 1).

Figure 1.

Abdominal ultrasonogram showing bilateral hydronephrosis.

The mesentery and gut wall appears thickened; peritoneal deposits and moderate ascites are found. A sample of the ascitic fluid sent for analysis reveals an exudative ascites, with a predominance of lymphocytes (80%). No organism is found on culture or Gram staining, and no malignant cells are noted on cytology.

Carcinoembryonic antigen (CEA) levels are found to be normal, but CA-125 is elevated at 93.5 μg/mL (normal range, 0-35 μg/mL). CT scanning of the abdomen and pelvis is performed, which confirms the presence of moderate ascites and peritoneal nodularity (Figure 2). The bladder and intestinal walls are thickened (Figure 3). Bilateral hydronephrosis and multiple enlarged para-aortic lymph nodes are also seen (Figure 4).

Figure 2.

A contrast-enhanced CT scan of the pelvis showing pelvic free fluid.

Figure 3.

A contrast-enhanced CT scan of the abdomen showing thickened bowel loops.

Figure 4.

A contrast-enhanced CT of the abdomen showing bilateral hydronephrosis.

In light of the above findings and past history of tuberculosis, a provisional diagnosis of tuberculous peritonitis is made, and the patient is started on antituberculous therapy (ATT). However, the patient’s symptoms do not abate, and her fevers and abdominal pain continue even after 3 weeks of ATT. Subsequently, the patient develops arthralgia involving both hands and wrists, and her ESR rises to 130 mm/h.

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