Massive infected ascites in an immunocompetent patient with gastrointestinal tuberculosis.

Mycobacterium tuberculosisis highly endemic in the Philippines. The diagnosis is challenging with its non-specific presentation and the organism could extend to any of the organs. Interestingly, bacterial peritonitis arising spontaneously from gastrointestinal tuberculosis (TB) in an otherwise healthy, non-cirrhotic patient is quite unusual. In this paper, we discuss the case of a 27-year-old HIV-seronegative woman with massive intraperitoneal mixed bacterial and tuberculous abscess presenting 20 months after being diagnosed with bacteriologically confirmed gastrointestinal TB. Repeated large-volume paracentesis was done to drain out the infected ascites instead of inserting a percutaneously implanted catheter. Clinical improvement was noted and she was discharged after 12 days of intravenous antibiotics. She had completed 6 months of antituberculosis therapy and been well since then. The case has demonstrated that repeated paracentesis along with appropriate antibiotic regimen, may be a viable option for patients with TB and bacterial coinfected peritonitis. And possibly, peritoneal TB may increase the risk for (spontaneous) bacterial peritonitis.

Infectious Aortitis with Abdominal Aortic Aneurysm in a 47-Year-Old Female with Systemic Lupus Erythematosus.

Aortic aneurysms are not commonly reported among patients with systemic lupus erythematosus (SLE). We report a case of a 47-year-old Filipino female diagnosed with SLE 17 years ago maintained on prolonged oral steroids, azathioprine, and hydroxychloroquine. She also had lupus nephritis, secondary hypertension, and dyslipidemia. She initially presented with a week-long watery nonbloody diarrhea with associated diffuse crampy abdominal pain and generalized weakness. She was admitted for a week at a provincial hospital and was given an unrecalled antibiotic with resolution of symptoms. Upon discharge, however, she experienced two weeks of severe right lower quadrant pain radiating to the back and left lower quadrant, with no history of diarrhea, vomiting, dysuria, and fever. Complete blood count showed slight leukocytosis and elevated C-reactive protein. Abdominal imaging revealed a saccular infrarenal aneurysm with dissection. An atherosclerotic mechanism was primarily considered, but a vasculitic process was likewise considered due to elevated acute phase reactants. The initial plan was Endovascular Aneurysm Repair (EVAR) but due to financial limitations, an exploratory laparotomy with infrarenal endoaneurysmorrhaphy was eventually performed. Intraoperative findings were a saccular infrarenal aneurysm with dissection up to the proximal right common iliac artery and an abscess compartment within the false lumen in the anterior aortic wall. Abscess culture yielded high growth of Salmonella group B. Micrographs of the aortic wall biopsy showed fibrin deposition necrosis and calcification with peripheral viable cellular infiltrates consisting of neutrophils and foamy macrophages. Inadvertently placing an endovascular graft in an infected aortic aneurysm would have led to graft infection and catastrophic morbidity. We highlight the significance of having a high index of suspicion for infectious causes of aortitis among immunocompromised patients presenting with aneurysm prior to pursuing an endovascular versus an open approach for repair.