A 26-year-old Pakistani woman presents to the emergency department with a 1-week history of nausea, vomiting, diarrhea, lower abdominal pain, and dysuria. She was treated for pulmonary tuberculosis about 2 years ago. She has 3 children, all of who were normal vaginal deliveries and were born healthy. She has a 1-year history of menstrual irregularity and dysmenorrhea. She is a nonsmoker and is not taking any medications on a regular basis. Her family history is unremarkable.
On physical examination, the patient appears toxic. Her oral temperature is 100°F (37.8°C). Her pulse is regular with a rate of 100 bpm. 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 distension with mild generalized tenderness. There is a mild-to-moderate amount of ascites. 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 level of 8 mg/dL; an elevated erythrocyte sedimentation rate (ESR) of 65 mm/hr; normal liver and renal functioning; and a urinalysis that is positive for red blood cells, white blood cells, 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. Ultrasonographic imaging of the abdomen and pelvis demonstrates bilateral hydronephrosis (Figure 1). The mesentery and gut wall appear thickened; peritoneal deposits and moderate ascites are found. A sample of the ascitic fluid sent for analysis reveals 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 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 noted to be thickened (Figure 3). Bilateral hydroureteronephrosis and multiple enlarged para-aortic lymph nodes are also seen (Figure 4). In light of the above findings and history of tuberculosis, a provisional diagnosis of tuberculous peritonitis is made, and the patient is started on antituberculous therapy (ATT). The patient’s symptoms, however, 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/hr.
What is the likely diagnosis?
Hint: Note the history of polyserositis.
Metastatic ovarian carcinoma
Peritoneal tuberculosis
Systemic lupus erythematosus (SLE)
Rheumatoid arthritis
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