55M MALNUTRITION ASCITIS ? TB PERITONITIS WITH LEFT PLEURAL EFFUSION

 A 55 YEAR OLD MALE CAME WITH C/0

ABDOMINAL DISTENTION SINCE 1 MONTH

DECREASED APPETITE SINCE 20 DAYS

FEVER SINCE 10 DAYS

HOPI: 55YEAR OLD MALE RESIDENT OF NARKETPALLY MECHANIC BY OCCUPATION , CHRONIC ALCOHOLIC SINCE 30 YEARS 2 QUARTERS PER DAY AND CHRONIC SMOOKER SINCE 30 YEARS , 10 BEEDIS PER DAY HIS WIFE EXPIRED 3 YEARS AGO FROM THEN HE INCREASED THE ALCOHOL INTAKE . 

PATIENT WAS APPARENTLY ASYMPTOMATIC 1 MONTH BACK, THEN DEVELOPED ABDOMINAL DISTENTION WHICH IS INSIDIOUS IN ONSET AND GRADUALLY PROGRESSIVE. 

FEVER SINCE 10 DAYS WHICH IS OF HIGH GRADE, ASSOCIATED WITH CHILLS AND RIGORS, RAISED DURING EVENING AND NIGHT AND RELIEVED ON MEDICATION. 

HE ALSO HAD DECREASED APPETITE SINCE 20 DAYS

H/O BLACK COLOURED STOOLS FROM 10 DAYS

NO H/O PAIN ABDOMEN

NO H/O VOMITING

NO H/O LOOSE MOTIONS/CONSTIPATION

NO H/O BURNING MICTURITION

NO H/O HEMOPTYSIS

PAST HISTORY:

N/K/C/O  HTN/DM/TB/CAD/CVA/THYROID DISORDER/EPILEPSY

PERSONAL HISTORY:

DIET- MIXED

APPETITE- DECREASED

SLEEP- ADEQUATE

BOWEL AND BLADDER MOVEMENTS- REGULAR

ADDICTIONS- 

HE IS A CHRONIC ALCOHOLIC SINCE 30 YEARS( 2 QUARTERS/DAY). STOPPED SINCE 20 DAYS. 

HE IS ALSO A CHRONIC SMOKER SINCE 30 YEARS( 9 BEEDI/DAY) 

ON EXAMINATION:

PATIENT IS CONSCIOUS, COHERENT, COOPERATIVE

PALLOR- ABSENT

ICTERUS- ABSENT

CYANOSIS- ABSENT

CLUBBING- ABSENT

LYMPHADENOPATHY- ABSENT

EDEMA- ABSENT

VITALS :

AT THE TIME OF ADMISSION :

TEMP. : 97.2

PR : 88 BPM

RR : 18 CPM

BP : 100/60 MM HG

SpO2 : 98%

GRBS:108 GM/DL

WEIGHT-49. 4KGS(6/7/23)

                   49KGS(7/3/23) 

                   48. 6KGS(8/3/23) 

                   47. 6KGS(9/3/23) 

                   47. 58 KGS(10/3/23) 

ABDOMINAL GIRTH- 

77.8CMS(6/3/23)

77.5CMS(7/3/23)

77 CMS(8/3/23)

73CMS(9/3/23) 

78. 5CMS(10/3/23) 

ON SYSTEMIC EXAMINATION:

CVS : S1, S2 HEARD

RS : BAE PRESENT

        DECREASED BREATH SOUNDS IN LEFT IAA

        

P/A : TENDERNESS PRESENT IN EPIGASTRIC AND UMBLICAL REGIONS

CNS : HMF INTACT

INVESTIGATIONS:

ON 28/2/23

ON 6/3/23

ON 7/3/23:

ASCITIC TAP IS DONE ON 6/3/23- 

ASCITIC TAP OF 450ML WAS DONE

On 8/3/23:

ASCITIC TAP WAS FONE(8/3/23) -

ASCITIC TAP WAS DONEOF 150ML

X ray done post ascitic tap

LIGHT'S CRITERIA-

ASCITIC FLUID Add

  

On 9/3/34

10/3/23

MANTOUX TEST:DONE ON 8/3/23

BEFORE TEST

DAY 0

DAY1

           DAY 2

DAY3

PROVISIONAL DIAGNOSIS:

ASCITIS UNDER EVALUATION(LOW SAAG HIGH PROTEIN ) SECONDARY TO

?CHRONIC LIVER DISEASE  TO  RULE OUT SPONTANEOUS BACTERIAL PERITONITIS 

?TB PERITONITIS 

LEFT PLUERAL EFFUSION

TREATMENT:

1) SALT RESTRICTION<2GM/DAY

2) FLUID RESTRICTION<1.2LIT/DAY

3) INJ CEFTOXIME 1GM IV/BD

4) INJ PAN 40MG  IV/BD

5) INJ LACILACTONE20/25 PO/OD@9AM

6) SYP LACTULOSE 10ML PO/BD

7) TAB DOLO 650MG PO/TID

8) STRICT INPUT /OUTPUT CHARTING

Evidence to start ATT :

1)Ascitic & pleural cells=Lymphocytic predominant

2)Ascitic ADA=100(<30 normal)

3)Exudative pleural effusion 

4)Low SAAG High protien

wats app conversation by Dr.KEERTHI MADIREDDI PGY2 

India’s Revised National TB Control Programme guidelines which recommend that patients with two negative sputum smear results should be treated with broad-spectrum antibiotics for 2 weeks with a follow-up chest X-ray if symptoms persist.

but in this case ascitic and pleural fluid shows lymphocytic predominance , ascitic ada is pointing towards TB most likely so starting ATT empirically and keeping a regular followup with the patient will be helpful sir

on 10 th march gastroenterologist opinion taken

 adviced

To start ATT now 

To avoid pyrazinamide in ATT as the patient already has background CLD asked to speak with pulmonology dept for fixing dose   

CT scan can be adviced to check for any malignancy.

on 11 th march pulmonology opinion taken 

Patient diagnosed as TB PERITONITIS came for follow up on 20th march 2023 and is doing well

Patient came for follow up on 8th april 2023 and has no complaints.

He is receiving ATT from Nalgonda district hospital

His LFT ON 8-4-2023

The patient was contacted via phone calls and communication was made with his daughter. He received ATT from the local government hospital and discontinued ATT after one year as instructed by the doctor at the government hospital. The patient is doing well and has no complaints.

OUTCOME - COMPLETELY RECOVERED