Intended for healthcare professionals

Endgames Case report

Abdominal distension and low grade fever in a refugee from Sudan

BMJ 2008; 337 doi: (Published 10 September 2008) Cite this as: BMJ 2008;337:a1252
  1. Rachel J Ali, specialist registrar in gastroenterology1,
  2. Harry R Dalton, consultant gastroenterologist and honorary senior lecturer12
  1. 1Cornwall Gastrointestinal Unit, Royal Cornwall Hospital, Truro
  2. 2Peninsula College of Medicine and Dentistry, Royal Cornwall Hospital, Truro
  1. harry.dalton{at}

    A 34 year old Sudanese refugee presented with a four month history of malaise and generalised abdominal swelling. On examination, he had a temperature of 37.9°C and moderate ascites.

    Initial investigations are as follows.

    • Alkaline phosphatase 171 U/l (3-110 U/l)

    • Alanine transaminase 54 U/l (3-35 U/l)

    • Bilirubin 18 μmol/L (3-17 μmol/l)

    • Albumin 36 g/l (35-45 g/l)

    • International normalised ratio 1.0

    • HIV negative

    • Normal chest radiograph

    • Abdominal ultrasonography showed moderate ascites, normal looking liver, portal, and hepatic veins

    • Abdominal triphasic computed tomography confirmed ultrasonography findings, no other abnormality was seen

    • Bloodstained peritoneal aspirate

    • White cell count 1250/µl (80% lymphocytes)

    • Albumin 27 g/l

    • Cytology negative (×2 samples)

    • Gram and acid fast bacilli stain negative (×2 samples)

    • Culture awaited


    • 1. What is the diagnosis?

    • 2. What investigation would best confirm this diagnosis?

    • 3. What is the treatment?


    Short answers

    • 1. In view of this patient’s background, low serum-ascites albumin gradient, low grade fever, negative cytology, and unhelpful cross sectional radiology the most likely diagnosis is tuberculous peritonitis. A normal chest radiograph does not exclude this diagnosis.

    • 2. The diagnosis should be confirmed by laparoscopy and biopsy of omental tuberculous deposits in the peritoneal cavity.

    • 3. Anti-tuberculous chemotherapy for six …

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