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Omental Tuberculosis in a Patient with Alcoholic Liver Cirrhosis-the Diagnostic and Treatment Dilemma

Alcoholic cirrhosis is frequently complicated by spontaneous bacterial peritonitis (SBP) due to the translocation of gut bacteria. However, in immigrants to the USA from parts of the world with high tuberculosis burden, a high degree of clinical suspicion of tuberculous peritonitis should be maintained when a patient presents with symptoms similar to SBP. We describe a case of a 45-year-old Nepali man with a history of alcohol abuse who immigrated to the USA six years prior and presented to the hospital with abdominal pain, night sweats, fevers, and a 10 kg weight loss. A CT scan revealed abdominopelvic ascites, liver nodularity suggestive of cirrhosis, and heterogeneous attenuation of the omentum. A CTguided biopsy of the omentum was done, and the histopathology revealed non-necrotizing granulomas. However, given the demographics of the patient along with his constitutional symptoms, there was high suspicion for abdominal tuberculosis, and a second CT-guided omental biopsy was done and sent for tissue cultures. Due to the delay in getting microbiological confirmation of tuberculosis and persistent fevers, an empiric trial of isoniazid, rifampicin, pyrazinamide, and ethambutol (RIPE) was started with close monitoring of liver function tests. Since the patient’s symptoms improved, the RIPE regimen was continued. Twenty-five days later, tuberculosis was confirmed on omental biopsy tissue culture. This case highlights the diagnostic and treatment challenges associated with omental tuberculosis with liver cirrhosis and suggests a potential role for an empiric trial of RIPE regimen in the appropriate clinical context.