Peritoneal Tuberculosis and Chronic Myeloid Leukaemia: A Case of Hickam's Dictum.
Zayn Al-Timimi, Gem Chew, Martin Browne et al.
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Case in brief
A 34-year-old man presented with persistent fever, ascites, thrombocytosis and clinical deterioration despite broad-spectrum therapy. Initial interferon-γ release assay and ascitic acid-fast bacilli testing were negative. Molecular testing and ascitic adenosine deaminase measurement supported peritoneal tuberculosis, later confirmed by culture. Bone marrow aspirate and trephine, obtained to broaden the differential diagnosis, revealed a Philadelphia chromosome, leading to a concurrent diagnosis of chronic myeloid leukaemia.
What made this case unusual
Two concurrent diagnoses—peritoneal tuberculosis and chronic myeloid leukaemia—accounted for the presentation, illustrating the risk of diagnostic parsimony. Initial tests for tuberculosis were negative, and confirmation required multimodal investigation and culture.
Diagnostic / clinical pearl
Negative initial tests do not exclude extrapulmonary tuberculosis; persistent suspicion may warrant complementary molecular testing, adenosine deaminase measurement and culture. Broaden the differential when the clinical course remains unexplained.