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Vol. 5, No. 4 April 2024 http://jist.publikasiindonesia.id/

Jurnal Indonesia Sosial Teknologi, Vol. 5, No. 4, April 2024 1400

A Case of Tuberculous Peritonitis Accompanied By

Tuberculous Pleuritis

The successful completion of a project is the goal of carrying out a project, where

the project is a unique activity and has a period (end); then, the success of the completion

of a project will be determined at the end of the project (Vaid & C. Kane, 2017). The

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Delays in construction projects refer to situations where the project is not completed

according to the planned schedule. This means construction work took longer than

expected in the initial planning (Dahale et al., 2021). Delays in construction projects can

occur for various reasons, including those previously mentioned, such as scope changes,

lousy weather, obstacles in obtaining permits, delays in shipping materials, and other

issues. A budget for a construction project means that the project's cost exceeds the budget

set or planned in the initial planning (Atzori, Vidili, & Delitala, 2012). In this situation,

the actual expenditure on a construction project exceeds a predetermined estimated cost.

In a construction project, delays and overbudgets will affect the project's

performance, which also affects the performance of the construction company working

1 below:

Figure 1 The Project is late and over budget at PT. WER

Of the 18 (eighteen) projects that experienced overbudget, including four road and

bridge type projects, five water building type projects, three building type projects, one

transmission and distribution type project, 3 EPC type projects, and two railway type

projects, as illustrated in Figure 2 TB peritonitis is a form of extrapulmonary tuberculosis,

a peritoneal or visceral inflammation caused by Mycobacterium tuberculosis1. The most

common sites of extrapulmonary TB in the body are the lymph nodes, bones, joints,

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10% of extra-pulmonary tuberculosis. The incidence and severity of abdominal TB have

been reported to increase with the rising incidence of TB and HIV infection2. TB

peritonitis is a rare type of abdominal TB, reported to occur in less than 5% of all TB

patients (Sudirman, 2018). TB peritonitis cases are often found in individuals aged 25-45

years, with a female-to-male ratio of 1.5:13.

TB peritonitis infection develops slowly and is characterized by nonspecific

symptoms, so delayed diagnosis can increase morbidity and mortality (Murlistyarini,

Prawitasari, & Setyowatie, 2018). Patients with TB peritonitis usually present with

symptoms lasting 1-12 months and present with symptoms of abdominal pain, weight

loss, loss of appetite, fever, diarrhea, constipation, rectal bleeding, edema, and ascites,

appeared for ± 19 days SMRS, and complaints accompanied by heartburn complaints

such as nausea and vomiting were denied. Other complaints are liquid stools with a

frequency of 2-3 times a day accompanied by mucus, without blood since ± 19 days ago,

urination within normal limits, and decreased appetite. Complaints, such as coughing,

tightness, and weight loss, are denied. Menstruation is within normal limits. The patient

said he had no previous history of illness. Treatment history: The patient took Acitral 3x1,

Zinc 1x1, and Metronidazole 3x500 mg, obtained from a general practitioner.

The physical examination revealed a weak general condition, compos mentis

consciousness, blood pressure 120/80, pulse 90x, respiration 20x, axilla temperature

39.5ºC, Spo2 99% on room air. Body weight is 50kg, height is 160 cm, and BMI is 19.5

examination was within normal limits with no murmurs, gallops, or extrasystoles.

Abdominal examination; inspection found distension, on palpation; muscular

defans (-) epigastric tenderness (+), undulation (+), on percussion; shifting dullness (+),

checkerboard phenomenon (+), on auscultation found increased bowel noise.

Examination of extremities: warm (+) on all four extremities, edema (-), CRT < 2 seconds.

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Sodium: 134.2 mmol/L, Potassium: 4.06 mmol/L, Chloride: 98.9 mmol/L, Albumin: 4.25

g/dl. Upon complete urine examination, the results were within normal limits. Complete

stool; yellow color, mucus (+), blood (-) leukocytes 4-6 / LPB, bacteria (+), worms (-),

fungi (-), amoeba (-). On the thorax photo was an impression of left pleural effusion,

ECG: within normal limits, BOF 3 position: there were ascites, no ileus, and

pneumoperitoneum. Abdominal ultrasound results: thickening of the peritoneum, ascites,

suspected TB peritonitis, Liver, gallbladder, pancreas, spleen, kidneys, buli-buli, and

uterus within normal limits. The rapid molecular test (TCM) and HIV test were negative.

The patient was diagnosed with the observation of ascites ec suspected TB, pleural

effusion ec suspected TB, and Acute Gastroenteritis. The next plan is to ascite pleural

examination of the fluid; there were no malignant cells. Diagnosis: TB peritonitis and TB

pleurisy, followed by OAT therapy; FDC 1x3 tab. The patient was hospitalized for five

days with an improved condition, then the Anti Tuberculosis Drug therapy program for

12 months.

TB peritonitis has nonspecific clinical symptoms. The most common complaints

are abdominal pain (73%) and ascites (93%), followed by loss of appetite and weight,

nausea, vomiting, cough, fever (58%), diarrhea, constipation, and night sweats; ascites

can be caused by peritoneal tuberculosis or can originate from liver disease, malignancy,

heart, kidney and other infectious diseases5 (Febrianto, 2019). Peritoneal TB with ascites

unpasteurized milk in the case of Mycobacterium bovis), or through direct contact from

adjacent foci of infection7 (JUWITA, 2013).

In tuberculous peritonitis, clinical symptoms are non-specific or variable.

Complaints and symptoms occur slowly over months, so patients are often unaware of

their condition. Complaints range from 2 weeks to 2 years, with an average of more than

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phenomenon, lymphadenopathy, and lung & pleural involvement (based on chest

photograph)7. Infection of the adjacent pleura may reach the peritoneum, resulting in

peritoneal tuberculosis. Pleural effusion is observed in 22 to 32% of patients with

peritoneal tuberculosis and pulmonary source in 15 to 20% of cases8.

No single test can effectively rule out the diagnosis of peritoneal TB. TB, and a

combination of socio-epidemiologic history (e.g., travel, homelessness, incarceration,

sick contacts, drug use) and immunologic risk assessment is essential. Classic symptoms

such as fever, weight loss, and night sweats may be absent8.

The patient was directed to the diagnosis of tuberculous peritonitis and pleural

tuberculosis based on several symptoms such as an enlarged abdomen, fever,

blood count, liver function tests, renal function tests, chest X-ray, abdominal

ultrasonography, and ascitic fluid analysis, including cell count, albumin, protein, and

Adenosine Deaminase Activity (ADA)9.

Changes in hematological indices, including white blood cell count and erythrocyte

sedimentation rate, are nonspecific. Mild to moderate normochromic, normocytic anemia

seen in 100% of patients with TB peritonitis, but the specificity remains low. Due to its

low accuracy, ascites LDH measurement is not routinely used10. In TB pleurisy,

biochemical features include elevated protein levels of more than 4.5 g/dL and slightly

elevated DHL10. The diagnosis of TB pleurisy is usually made through a combination of

clinical history, pleural fluid analysis (predominantly lymphocytic cell count, protein

concentration >3.0 g/dL, elevated lactate dehydrogenase often >500 IU/L, and glucose

level <60 mg/dL), positive culture in sputum or pleural fluid, and positive ADA level >40

U/L10.

Ultrasound is an essential tool for diagnosing peritoneal tuberculosis due to its

accessibility, low cost, and ease of performance. Ultrasound is diagnosis-oriented and

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omental thickening (73.6%), sonography is more sensitive than CT in detecting diffuse

peritoneal thickening, especially in the presence of ascites, which is usually found in

chronic inflammation. Mesentery involvement is joint and can be found in the early

stages. It is characterized by wall thickening and is associated with increased echogenicity

and multiple lymph nodes. Other abdominal lesions are as follows: Splenic nodules,

ileocaecal involvement, and hepatic nodules; in advanced stages of the disease, lymph

nodes can be visualized sonographically as hypoechoic areas with irregular borders due

to ossified conglomerates of necrosis12.

Adenosine Deaminase Activity (ADA) has been studied in body fluids, including

ascitic fluid, to diagnose TB peritonitis and has been shown to have high sensitivity and

lymphocyte stimulation is caused by the tuberculosis bacteria, which activates the cellular

immune response and, in turn, increases ADA levels. In studies using meta-analysis and

systematic review, the results of data calculated from 20 studies, including studies that

had a total of 2,291 patients, showed a pooled sensitivity of 0.90 (95% CI: 0.85 -0.94), a

pooled specificity of 0.94 (95% CI: 0.92 - 0.95), and a DOR of 149 (95% CI: 86–255).

pathologies such as rheumatoid arthritis, systemic lupus erythematosus, lymphoma, some

adenocarcinomas, and empyema. The sensitivity of this method varies from 90 to 100%,

and its specificity ranges from 89 to 100%. This method of diagnosis is more sensitive

for pleural tuberculosis than pleural histopathologic examination and bacteriologic

tests12,13.

Many doctors prefer a combination of clinical examination with other methods,

such as laparoscopic biopsy and histopathological examination of peritoneal tissue (which

can show caseation necrosis), acid-fast bacilli (AFB) staining, as well as radio-imaging

techniques such as abdominal computed tomography (CT) scanning for diagnosis.

However, all these methods are time-consuming, expensive, insensitive, invasive, or non-

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patients should receive at least six months of therapy. Patients who have not received

treatment and are not resistant to oral antituberculosis drugs are treated with a first-line

regimen consisting of an initial phase including Isoniazid 5 mg/kgBW, 15 mg/kgBW

Etambutol, Rifampicin 10 mg/kgBW, and Pyrazinamide 25 mg/kgBW given daily for

two months, then an advanced phase including a combination of Isoniazid (10 mg/kg

BW) and Rifampicin (30mg/kg BW) 3x a week for four months. This therapy guideline

gives good results after two months. Tuberculous peritonitis can be treated for 9-12

months (2HRZE/710RH). The treatment guideline can use a Fixed Drug Combination

(FDC), which consists of a combination of 2 or 4 types of drugs in one tablet with a dose

according to the patient's weight packaged in a package for one patient consisting of an

supporting examinations (radiology) are needed to make the correct diagnosis, and body

fluid analysis examination can help confirm the diagnosis, with the advantages of being

non-invasive, easy to perform, cost-effective, and primarily available in health facilities.

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