What is the diagnosis and management for a 39-year-old female with a history of pulmonary tuberculosis (PTB), presenting with progressive bipedal edema, abdominal pain, increasing abdominal girth, dyspnea, hypotension requiring vasopressor support (norepinephrine and dopamine infusion), impaired renal function, electrolyte disturbances, and signs of liver dysfunction?

Diagnosis and Management

Primary Diagnosis

This patient most likely has peritoneal tuberculosis with secondary complications including acute kidney injury, hypoalbuminemia-related edema, and distributive shock, requiring immediate vasopressor support, diagnostic paracentesis, and anti-tuberculous therapy. 1

The constellation of progressive ascites, abdominal pain, bipedal edema, history of pulmonary tuberculosis (treated in prior years), moderate ascites on ultrasound, hypoalbuminemia (26.22 g/L), proteinuria, and systemic inflammatory response strongly suggests abdominal tuberculosis as the primary pathology 1. The hypotension requiring vasopressors indicates progression to septic shock, likely from tuberculous peritonitis 1.

Immediate Management Priorities

Hemodynamic Stabilization

• Continue norepinephrine as the first-line vasopressor to maintain mean arterial pressure and organ perfusion, as it is superior to dopamine with fewer arrhythmogenic effects 1
• Transition away from dopamine given the significantly higher risk of cardiac arrhythmias (19.4% vs 3.4% with norepinephrine) and increased mortality association 2
• Target mean arterial pressure adequate for organ perfusion while monitoring skin perfusion, mental status, and urine output 1
• Avoid aggressive fluid resuscitation beyond modest 500 mL challenges, as bowel edema and forced closure can worsen intra-abdominal hypertension and compromise renal, pulmonary, and cardiovascular function 1
• Use repeated IVC diameter measurements by ultrasound to guide fluid requirements 1

Respiratory Support

• Maintain oxygen supplementation to correct hypoxemia (current ABG shows pH 7.23, PCO₂ 66.6 mmHg indicating respiratory acidosis with adequate oxygenation on 8-9 LPM) 1
• Monitor closely for worsening respiratory failure given left lung consolidation-atelectasis on ultrasound 3
• If mechanical ventilation becomes necessary, use low tidal volumes (6 mL/kg) and cautious positive end-expiratory pressure to avoid worsening right ventricular function 1

Diagnostic Workup

Ascitic Fluid Analysis (Urgent)

• Perform diagnostic paracentesis immediately to analyze ascitic fluid for:
  • Cell count with differential (lymphocytic predominance suggests TB)
  • Protein and albumin (calculate serum-ascites albumin gradient)
  • Gram stain, bacterial culture, and acid-fast bacilli smear and culture
  • Adenosine deaminase level (>40 U/L supports tuberculous peritonitis)
  • Cytology to exclude malignancy 1

Additional Imaging

• Chest CT scan to evaluate for active pulmonary tuberculosis reactivation given history of treated PTB and current left lung consolidation 1
• Consider abdominal CT with contrast (if renal function permits) to better characterize peritoneal thickening, lymphadenopathy, and bowel involvement typical of abdominal TB 1

Microbiologic Studies

• Blood cultures (aerobic, anaerobic, and mycobacterial) before initiating antimicrobials 1
• Sputum for acid-fast bacilli smear and culture if productive cough present 1
• Urine culture given bacteriuria on urinalysis 1

Definitive Treatment

Anti-Tuberculous Therapy

Initiate empiric four-drug anti-tuberculous therapy immediately given high clinical suspicion:

• Rifampin 600 mg daily
• Isoniazid 300 mg daily
• Pyrazinamide 2000 mg daily (adjust for renal function)
• Ethambutol 1200 mg daily (adjust for renal function) 1

Continue treatment for minimum 6 months, extending to 9-12 months based on clinical response and culture results 1

Renal Support

• Monitor creatinine closely (currently elevated at 123.04 µmol/L and rising from 84.33) 1
• Avoid nephrotoxic agents including NSAIDs 1
• Consider continuous renal replacement therapy if acute kidney injury progresses or volume overload worsens despite diuretics 1
• Adjust all medication doses for declining renal function 1

Metabolic Correction

• Correct hypoalbuminemia with albumin infusion (current 26.22 g/L) to improve oncotic pressure and reduce third-spacing 1
• Replete electrolytes: calcium (1.92 mmol/L), magnesium (0.64 mmol/L), and maintain potassium 4-5 mmol/L 1
• Monitor and correct hypoglycemia (FBS 3.11 mmol/L) with dextrose-containing fluids and frequent glucose monitoring 1
• Follow phosphate, as hypophosphatemia commonly develops with refeeding 1

Infection Surveillance

• Initiate broad-spectrum antibiotics empirically for possible secondary bacterial peritonitis or sepsis while awaiting culture results:
  • Piperacillin-tazobactam 4.5 g IV every 6-8 hours (adjust for renal function) or
  • Third-generation cephalosporin plus metronidazole 1
• Maintain high suspicion for nosocomial infections given vasopressor requirement and critical illness 1

Surgical Consultation

• Obtain urgent surgical evaluation to assess need for diagnostic laparoscopy if ascitic fluid analysis is non-diagnostic or if bowel perforation is suspected 1
• In abdominal tuberculosis with perforation, resection of affected bowel segment with primary anastomosis is preferred over simple closure 1
• If diffuse peritonitis with friable tissue, ileostomy may be necessary as life-saving measure 1

Critical Pitfalls to Avoid

• Do not delay anti-tuberculous therapy while awaiting culture confirmation, as abdominal TB has variable and non-specific presentation that can mimic malignancy or other inflammatory conditions 1
• Avoid vasopressin in acute liver failure states, as it is potentially harmful 1
• Do not use dobutamine as it may worsen tachycardia and arrhythmias without proven benefit in this clinical scenario 1
• Recognize that aggressive volume expansion worsens outcomes in abdominal compartment syndrome and right ventricular dysfunction 1, 4
• Monitor for hepatotoxicity from anti-tuberculous medications given baseline elevated AST (53.9 U/L) and bilirubin (35.96 µmol/L) 1
• The elevated D-dimer (>10) should not automatically trigger anticoagulation without confirmed thromboembolism, as it is non-specific in sepsis and inflammation 1

Monitoring Parameters

• Continuous hemodynamic monitoring with arterial line for blood pressure and serial lactate measurements 1
• Hourly urine output (target >0.5 mL/kg/hr) 1
• Serial creatinine, electrolytes, and liver function tests every 12-24 hours 1
• Daily abdominal girth measurements and weight 4
• Cardiac rhythm monitoring for arrhythmias, particularly given dopamine use 2
• Serial chest imaging to monitor for pulmonary edema or worsening consolidation 3