Delayed Diagnosis of Peritoneal Mesothelioma in Recurrent Ascites: A Case Report

Our plain-English summary of Delayed Diagnosis of Peritoneal Mesothelioma in Recurrent Ascites: A Case Report, by H. Javed, A. Ahmad, A. Rehman, et al (The American Journal of Case Reports, 2025).

The study

• Authors: H. Javed, A. Ahmad, A. Rehman, M. Wagner, J.E. McKnight
• Journal: The American Journal of Case Reports
• Published: 2025;26:e946777
• Type of article: Case report
• Cited by: 1 article, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

BACKGROUND Ascites is a common clinical sign noted in 3% to 4% of hospitalized medical patients. Nearly 94% of patients with ascites have non-malignant etiologies, with the most common being chronic liver disease. Peritoneal mesothelioma is an exceedingly rare malignancy associated with asbestos exposure. Here, we report the case of an elderly man who presented with recurrent loculated ascites and received a diagnosis of peritoneal mesothelioma after a delay of approximately 10 weeks. CASE REPORT A 67-year-old man with a history of asbestos exposure presented with abdominal distension and muscle wasting for 1 month. Initial abdominal CT was notable for smooth liver contour and massive ascites. Ascitic fluid analysis was consistent with low serum albumin-ascites gradient but showed negative cytology for malignant cells. Upper and lower endoscopies did not reveal lesions. Due to recurring ascites, serial abdominal paracenteses were performed, although cytology was negative for malignant cells. Repeat abdominal CT performed after 6 weeks showed worsening loculated ascites, with possible peritoneal carcinomatosis. At this point, percutaneous omental biopsy was performed, which established the diagnosis of peritoneal mesothelioma (75 days after initial presentation). CONCLUSIONS In patients presenting with recurrent ascites and a history of asbestos exposure, it is important to consider the diagnosis of peritoneal mesothelioma. While 94% of patients with ascites have non-malignant etiologies, a small proportion of patients can have malignant ascites. In patients in which the first set of ascitic fluid studies are inconclusive, repeat abdominal paracentesis and omental biopsy or diagnostic laparoscopy should be expedited to avoid delays in diagnosis.

In plain English

This case report described one man, aged 67, with past occupational asbestos exposure from working for a shipbuilding company. He came to the authors' hospital in June 2024 with weight loss and abdominal swelling lasting 4 weeks. Scans showed a large build-up of fluid in the abdomen (ascites). The first drainage removed 14.7 L, and no cancer cells were found in that fluid. The fluid kept returning. Four more drainages followed on days 14, 23, 31 and 46, but no further cell testing was ordered on that fluid. A later scan showed pockets of fluid, a thickened layer of fatty abdominal tissue (omental caking), and a large fluid collection around the left lung. A biopsy of that abdominal tissue, taken through the skin, led to a diagnosis of peritoneal epithelioid mesothelioma 75 days after he first presented. He chose hospice care and died 4 months after first presenting. The article did not name asbestos fiber types. The authors concluded that mesothelioma should be kept in mind in people with asbestos exposure and suggestive symptoms, and that repeat fluid testing with biopsy should be sped up when first tests are inconclusive.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Case report (one patient)
• Who was studied: One 67-year-old man seen at the authors' hospital (affiliations: TidalHealth Peninsula Regional, Salisbury, Maryland, USA) in June 2024, with weight loss and abdominal distension for 4 weeks
• Exposure: Occupational asbestos exposure while working for a shipbuilding company. No fiber type, duration or dose was reported. The patient denied cigarette smoking.
• Main results:
  • First paracentesis (abdominal fluid drainage) removed 14.7 L of fluid. The fluid was exudative with a low serum albumin-ascites gradient (reported as 0.8 g/dL in the text, 0.4 g/dL in Table 1).
  • Cytology on the first fluid sample was negative for malignant cells and showed only reactive mesothelial cells.
  • Four further paracenteses were done on days 14, 23, 31 and 46 without cytology or other fluid analyses being ordered.
  • Repeat CT showed loculated ascites, omental caking and a large left-sided pleural effusion. Upper and lower endoscopies showed no malignant lesions.
  • Percutaneous omental biopsy led to a diagnosis of peritoneal epithelioid mesothelioma 75 days after initial presentation.
  • Pleural fluid cytology was positive for malignant cells. The pleural effusion was considered a malignant pleural effusion associated with the peritoneal mesothelioma.
  • The patient was offered cytoreductive surgery with HIPEC but chose hospice care, and died 4 months after initial presentation.
• The authors' conclusion: The authors concluded that in patients with a history of asbestos exposure and suggestive symptoms, mesothelioma should always be kept in mind. When the first ascitic fluid studies are inconclusive, repeat paracentesis with omental biopsy or diagnostic laparoscopy should be expedited to avoid delays in diagnosis.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Lung cancer, Mesothelioma, Peritoneal mesothelioma.

Medical terms in this study, explained in our Lexicon: Peritoneal Mesothelioma, Ascites, Asbestos Exposure, Cytology, Biopsy, paracentesis, Diagnostic Laparoscopy.

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• An unusual case of ascites: pitfalls in diagnosis of malignant peritoneal mesothelioma — J.R. Clark, W.B. Ross (2000)
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• The role of "closed abdomen" hyperthermic intraperitoneal chemotherapy (HIPEC) in the palliative treatment of neoplastic ascites from peritoneal carcinomatosis: report of a single-center experience — L. Orgiano, F. Pani, et al. (2016)
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