case_images: PMC10588666_01
case_images: Computed tomography of the abdomen and chest on days 1, 74, and 177. Arrows indicate the lesions in the abdomen and lungs. Compared with the CT results on days 1 and 177, the low-density cystic lesion in the left adnexal area cavity disappeared, but patchy high-density lesions in both lungs did not improve.
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case_images: fig1
case_images: A large amount of effusion was observed in the abdominal cavity and pelvic cavity, along with a low-density cystic lesion of approximately 4.5 x 4.9 cm in the left adnexal area, along with an unclear and disarranged structure in the right adnexal area (Figure 1). The cystic lesion in the left adnexal area shrank, but the lesion on the right side was enlarged (Figure 1). Clarithromycin was added to the original treatment (ethambutol hydrochloride, pyrazinamide, rifampicin, and isoniazid) according to BacDive's guidance.3 On March 21, 2023, the patient reported no abdominal discomfort and abdominal CT showed that the lesion in the left adnexal area disappeared (Figure 1).
case_images: Histopathology of the nodular lesions on the greater omentum. (A) Hematoxylin-eosin staining shows hyperplasia of fibrous tissue (black arrows) with chronic granulomatous inflammation (red arrows). (B) Acid-fast staining was negative.
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case_images: fig2
case_images: On the 2nd day, the histopathology of the greater omentum showed hyperplasia of fibrous tissue with chronic granulomatous inflammation, but acid-fast staining was negative (Figure 2).
case_images: Identification of Mycobacterium syngnathidarum from the patient's ascites fluid. (A)
  Mycobacterium tuberculosis grew in the ascites fluid of Lowenstein-Jensen medium on the 12th day. (B) The acid-fast staining of Mycobacterium syngnathidarum. (C) The WGS result showed that the coverage of Mycobacterium syngnathidarum was 90.5%. (D) Polymerase chain reaction and the capillary electrophoresis technique confirmed the Mycobacterium syngnathidarum infection in the patient.
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case_images: fig3
case_images: On 14th October, the presence of yellow-green bacteria similar to Mycobacterium tuberculosis was observed in the ascites fluid culture after 12 days of incubation in the Lowenstein-Jensen medium (Figure 3A). The acid-fast staining was positive (Figure 3B), and single colonies were successfully grown after 3-4 days of bacteria isolation on blood agar plates and Lowenstein-Jensen medium. To gain further insight, WGS was performed on the cultures on 19th October, and the sequences of Mycobacterium syngnathidarum (ANI = 99.4282) were identified (Figure 3C). The primers were designed and verified using Primer-BLAST1 based on the reference genome sequence of Mycobacterium syngnathidarum available in NCBI.2 The capillary electrophoresis technique (Qsep 100 ; Bioptic) and Sanger sequencing confirmed the presence of Mycobacterium syngnathidarum (Figure 3D).