A 52-year-old Indian man with a history of cirrhosis, alcoholic liver disease, esophageal varices, hemolytic anemia, and type 2 diabetes mellitus presented with a 2-week history of increased abdominal girth, 15 pounds of weight gain and epigastric pain. He also complained of decreased energy and shortness of breath with exercise and denied any other changes, including fever, chills, nausea and vomiting.
His past medical history was significant for two decades of heavy alcohol consumption (approximately 325 mL whiskey daily), which led to alcoholic cirrhosis, portal hypertension with gastric and esophageal varices, ascites, and a left pleural effusion at the age of 50. The patient had stopped alcohol consumption 18 months prior to the current presentation. He also had a history of diabetes and hyperlipidemia since age 45; gastritis with H. pylori infection since age 50; and autoimmune hemolytic anemia since age 51. His oral home medications were Captopril 50 mg daily, Folic acid 1 mg daily, Furosemide 20 mg daily, Glipizide 5 mg daily, Prednisone 80 mg daily, and Spironolactone 50 mg daily.
The patient had no drug allergies and was married, with two adult children. He was employed as an electrician. The patient did not smoke tobacco and had no history of illicit drug use.
His past family history was significant for his mother having been diagnosed with diabetes.
At admission, the patient was alert and in no acute distress, with a pulse of 80/min, blood pressure 104/62 mmHg, respiratory rate 18/min, temperature 99 degrees Fahrenheit, and 100% oxygen saturation on room air. Significant findings on physical exam were slight conjunctival pallor and scleral icterus; a distended abdomen which was minimally tender to palpation and with full, shifting dullness to percussion; and 1+ bilateral lower extremity pitting edema.
Diagnostic paracentesis was performed in the emergency room and demonstrated an increased white blood cell count (12,500/μL, 95% neutrophils) and occasional sperm in the peritoneal fluid (Figure ). Treatment for spontaneous bacterial peritonitis was initiated with intravenous Rocephin. Two days later, a subsequent paracentesis demonstrated a lower white blood cell count (5,500/μL, 51% neutrophils) and persistent rare sperm in the peritoneal fluid (Figure ). A Urology consult was initiated to further investigate the finding of sperm in the ascitic fluid. The patient reported no history of trauma or instrumentation to the bladder or urethra, no history of a vasectomy, and no history of congenital urogenital defects. The possibility of a bladder rupture with retrograde ejaculation was ruled out by a cystogram that showed no signs of rupture. Furthermore, the fluid creatinine was similar to the serum creatinine and the patient was without urinary symptoms, thus ruling against a urinary ascites. It was concluded that the abdominal tap was either contaminated or the vas deferens had been incidentally injured during the paracentesis procedure. At that point, it was felt that there were no increased risks that would affect his immediate health and no additional workup was recommended. The patient was eventually transitioned to oral Ciprofloxacin (50 mg p.o., b.i.d for 7 days) and discharged in good condition, three days after admission. Throughout his hospital course, the patient remained afebrile and asymptomatic. He had subsequent episodes of spontaneous bacterial peritonitis in the months following his initial presentation; however, no sperm were identified in the ascitic fluid in any of those instances.
Peritoneal fluid (Wright-Giemsa stain; 1,000× magnification). There are several spermatozoa in a background of frequent neutrophils and occasional red blood cells.
Peritoneal fluid (Wright-Giemsa stain; 1,000× magnification). There is a spermatozoon in a background of frequent neutrophils, rare mononuclear cells and occasional red blood cells.