Mr. S., a 41-year-old accountant from Bangladesh, is admitted to hospital with a 2-month history of anorexia, associated with recurrent spiking fevers and a 15-kg weight loss. Over the past month, he has noted diffuse abdominal pain associated with progressive abdominal distention.

The patient has a long history of ethanol abuse as well as a 7-year history of type 2 diabetes mellitus. He has previously been investigated for persistently elevated transaminase levels, and has been diagnosed with steatohepatitis related to insulin resistance and alcohol abuse.

On admission, Mr. S. is a toxic appearing East Indian man with a heart rate of 120 beats/min and an oral temperature of 39.1° C. His cardiorespiratory examination is unremarkable. The abdomen is moderately distended and diffusely tender. There are no abdominal masses or organomegally. He has marked peripheral muscle wasting.

Laboratory investigations reveal a normochromic normocytic anemia with a hemoglobin of 117 g/L. His alkaline phosphatase and aspartate transaminase levels are mildly elevated. Blood, urine and sputum cultures are consistently negative; sputum stain for acid-fast bacilli is negative as well. A chest x-ray is unremarkable aside from a small left pleural effusion, and a chest CT scan shows multiple focal densities -- up to 5 mm in diameter -- predominantly in the upper lobes of the lungs. A few mildly prominent mediastinal lymph nodes are also noted.

CT of the abdomen is significant only for ascites, as well as mural thickening of the right hemicolon and mild hepatomegally. Aspiration of ascitic fluid shows an elevated white blood cell count of 3,000 x 10⁶ cells/L, of which 95% are mononuclear. Ascitic fluid culture and cytology are negative, and a serum-to-ascitic fluid albumin gradient of 10 g/L is calculated. Flow cytometry with immunophenotypic analysis of the ascitic fluid is negative for lymphoma.

Mr. S. continues to have spiking fevers of up to 39.4° C. Screening for malaria is negative. What's your diagnosis?