Unusual clinical course, Challenging differential diagnosis
Dedrick Kok-Hong Chan, Kuok-Chung Lee
(Division of Colorectal Surgery, University Surgical Cluster, National University Health System, Singapore, Singapore)
Am J Case Rep 2015; 16:719-722
Intestinal tuberculosis can mimic many conditions. The incidence of intestinal tuberculosis in developed countries has risen in tandem with the increase in patients with immunocompromised states. This is a condition which needs to be considered in patients who present with symptoms and signs of bowel perforation on a background of immunosuppression in order to obtain the correct diagnosis and, consequently, the correct treatment.
CASE REPORT: We report a patient with a background of sarcoidosis who had been on mycophenolate mofetil, tacrolimus, and high-dose prednisolone. He presented with abdominal pain without overt peritonitis. Initial imaging showed small locules of free air in the abdominal cavity. The patient was managed with intravenous antibiotics as upfront surgery was deemed to be high risk. However, on a repeat imaging scan 3 days later, larger locules of gas were seen within the abdominal cavity, indicating progression and non-resolution of his acute condition.
The patient was brought to the operating theatre and a perforation at the ileum was found. A segment of small bowel containing the perforation was resected. Histology showed the presence of acid-fast bacilli (AFB) on Ziehl-Neelsen stain, leading to a diagnosis of intestinal tuberculosis.
CONCLUSIONS: A high index of suspicion for intestinal tuberculosis is needed in patients who are on immunosuppression. Intestinal tuberculosis presenting with perforation is unlikely to lead to spontaneous resolution without operative management, and patients should be brought to the operating theatre for immediate surgery.
Keywords: Humans, Aged, Acquired Immunodeficiency Syndrome, Ileum, Immunocompromised Host, Intestinal Perforation - etiology, Male, Tomography, X-Ray Computed, Tuberculosis, Gastrointestinal - diagnosis