Tuberculosis (TB) remains a worldwide problem with slight male preponderance (1). TB is an important cause of morbidity and mortality in underdeveloped and developing nations. The incidence of intestinal TB in western countries has increased along with an overall resurgence of TB particularly due to increased migration from endemic areas. Extra pulmonary TB particularly gastrointestinal tract can present with a variety of clinical manifestations with the main differential diagnosis being inflammatory bowel disease and malignancy. Generally, gastrointestinal (GI) TB occurs, in an immunocompromised patient, but can also happen in immunocompetent individuals as well. GI TB accounts for 11% of all extra pulmonary TB involvement (1). Free intestinal perforation is a rare serious complication of intestinal TB and failure to diagnose it in a timely manner can be associated with high mortality. We report a case of TB presenting as a free intestinal perforation without any prior clinical manifestations in an immunocompetent patient.
A 25-year-old Asian male presented to the emergency department with acute abdominal pain of 2 hours duration. Examination revealed peritoneal signs. A plain upright film of chest demonstrated sub-diaphragmatic free air (Figure 1). An emergent laparotomy was performed and a cecal mass with perforation, 3 centimetres from the ileocecal valve was found, with faecal peritonitis. A right hemicolectomy with terminal ileal resection was carried out along with end to end anastomosis and the resected specimen was sent for further histo-pathological examination. Initial histopathology was reported as Crohn’s disease, and acid fast bacilli (AFB) staining was not performed. Post-operative course was complicated with wound infection and enterocutaneous fistula formation and a weight loss of 20 kilograms within a duration of 3 weeks. Patient was managed during this period with IV antibiotics. Further histopathological examination at a tertiary center revealed features, consistent with ileocecal tuberculosis along with positive AFB staining. Anti-tuberculous treatment was initiated with rifampicin, isoniazid, pyrazinamide, ethambutol with pyridoxine supplementation. Within three days of initiation of treatment, fistula started healing and was closed within 10 days.
TB is projected to be one of the leading causes of adult mortality by 2020 (2). Global impact of TB is huge, 200 million is estimated to be affected by 2020. Abdominal TB accounts for 5% of the TB patients, with 25% of them having peritoneal involvement (3,4).
The most common site affected by TB is lung. Extra pulmonary sites include lymph nodes, vertebral bodies, adrenal glands, meninges, genitourinary (GU) tract and GI tract. Mycobacterium tuberculosis is responsible for majority cases of abdominal tuberculosis (5). Possible mechanisms of spread include hematological, ingestion of contaminated milk or food, swallowing infected sputum in a patient with active pulmonary TB, contiguous transcoelomic spread and through lymphatic channels (6).
The most common symptoms of intestinal TB are abdominal pain, diarrhea, weight loss, anorexia, fever, anemia and lower gastrointestinal bleeding (7). The most common site affected by intestinal TB is the ileocecal region (7). Free perforation is uncommon due to reactive thickening of the peritoneum and the formation of adhesions to the adjacent tissues (8). However, in our case the initial presentation of tuberculosis was with intestinal perforation without any prior clinical manifestations. Crohn’s disease is an important differential diagnosis for Ileocecal tuberculosis. Differentiating features of crohn’s disease from ileocecal tuberculosis is shown in Table 1 (9-11). Diagnosis should be established early as the treatment differs significantly and will influence the outcome.
The treatment of choice for intestinal perforation TB is resection of the affected bowel segment followed by an end-to-end anastomosis (12). Anti-tuberculous therapy should be started as soon as possible with a four-drug regimen for 6 to 9 months (13).
In general, anti-tuberculous therapy for abdominal tuberculosis is similar to pulmonary TB. Duration of treatment is a matter of debate—however evidence suggests that 6 months of anti-tuberculous treatment is as good as 9 months (14-16).
High mortality is associated with tuberculous intestinal perforation, with reported figures ranging from 25% to 100% (12). This case highlights the need to consider tuberculosis as an important differential diagnosis in patients presenting with intestinal perforation particularly from endemic areas. Crohn’s disease is often an important differential, mistreatment can have significant consequences, prolonging the course of intestinal tuberculosis. Surgical intervention should be considered in complicated cases as soon as possible.
Conflicts of Interest: The authors have no conflicts of interest to declare.
Informed Consent: Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
- Lwin S, Lau Lee Jing N, Suharjono H, et al. Caecal Perforation from Primary Intestinal Tuberculosis in Pregnancy. Case Rep Gastrointest Med 2017;2017:2173724. [Crossref] [PubMed]
- WHO. Tuberculosis control. Available online: http://www.who.int/trade/distance_learning/gpgh/gpgh3/en/index4.html
- Marshall JB. Tuberculosis of the gastrointestinal tract and peritoneum. Am J Gastroenterol 1993;88:989-99. [PubMed]
- Ved Bhushan ST, Mulla MA, Kumar V. Ruptured appendix in tuberculous abdomen. Biol syst Open Access 2015;4:134.
- Muquit S, Shah M, Abayajeewa K. A case of miliary tuberculosis presenting with bowel perforation. Emerg Med J 2006;23:e62. [Crossref] [PubMed]
- Debi U, Ravisankar V, Prasad KK, et al. Abdominal tuberculosis of the gastrointestinal tract: revisited. World J Gastroenterol 2014;20:14831-40. [Crossref] [PubMed]
- Polat KY, Aydinli B, Yilmaz O, et al. Intestinal tuberculosis and secondary liver abscess. Mt Sinai J Med 2006;73:887-90. [PubMed]
- Seliger G, Pinto RS. Pneumoperitoneum Secondary to Acute Perforation of a Tuberculous Ulcer of the Small Intestine. Am J Gastroenterol 1974;62:430-4. [PubMed]
- Sharma R, Madhusudhan KS, Ahuja V. Intestinal tuberculosis versus crohn's disease: Clinical and radiological recommendations. Indian J Radiol Imaging 2016;26:161-72. [Crossref] [PubMed]
- Pulimood AB, Amarapurkar DN, Ghoshal U, et al. Differentiation of Crohn’s disease from intestinal tuberculosis in India in 2010. World J Gastroenterol 2011;17:433-43. [Crossref] [PubMed]
- Wu YF, Ho CM, Yuan CT, et al. Intestinal tuberculosis previously mistreated as Crohn’s disease and complicated with perforation: a case report and literature review. Springerplus 2015;4:326. [Crossref] [PubMed]
- Ara C, Sogutlu G, Yildiz R, et al. Spontaneous small bowel perforations due to intestinal tuberculosis should not be repaired by simple closure. J Gastrointest Surg 2005;9:514-7. [Crossref] [PubMed]
- Blumberg HM, Burman WJ, Chaisson RE, et al. American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America: treatment of tuberculosis. Am J Respir Crit Care Med 2003;167:603-62. [Crossref] [PubMed]
- Jullien S, Jain S, Ryan H, et al. Six-month therapy for abdominal tuberculosis. Cochrane Database Syst Rev 2016;11:CD012163. [PubMed]
- Makharia GK, Ghoshal UC, Ramakrishna BS, et al. Intermittent directly observed therapy for abdominal tuberculosis: a multicenter randomized controlled trial comparing 6 months versus 9 months of therapy. Clin Infect Dis 2015;61:750-7. [Crossref] [PubMed]
- Tony J, Sunilkumar K, Thomas V. Randomized controlled trial of DOTS versus conventional regime for treatment of ileocecal and colonic tuberculosis. Indian J Gastroenterol 2008;27:19-21. [PubMed]
Cite this article as: Konala VM, Adapa S, Agrawal N, Naramala S, Dhingra H, Aronow WS. Misdiagnosis of ileocecal tuberculosis—diagnostic dilemma with Crohn’s disease. AME Med J 2019;4:15.