Free Perforation of Ileal Tubercular Ulcer- A Case Report and Literature Review

Abstract

Primary intestinal tuberculosis is unusual in North American, European and Caribbean countries. Its diagnosis is often surprising and differentiation from inflammatory bowel diseases is difficult. Intestinal perforation is an uncommon but potentially fatal complication of intestinal tuberculosis. There is no reported case of ileal tubercular ulcer perforation from the Caribbean. We present a 59 year old HIV negative patient presented with peritonitis with solitary perforation of terminal ileum. Histology revealed presence of Langerhan's cell with caseating granulomatous inflammation and culture grew acid fast bacilli. A subsequent Manteaux test was strongly positive. There was no radiological evidence of pulmonary tuberculosis. Patient was started on anti-tubercular therapy and it is now over one year, the symptoms have not recurs back again. Keywords: Intestinal tuberculosis; Perforation Case ReportA 59 year old known diabetic, hypertensive male presented with 2/7 history of sudden peri-umbilical pain and vomiting. History revealed that the pain was of sudden onset, peri-umbilical, and aggravated by movement and relieved by lying flat. He had no fever, shortness of breath or night sweats. He denied any history of recent travel or contact with anyone infected with tuberculosis. On examination, he was ill looking, moderately dehydrated, tachycardic (pulse of 120 beat per minute) but his blood pressure and body temperature were within normal range. His abdomen was grossly distended with mild diffuse tenderness, mild guarding but no rebound tenderness. There were sluggish bowel sounds. Digital rectal examination was normal. The white blood cell count was elevated (15.5 × 10 3 /ul) and all other labs within normal limit. Erect chest X-rayrevealed no free air however, a CT scan of abdomen and pelvis with intra-venous contrast revealed free air and free fluid in abdomen. After resuscitation patient was prepared for exploratory laparotomy which revealed a solitary 0.5 to 0.8 cm transverse perforation in the anti-mesenteric border of terminal ileum (Figure 1). There was no evidence malignancy or inflammatory bowel diseases (IBD). There was 200 mls of pus-like fluid in peritoneal cavity with inter-loop abscesses with pus flakes and exudates throughout. Segmental resection and primary anastomosis was performed. Patient had a good post op recovery. His ELISA Test for HIV was negative and serum ESR level was elevated. The chest xray showed no radiological evidence of pulmonary tuberculosis. The tuberculin skin test (Manteaux) was done on post-op day #5. It was strongly positive. Microscopic examination of the ileum revealed trans-mural perforation with presence of Langerhan's cell with caseating granulomatous inflammation consistent with small bowel tuberculosis. Acid fast bacilli stain confirmed the presence of Mycobacterium. The patient was started on anti-tubercular therapy (isoniazid, ethambutol, rifampicin). At one year follow up, he remains symptom free (Figure 2a and 2b).

Coinfection of Typhoid Fever With Tuberculosis: A Challenge to Surgical Management

“…The ulcerative type complicates by tubercular perforation, especially in immunocompromised patients. The perforation is solitary in 90% of the cases [1]. In our patient, there was a single perforation involving the terminal ileum.…”

“…It is more common in immunodeficient patients, where the ulcerative type of intestinal tuberculosis predominates. Patients with tubercular ileal perforations have high mortality of up to 30% in various studies [1]. Various factors play a role in the outcome of these patients, such as age and comorbid illness, though the lag period (the advent of symptoms to time of admission to hospital) correlated directly to the mortality in these patients [2].…”