A 26-year-old female known with Human Immunodeficiency Virus (HIV) was referred from a peripheral clinic with a 6-day history of abdominal pain and multiple, irreducible, umbilical masses. This was preceded by a 6-month history of multiple, painless swellings around the umbilicus, that were previously reduced by the patient. No associated abdominal distension, weight-loss, reflux or change in bowel habits were noted. Background history revealed a diagnosis of HIV in 2013, with subsequent Anti-retroviral (ARV) initiation soon after. The patient reported good compliance and routine follow up, with no adverse incidents/reactions associated with ARV use. Alcohol, cigarette smoking, and alternative medication use were denied. Surgical history revealed a Pfannenstiel caesarean section performed in 2012. Although living in a high endemic area of pulmonary tuberculosis (TB), no contact history was forthcoming.
On examination, the patient appeared healthy, with a normal body mass index (BMI) and no obvious HIV associated stigmata. The patient was apyrexic, blood pressure and pulse recorded were within normal parameters. Abdominal examination revealed two tender irreducible para-umbilical hernias at 9 and 12'oclock in relation to the umbilicus. A Pfannenstiel incision scar was present, however, no abdominal distension, ascites, or masses were noted. Digital rectal examination revealed soft brown stools. Relevant systemic history and examination were unremarkable.
Relevant blood chemistry analysis demonstrated renal functions and electrolytes to be within normal parameters. A raised C-Reactive protein (CRP) 137 mg/L, with a low haemoglobin (Hb) 11.2 g/dL and normal white cell count (WCC) 4.60 x 109/L was noted. The patient's absolute CD4 count was 656 cells/uL and the HIV Viral Load 691 copies/mL respectively. Pre-operative chest X-ray was unremarkable.
The patient was diagnosed with two irreducible para-umbilical hernias and was consented for an emergency hernia repair by a specialist general surgeon and medical officer. A midline incision over the hernial sac was made however due to the substantial amount of herniated omentum, the incision was converted to a midline laparotomy. Upon laparotomy, intraoperative findings included 2 separate 1 cm defects at 9 and 12 o'clock in relation to the umbilicus. The herniated contents included thickened omentum adhered to the hernial sac. Furthermore, blood-stained peritoneal fluid, extensive lymphadenopathy and liver nodules were reported. Due to the intra-operative findings the peritoneal fluid, omental tissue and hernial sac were sent for histopathology. In lieu of contaminated surgical field
hernial defects repaired without mesh.
Polymerase chain reaction (PCR) results from both peritoneal fluid and omental tissue confirmed drug-sensitive M. tuberculosis and the patient was promptly initiated on antituberculous therapy. TB culture was positive, and histopathology confirmed the presence of caseous necrosis without acid-fast bacilli (Fig. 1.4 for Microscopy). Post-operative management was unremarkable and at discharge, no issues were raised by the patient. Although concerned about the unexpected diagnosis of abdominal tuberculosis, she received extensively education and counselling with regards to the illness. Routine anti-tuberculosis therapy was initiated and follow up was prescribed at specialist TB facility. The diagnosis of abdominal TB was not anticipated pre-operatively due to the atypical presentation and absence of applicable clinical findings.