A 19 year-old-spastic man arrived at our emergency department with abdominal distension, vomiting, and fatigue for 3 days. He also had a low-grade fever for 2 weeks. Since birth, he has been diagnosed with CP and has been living in a disabled children's center as a disabled person. His abdominal pain could not be assessed due to his mental status. Physical examination confirmed low-grade fever and showed signs of dehydration and enlarged cervical lymph nodes. There was a presence of abdominal distension with decreased bowel sound and mildly generalized tenderness. Laboratory tests revealed a total white blood cell count of 17,000 per microliter and a neutrophil count of 90%. Test for human immunodeficiency virus was negative. Abdominal radiography showed ileus with dilatation of both small and large bowel (Fig. 1). Due to suspicion of infection, computed tomography (CT) scan was obtained showing a diffusely thickened bowel wall, generalized small and large bowel dilatation, and ascites at the cul-de-sac (Fig. 2). There was no point of obstruction. The appendix could not be outlined and no pneumoperitoneum was found.
Initially, intravenous 1 g ceftriaxone and 500 mg metronidazole were started. Following a day of observation, there were sudden changes of abdominal signs. His abdominal signs got worse revealing increased distension, generalized involuntary guarding and marked tenderness at the right side of the abdomen. As a result, a diagnosis of perforated appendicitis was made, as it is commonly founded in this group of patients with peritonitis. Consequently, the patient was transferred to operating room. At the theatre, there was a presence of small and large bowel dilatation without a point of obstruction or perforation. Interestingly, there were multiple small nodules at the serosa of small and large intestine, mesentery, parietal peritoneum, and cul-de-sac (Fig. 3). Clear yellowish ascites about 500 mL at cul-de-sac were obtained. Only the peritoneal tissue biopsy was performed. No acid-fast organism was seen in ascites. The pathologic report unfolded caseous granuloma with a positive 1+ Ziehl-Neelsen staining and a positive PCR for tuberculous complex. The tissue culture result was positive for Mycobacterium TB. Therefore, the sputum was sent for Ziehl-Neelsen stain and found positive 1+. Post-operatively, abdominal distension and bowel movement had improved after taking anti-TB medication. Unfortunately, however, the patient passed away on post-operative day 11 due to Acinetobacter baumannii hospital acquired pneumonia.