A 36-year-old woman presented in the emergency room with a history of central abdominal pain for 3 days and complaints of abdominal fullness and vomiting for the last 2 days associated with non-passage of flatus and feces. She also gave a history of evening rise in temperature and non-productive cough for the past 3 months. She was receiving antitubercular treatment for pulmonary tuberculosis, which was diagnosed 3 months back. Upon examination, she was found to be in distributive shock with mild pallor and a body mass index (BMI) of 17.8 kg/m2. The abdomen was distended, tender with muscle guard, and peristaltic sounds were absent. A contrast-enhanced CT (CECT) scan of the whole abdomen showed pneumo-peritoneum with ascites and dilated bowel loops. She was taken up for an emergency exploratory laparotomy, and during surgery 3 l of foul-smelling enteric fluid was drained and two perforations were found in the terminal ileum 60 cm proximal to the ileocecal junction. The 5 cm segment bearing the perforations was resected, and a double-barrel ileostomy was fashioned. Postoperatively, her stoma started functioning within 48 h, she was allowed a soft diet by the fifth day and was advised on restarting the ATD. She developed a deep surgical site infection (SSI) on the seventh day, which was managed by antibiotics and regular dressings.
In the second week, she started developing recurrent bilious vomiting and a low-grade fever for which she was resuscitated with intravenous fluids, proton pump inhibitors, and prokinetics. She developed bilateral moderate pulmonary effusion and jaundice (total bilirubin 3.4 mg/dl), for which multiple percutaneous pleural taps were done, and she was started on second-line ATD. However, her bilious vomiting persisted even after stopping the first-line ATD. A gastroduodenoscopic examination revealed edematous but normal duodenal mucosa and a progressive luminal compromise until the third part (D3), beyond which the scope could not be negotiated suggestive of extrinsic compression. An attempt to negotiate a nasojejunal feeding tube beyond the D3 failed, and she was started on total parenteral nutrition. A CECT whole abdomen showed a distention of the proximal duodenum with air-fluid level and a transition point at the distal D3. There was no abnormal mural thickening, and the D4 and jejunal loops were found collapsed. The aorto-mesenteric angle was 16.5  (Figure 1) and the aorto-mesenteric distance was 6.38 mm (Figure 2), suggesting SMA syndrome. A trial of non-operative management was started due to her early postoperative status. She was nursed in the left lateral position with continuous nasogastric aspiration and parenteral nutritional support.  
In the third postoperative week, she started developing features of septicemia, and hypotension. She was placed on vasopressor support for persistent hypotension and intravenous injection of Meropenem and Metronidazole for septicemia to which she did not respond adequately. Histopathological report of the resected intestinal segment showed areas of inflammatory infiltrates with fungal colonies, and the fungal culture was positive for Candida spp., which was treated with systemic antifungal agents. By the end of the third week, due to the subsidence of mucosal edema, a nasojejunal feeding (NJ) tube could be placed endoscopically beyond the narrowed segment, and tube feeding was started. Gradually over the next week, she responded to treatment, her vomiting subsided, she became afebrile, and started tolerating a liquid diet. After the fifth week, she started tolerating a normal diet by mouth and was discharged. She registered an increase in body weight by almost 3 kg at the end of the second month of follow-up.