A 22-year-old male patient from Agarfa district, southeast Ethiopia, presented to Goba Referral Hospital with complaints of severe abdominal cramp, periumbilical pain which shifted to the right lower quadrant of the abdomen for 30-hours duration, and 2 episodes of nonbilious vomiting as well as high-grade fever. He had no past history or family history of TB. He had no cough, sweating, and weight loss, which suggested the evidence of pulmonary TB. Similarly, the patient had no history of subacute intestinal obstruction in the past, had no diarrhea and constipation, and had no urgency or pain during urination.
During admission, the patient was acutely sick looking and vital signs were as follows: blood pressure 90/60, pulse rate 104 beat/min, respiratory rate 26 breath/min, and body temperature 38.3 C. Examination of respiratory and cardiovascular systems was essentially normal. Local examination of the abdomen revealed that abdomen moved with respiration, there was direct tenderness below the umbilicus bilaterally, and rebound tenderness over the right lower quadrant of the abdomen. Laboratory studies on blood revealed hemoglobin to be 12 g/dL; white blood cell count 15,800/microL, neutrophil 88%, and HIV serology result negative.
With the clinical diagnosis of pelvic peritonitis secondary to perforated acute appendicitis, the patient was taken up for surgery. The peritoneal cavity was opened through the lower midline incision and 30 mL of thick offensive pus in the right lower abdomen and perforated appendix at the base was found. Then, the pus was drained, appendectomy and abdominal lavage were performed, and the abdominal wall was closed inlayer.
From the resected appendix, excisional biopsy was sent for histopathology, and the histological picture revealed granulomatous caseification lesion in the body of the appendix, which is diagnostic for extrapulmonary TB (Figure 1). However, the intra-abdominal fluid, bowel, and omentum did not show any granulomatous lesions and no mesenteric lymphadenopathy. Based on these findings, the final diagnosis of perforated tuberculous appendicitis was made. After surgery, the patient took 1 g of ceftriaxone intravenously (IV) twice per day for 7 days and 500 mg of metronidazole IV 3 times per day for 7 days, and then started anti-TB treatment on the fourth postoperative day and continued it for 6 months. During the follow-up visits, the abdominal signs and symptoms were resolved and the patient had marked clinical recovery to date.