A 57-year-old HIV-negative aboriginal male was initially admitted with community-acquired pneumonia, which progressively worsened. A subsequent bronchoscopy with bronchoalveolar lavage revealed acid-fast bacilli on ziehl-neelsen staining. A subsequent CT chest demonstrated bilateral pulmonary infiltrates and cavitating lesions consistent with active pulmonary tuberculosis infection. His treatment was initiated with the standard 4-drug regimen: pyrazinamide, rifampin, ethambutol, and isoniazid (INH). Sputum mycobacterial TB culture demonstrated susceptibility to the 4-drug regimen. 
During his admission to hospital, he developed diffuse abdominal pain with peritonitis on examination. He also developed tachycardia and hypotension, and an abdominal X-ray revealed free air under the diaphragm. Arrangements were made for emergent exploratory laparotomy in the operating room. Intraoperatively a single contiguous inflammatory mass was found in the left upper quadrant, which revealed a gangrenous necrotic splenic colon. A left hemicolectomy was preformed. This revealed a region of necrotic-appearing pancreatic tissue which was likely associated with the necrosis of the adjacent splenic colon. Further exploration of this inflammatory mass demonstrated particulate matter and peritoneal fluid and a large perforation in the posterior wall of the stomach, which was the initial insult. Peritoneal fluid mixed with enteric contents from the gastric perforation was sent for culture and was positive for mycobacterium tuberculosis. An intraoperative gastroscopy was preformed which identified an ulcer approximately 5-10 cm from the gastroesophageal junction. The patient hemodynamic status worsened in the operating room despite ongoing resuscitation and significant quantities of norepinephrine intravenously were needed. It was decided to stabilize the patient with a damage control laparotomy and take the patient to the intensive care unit rather than perform a definitive repair of the gastric perforation because of the severe hemodynamic instability. Drains surrounding the ulcer were placed and the skin closed. Plans were made to return to the operating room in 24 hours for definitive treatment if the patient's hemodynamic status improved. 
The patient's condition stabilized in the intensive care unit, and he was brought to the operation room the following day. Multiple biopsies of the large 3 cm gastric ulcer were taken. The patient was deemed to be unable to tolerate a total gastrectomy at this time, and unfortunately wedge resection of the stomach was not possible due to the position and size of the ulcer. Thus, the ulcer was repaired with primary closure, and creation of a feeding jejunostomy was completed. The patient was returned to the intensive care unit. Biopsies from the gastric ulcer revealed no malignancy but did demonstrate fungal elements (Candida albicans) indicative of secondary infection. Also, focal reactive changes in the surface epithelium suggested a reactive process. No granulomata or giant cells were identified. Biopsies were also negative for Helicobacter pylori. The patient did not receive nonsteroidal anti-inflammatory medications and was on Pantoprazole to prevent stress-related ulceration. The peritoneal fluid cultures collected during operation for the gastric perforation demonstrated mycobacterium tuberculosis and fungal elements. Gastric tissue sent intraoperatively for culture was positive for mycobacterium TB, which led to the presumptive diagnosis of gastric perforation, associated with TB. Pathologic examination of the resected left colon revealed an area of necrosis, but no perforation. Microscopic examination demonstrated numerous caseating granulomas with multinucleated giant cells, demonstrating mycobacterial colitis. 
The patient remained in the intensive care unit, and a small-bowel follow-through with contrast revealed no extravasation of contrast. The TB-associated gastric perforation was adequately repaired. Postoperatively the patient was continued on INH 300 mg intramuscularly and rifampin 600 mg intravenously daily according to sensitivities from peritoneal fluid cultures. Imipenum, levofloxacin, and fluconazole were also continued according to culture results. 
The patient's pulmonary tuberculosis persisted over the subsequent weeks despite appropriate antituberculosis treatment. Deteriorating lung function was likely a combination of previous smoking damage, edema secondary to recent aggressive fluid resuscitation, and persistent pneumothorax. Eventually multiorgan failure ensued, and life support was discontinued following discussion with the family.