A 20-year-old man presented to the ED of Hospital Regional Lambayeque on July 18, 2020. He denied any previous disease, but had been incarcerated for almost two years before admission. He presented for six months before admission with fever, productive cough, abdominal pain, nausea and weight loss. One week before admission, he initiated with colicky abdominal pain, nausea, vomiting, and anorexia for three days. One day before admission, abdominal pain turned into intense and diffuse, and fever, persistent vomiting, and absence of passage of flatus and feces were added.
 Physical examination at admission. The patient was emaciated and mildly dehydrated; blood pressure: 100/60 mmHg, respiratory rate: 20 breathes per minute, heart rate 136 beats per minute, temperature: 37.9  C, and oxygen saturation: 95% at room air. Absent breathe sounds and dullness in both lung bases. Tachycardia. Distended and painful abdomen, bowel sounds diminished in frequency, McBurney's and Blumberg's signs were positive. Awake and oriented patient, no focal deficit, no meningeal signs.
 Evolution. After admission, acute abdomen due to appendicitis was diagnosed. Symptomatic treatment was initiated and preoperative exams and plain chest and abdominal x-ray were ordered, which showed significant bilateral pleural effusion and ascites. Three hours after admission, the patient was transferred to the operating room. During exploratory laparotomy "multiple cerebroid nodules scattered through parietal and visceral peritoneum, small bowel, colon and epiploon; and plenty of ascitic fluid were observed". The postoperative diagnosis was "carcinomatosis". After surgery, he was transferred to the ICU, and continued treatment with saline, noradrenaline, imipenem, metronidazole, sedation with midazolam, analgesia with fentanyl, and ventilatory support. Based on clinical data, risk factors, intraoperative findings, and chest x ray imaging, TB was suspected. Then, stains and cultures of multiple samples for Mycobacterium tuberculosis (MTB) and a contrast-enhanced tomographic scan of thorax, abdomen and pelvis were ordered ( Figure 5). Three days after surgery thoracocentesis was performed. Five days after surgery RT-PCR resulted positive for MTB in pleural fluid and quadruple anti-tuberculous treatment for MTB was initiated (the same scheme as Case 1). Ten days after surgery histopathology of epiploon was obtained, showing extensive caseous necrosis with granulomas and Langhans multinucleated giant cells. The patient died seven days after initiation of anti-tuberculous treatment due to refractory septic shock ( Figure 6). A serial ZN smear for AFB in bronchial secretion, blood cultures, and urine culture, were negative. Serologies for HIV, HTLV-1, hepatitis B and C, and RPR/VDRL, were also negative.
Contrast-enhanced computed tomography showing massive pleural effusion (red stars) with consolidation of both lungs (yellow arrows) (A and B).