A 4 years old girl, was brought by the parents to the emergency unit of the "Hopital Saint Jean de Dieu" in Tanguieta, north of Benin at lunchtime. The parents referred abdominal pain and tenderness, fever, vomiting and anorexia since 48 hours, treated with local herbs infuse. The patient was agitated but confused, Glasgow Coma Scale 12 (E3, V4, M5), arterial blood pressure 75/50 mm Hg, heart rate of 135 beats/min, body temperature 38.9 C and respiratory rate of 22 cycles/min. Abdominal test revealed a remarkable symmetrical distention, with bulging flanks, positive fluid thrill. Crying on every attempt of abdominal palpation, which revealed tenderness and pain on all the abdomen. The percussion of the abdomen was dull on all the quadrants, no peristalsis. The patient was tachypnoic with no particular findings on the thorax examination. Abdominal ultrasound exam revealed diffuse and massive ascites of mixed liquid/solid content. Laboratory findings included a normal cell counts: white blood cells 1300 cells/mm3 (normal value 5000-10000 cells/mm3), hemoglobin 7.7 g/dl (normal value 12-15 g/dl), sodium 136 mEq/L (normal value 135-145 mEq/L), potassium 5.6 mEq/L (normal value 3.5-5.1 mEq/L), ESR 44 mm/h (normal value 3-13 mm/h). Obtained the consent from the parents, nasogastric and vescical catheters were positioned, and the patient was brought to the operatory room, candidate to emergency explorative laparotomy. Under general endotracheal anesthesia with halothane, the emergency laparotomy with midline incision, revealed 4 liters of purulent/alimentary free peritoneal fluid, massive retroperitoneal lymphomegaly, multiple caseous nodes diffuse on the peritoneum and the bowel, measuring about 0.5 to 4 mm of diameter, and some bigger nodules (up to 1.5 cm) covered by caseous mucus with the suspect aspect of miliary peritoneal tuberculosis. On the middle jejunum 3 major perforations on the antimesenteric side of the bowel were identified, surrounded by hyperemic and inflamated tissue with the typical aspect of typhoid bowel perforation.
Some intestinal hyperemic intestinal typhoid lesions were also present, but not perforated yet. The surgical findings are shown in Figure 1, Figure 2. The surgical procedure included a lavage of the abdominal cavity and exploration of all the bowel for small lesion or perforations. A primary closure of the 3 perforations was performed with a separate stitch technique always used in the hospital: a single-layer suture with 6 large vicryl 2/0 "U" stitches, through the seromuscular layer at 1cm from the perforation, to use the healthy tissue to close the perforation in a part of the bowel where there was less inflammatory involvement, with introflection of the perforation itself. A sample of the purulent material was taken for analysis, together with 2 peritoneal nodules. Considering the severity of the abdominal contamination, a delayed primary closure was planned, 3 drains were placed and a laparostomy was done fixing a grease gauze to the open aponeurosis with a continuous non-absorbable suture covered with sterile sponges. The samples sent for laboratory analysis showed a high load of acid fast bacilli on Ziehl-Neelsen staining and positive serology for Salmonella tiphy bacillus. The patient was very unstable throughout all the procedure, requiring correction of fluid and electrolyte imbalance, and one blood transfusion. A combined therapy of ciprofloxacine and metronidazole was administered intravenously ad the end of the surgical procedure for the treatment of the typhoid fever clearly recognized by the experienced local surgeon. A specifical treatment for the miliary peritoneal tuberculosis was not started due to the not certain origin of the peritoneal lesions. The general condition of the patient got worse hour by hour with a progressive septic shock and multi-organ failure. The young girl died 18 hours after the surgical procedure.