A 27-year-old patient from the Republic of Congo presented to our emergency department with severe cramp abdominal pain, vomiting and diarrhea that lasted for 3 days, followed by respite of bowel movements. The patient's history included only coughing for the past month. Clinical examination revealed abnormal respiratory sounds on the right semi-thoracic area and cough. Mild abdominal distention was noticed on abdominal inspection. No surgical wounds were noticed. On palpitation, diffuse abdominal tenderness was recorded with diffuse guarding and rebound tenderness. Systemic symptoms and signs showed dehydration manifesting as tachycardia and dry mucous membranes. The patient's temperature was normal and the patient did not mention fever in the last days. Laboratory blood tests were obtained demonstrating the following abnormal test results: C-reactive protein (CRP):11.2 mg/dL, erythrocyte sedimentation rate (ESR):46, normal white blood cell count (WBC) but with 90.6% neutrophil count (NEU) and 4.22% lymphocyte count (LYM), hematocrit/hemoglobin (Hct/Hgb):35.3/11.5, K+:5.2 and lactate dehydrogenase (LDH):305. A urinary catheter was placed and abdominal and chest X-rays were performed. On chest X-ray, consolidation of the upper zone of the right lung was diagnosed combined with cavities (Figure 1). On abdominal X-ray, in an upright position, typical small bowel obstruction signs were observed with multiple air-fluid levels and distended loops of the small bowel. A nasogastric tube was placed in the emergency department to drain the jejunum content. Per os feeding stopped and intravenous (IV) hydration and empirical antibiotic treatment were set. Contrast-enhanced chest and abdominal computed tomography (CT) was performed and revealed one large cavitation lesion and two smaller cavitation lesions in contact with the former on the upper lobe of the right lung with satellite consolidation lesions compatible with TB (Figure 2). Small bowel obstruction signs were confirmed with distended small bowel loops and diffuse multiple air-fluid levels. In addition, a mass possibly of lymphatic constitution with a proximately 3 cm diameter was demonstrated on the mesentery (Figure 3). Due to high clinical suspicion for specific pulmonary infection, a Mantoux test was performed while the patient's sputum was collected for smear microscopy. As HIV is a prognostic factor for extrapulmonary TB, a full virological blood test was sent for hepatitis B virus (HBV), hepatitis C virus (HCV) and HIV which came out negative.
The patient was isolated in a single bed chamber and safety measures were taken by the personnel of the surgical ward. A sputum culture was sent to another hospital's lab due to lack of potentiality in ours. Within 24 h from the patient's admission, he developed clinical deterioration and rise in the inflammation measurements despite the conservative treatment. The nasogastric tube had drained 1.5 L of jejunum content. The abdominal tenderness intensified. The patient was led to the operating room where diagnostic laparotomy was performed. The small bowel was found dilated from the Treitz ligament until the middle of the jejunum where a small bowel loop was attached to the mesenteric mass, causing a small bowel volvulus. The loop was detached carefully with no need of enterotomy. The small bowel was recovered to its proper rotation. The mildly ischemic small bowel involved in the volvulus regained its normal complexion after 10 min in warm saline. The mass of the mesentery resembled a caseating necrosis of mesenteric lymph nodes (Figure 4). Material for biopsy and microbiological analysis was obtained from the mass (Figure 5). No other lesions were found although the whole peritoneal cavity was inspected thoroughly.
The result from Mantoux test suggested TB infection and antitubercular therapy with isoniazid (INH), rifampicin (RIF), pyrazinamide (PZA) and ethambutol (EMB) commenced immediately. The sputum smear microscopy was also found positive for mycobacteria infection. The patient was transferred to another hospital due to lack of Pneumology ward in our hospital. He was discharged from the other hospital in 2 weeks, with antitubercular therapy for 6 months and normal bowel movement. The culture results of the sputum came positive for M. tuberculosis after a month. Lowenstein-Jensen medium was used for the culture and the results were sent to us from the other hospital's lab. The biopsy of the mass revealed granulomatous inflammation with central necrosis and infiltration with Langerhans giant cells.