Patient was 31-year-old female and 15 weeks into her second pregnancy, when she commenced her antenatal care. Her Body Mass Index (BMI) at booking was only 15.53 kg/m2, with a booking weight of 36 kg. She had been experiencing intermittent, dull, right-sided abdominal pain that was associated with diarrhea, for 3 months and in this span of time, her weight had decreased markedly by 20 kg. Her primary healthcare provider at the district maternal and child health clinic subsequently treated her for acute gastroenteritis twice in the following weeks, but she experienced no improvement in her symptoms.
At 29 weeks and 6 days of gestation, she was admitted to a district hospital, complaining of acute right-sided abdominal pain that radiated to the right lumbar region. She also complained of dyspnoea and near-syncopal episodes, as well as a reduced effort tolerance the preceding week. She had been compliant to her oral hematinics therapy and denied any history of dysuria, haematuria, haematemesis, or haematochezia. A recent peripheral blood film revealed normochromic, normocytic anaemia, and serum ferritin was normal.
On physical examination, she appeared pale and she was febrile. On palpation, her fundal height corresponded to 30 weeks of gestation. Tenderness and guarding were elicited at the right lumbar region. However, she did not exhibit any signs of preterm contraction and renal punch was negative. Transabdominal scan revealed a singleton fetus, with parameters corresponding to her gestation.
She had hemoglobin of 7.4 g/dl and a white cell count of 15.87 x 109. Broad-spectrum antibiotic was commenced. She was also transfused with 1 pint of packed cells and she was referred to both the obstetrics and surgical teams of a tertiary hospital.
An urgent ultrasound abdomen was arranged, which revealed a heterogeneous collection in the subhepatic region and multiple enlarged mesenteric lymph nodes. A diagnosis of likely perforated appendicitis was made and she underwent an emergency laparotomy.
The intraoperative finding was that of a perforated caecal tumour. The tumour was firm and hard with irregular margins and surface. There was evidence of multiple enlarged mesenteric lymph nodes. A right hemicolectomy was performed. Appendix was normal. She received 3 pints of packed cells transfusion and 4 units of fresh frozen plasma. Postoperatively, she was transferred to the Intensive Care Unit (ICU), where she recovered well and was transferred to the general ward after 2 days. 7 days after surgery, she developed spontaneous preterm contractions and delivered a baby boy of 1.2 kg, at 31 weeks of gestation with Apgar score of 7 in one minutes and 9 in five minutes. The baby was given Bacillus Calmette-Guerin (BCG) vaccination immediately after delivery as routine procedure.
The histopathological examination showed caecal tuberculosis. She was referred to the Infectious Disease (ID) team and started on anti-TB medication. She denied any pulmonary TB contact. Her pulmonary TB work-up including chest X-ray, sputum acid fast bacilli (AFB), and Mantoux test was negative. Screening tests for HIV were negative.
She developed surgical wound breakdown at 14 days postoperatively and secondary suturing was performed. Her baby was initially admitted to the Neonatal Intensive Care Unit (NICU) for extreme prematurity but was subsequently discharged well with good catch-up growth and a negative Tuberculin skin text/Mantoux test. At a subsequent follow-up upon completion of 6 months of anti-TB medications, she had put back most of her weight and her baby was assessed to have achieved age-appropriate developmental milestones.