We present a 23 year old female from Micronesia who presented as a transfer from Bowling Green, KY facility due to sepsis and abdominal pain. The patient had a previous admission for abdominal pain one year ago. A CT abdomen performed at that time was significant for what appeared to be widespread carcinomatosis. A biopsy was performed and pathology reports were significant for non-caseating granulomas, rather than occult malignancy. AFB and fungal stains were negative. Patient failed to follow up after this evaluation.
The patient then presented to Bowling Greene with a significant fever and recurring abdominal pain. A CT abdomen/pelvis was notable for a R. lower lobe infiltrate, left bibasilar atelectasis, a small pleural effusion, and lymphadenopathy in the mediastinum, abdomen, retroperitoneum, and pelvis. The patient was transferred to our facility for higher level of care. On presentation, labs were significant for a lactic acidosis and leukocytosis, with the patient requiring vasopressors. The patient was started on broad-spectrum antibiotics for the treatment of acute sepsis. ID and general surgery were consulted. General surgery recommended medical management only. Fungal, viral, and sarcoidosis work ups were started, per ID. The patient was placed on prophylactic steroids and a repeat Quantiferon was ordered. Both fungal and viral testing returned negative while the patient's quantiferon gold test returned positive. A CT chest with contrast was ordered for further work up of adenopathy with concern for TB after the positive quantiferon gold. Imaging was significant for multiple, small mediastinal lymph nodes and diffuse tree-in-bud findings throughout the lung parenchyma. Pulmonology was consulted for a bronchoscopy with EUS-guided biopsy. Pathology revealed necrotizing granuloma, consistent with tuberculosis. AFB PCR was positive for Mycobacterium tuberculosis complex. Antibiotics were altered to begin the RIPE regimen. Due to the patient's area of origin, (Micronesia is high in TB endemicity), positive IGRA, CT findings of tree-in-bud opacities with lymphadenopathy and diffuse granulomatous inflammation, and a positive PCR the patient was diagnosed with abdominal TB. The patient was discharged on long-term antitubercular therapy.