A 31-year old Sub-Saharan African woman known with HIV infection for the past 3 years and compliant to antiretroviral treatment and cotrimoxazole prophylaxis presented to our emergency unit with a 2-month history of slowly progressive abdominal distention, drenching night sweat and generalized fatigue without fever. She had regular bowel movement, no abdominal pain and no weight loss. She had two prior hospital visits for the same symptoms during which she received medical care but had no favorable outcome. On physical examination, she had a temperature of 37.4 C, blood pressure of 100/62 mmHg, heart rate of 93 beats/min and respiratory rate of 19 cycles/min. She was mildly icteric. Abdominal exam was remarkable for distention with a positive fluid thrill and shifting dullness, mild right hypochondriac tenderness without rebound tenderness and no guarding. Her chest exam and cardiovascular as well as the rest of the examination was unremarkable. Initial laboratory findings included a normal white cell count level of 8900 cells/mm3 (Normal Value (Nv): 4000-10000cells/mm3). Haemoglobin (HB) was 10g/dl (Nv 12-15g/dl). CD4+ count of 155 cells/microL, elevated aspartate amino transferase (AST) 97 IU/L (Nv; < 40U/L) and alanine amino transferase (ALT) 83IU/L (Nv: < 50IU/L). HBsAg and Anti-HCV tests were negative. Serum Creatinine was 1.2mg/dl (Nv: 0.6-1.2mg/dl). Abdominal ultrasound revealed massive ascites and a normal liver architecture. Chest X-ray film did not show any lung field changes and sputum analysis for acid fast bacilli were negative. A presumptive diagnosis of peritoneal TB based on a history of HIV infection, night sweats, generalised fatigue and ascites was made with a differential diagnosis of hepatitis based on elevated liver transaminases, jaundice and right hypochondriac tenderness. Initial management constituted of a diagnostic and therapeutic paracentesis with drainage of 2 liters of straw- coloured fluid. She was placed on albumin infusion and Amoxicillin 500mg TID empirically prior to ascitic tap. Analysis of peritoneal ascitic fluid revealed a white cell count of 30 cells/microL with lymphocytic predominance. Ziehl-Neelsen staining of the centrifuged aspirate was negative for acid fast bacilli. Biochemistry analysis of the fluid was not done due to a lack of reagents in our center. A PPD skin test done during admission read 14mm induration in favour of TB infection.
The plan of management for TB was discussed with the patient, but she declined treatment. The patient requested to be discharged from the hospital, despite advice from the treating physicians not to. She signed to leave against medical advice. Two days after discharge, she was readmitted in the hospital for generalized abdominal pain with rebound tenderness, spontaneous vomiting, low-grade fever of 38.8 C, blood pressure (BP) of 70/40 mmHg, weak thready pulse at 115 beats/min and cold clammy skin. Serum Creatinine was 3.5mg/dl, BUN of 78mg/dl (NV: 7-18mg/dl). A repeat white cell count showed leukocytosis of 15,700 cells/mm3 with neutrophil predominance of 87%. She had haemoglobin of 8g/dl. A presumptive diagnosis of spontaneous bacterial peritonitis was made. Initial management included 2 liters of intravenous normal saline 0.9% infusion, metronidazole 500mg, ampicillin 1g administered intravenously and transfusion of 2 units of cross- matched O Rhesus positive whole blood pre-operatively.Emergency laparotomy via a midline incision revealed about 4 liters of purulent peritoneal fluid, multiple enlarged peritoneal nodes measuring about 0.5 to 2mm thick, caseous necrosis of the omentum, and small bowel wall with three distinct sites of jejunal perforations (Figure 1). Resection of the necrotic jejunal segment with a primary end-to-end anastomosis was done. The intraoperative period was complicated by a cardiac arrest which was managed with cardiopulmonary resuscitation (CPR), clamping of the abdominal aorta along with administration of IV adrenaline and oxygen support. A sample of the purulent material was sent for laboratory analysis which showed a high load of acid fast bacilli on Ziehl-Neelsen staining. During the post-operative period, she was placed on parenteral nutrition, intravenous fluids, metronidazole 500mg 8hourly and Ampicillin 1g 6 hourly via the intravenous route. She was restricted from enteral feeding except for per os administration of anti-tuberculosis medication for the first 3 postoperative days. She had a favourable evolution with return of bowel movements and resumed oral feeding on post-operative day 4 against medical advice. On post-operative day 8, the patient developed increasing abdominal pains, associated with constipation and mild abdominal distention. Enteral feeding was again restricted. By post-operative day 10, her bowel sounds were absent and abdominal exam was remarkable for rebound tenderness and guarding. A repeat emergency laparotomy revealed a breakdown of her anastomosis. A repair was successfully done. Parenteral nutrition and antibiotics were continued. Two days after her second laparotomy, the patient had a cardiopulmonary arrest. Resuscitation efforts were unsuccessful.