A 30-year-old man presented with fever for seven days and generalized abdominal pain for one day. On examination, he was febrile, and had signs of peritonitis. X-ray examination of the chest showed free air under both the domes of the diaphragm. He was taken up for exploratory laparotomy after adequate resuscitation.
Laparotomy was performed by a midline incision and revealed purulent peritoneal fluid, mainly in the pelvis. The terminal ileum had a small perforation along the anti- mesenteric border, about one foot proximal to the ileocaecal junction. There were no other significant findings on
laparotomy. After thorough peritoneal lavage, the ileal perforation was freshened along the margins and closed primarily using interrupted sutures. The edges of the perforation were sent for histopathological examination.
The post-operative period was uneventful. The histopathological report of the perforation margins that were sent intra-operatively revealed caseating epithelioid cell granulomas with Langhans' giant cells and a dense mixed inflammatory cell infiltrate within the mucosa and submucosa (Figure 1). On receiving this report, the patient was started on anti-tubercular treatment and remained well on follow up. Efforts were made to detect a primary focus of tuberculosis, but were unsuccessful.