A 32-year-old man presented to the Emergency Department (ED) of Hospital Regional Lambayeque in Peru on July 21, 2019. He had been diagnosed with diabetes mellitus (type 2) two years before, but he did not follow treatment because of financial reasons. He denied risky sexual behavior, smoking, alcoholism, or any previous infectious disease. Furthermore, he denied weight loss, cough, hemoptysis, sweating, diarrhea or constipation. Thirty days before admission, he reported mild colicky hypogastric pain, without irradiation. One week before admission, abdominal pain turned to severe, diffuse, and persistent; and anorexia, general malaise, and premature abdominal fullness after meals were added. Three days before admission, fever and vomiting started.
At admission, remarkable basic hematology and biochemistry were leukocytosis (15 200/muL), lymphopenia (608/muL), hypoalbuminemia (2.9 g/dL), and a glycated hemoglobin of 6.8 mg/dL. Serologies for human immunodeficiency virus (HIV), human T-lymphotropic virus type 1 (HTLV-1), hepatitis B and C, and rapid plasma reagin/Venereal Disease Research Laboratory (RPR/VDRL), were negative. A chest x-ray (CxR) was normal. An abdominal ultrasound showed free fluid (200 ml) in the pelvic cavity associated with inflammatory signs of mesenteric fat in the right iliac fossa. Acute appendicitis was diagnosed and laparotomy was scheduled. The surgical report described: "multiple and widespread adhesions, linitis plastica, carcinomatosis, hard tumors (0.3-0.5 cm) in the peritoneum, short bowels, and cecum, and multiple abscess in both iliac fossae with purulent and foul-smelling secretion" . 
 Evolution. One hour after surgery, because of clinical signs of hemodynamic shock, the patient was transferred to the intensive care unit (ICU). At ICU admission the patient was febrile (38.5 C), with hypotension (arterial blood pressure 70/30 mmHg), tachycardia (116 beats per minute), tachypnea (26 breathes per minute) without hypoxia (peripheric saturation 96% in ambient-air). Severe dehydration with cold and mottled skin with prolonged capillary refill time, with sleepiness but respondent to verbal stimulus; the abdomen was distended and painful, with reduced intestinal peristalsis, and the wound (8 cm in length) of the recent surgery was macroscopically in order and percutaneous drainages in both iliac fossa were in place showing serohematic secretion. A broad-spectrum antibiotic therapy (meropenem and metronidazole) was started, together with supportive treatment including vasopressors (noradrenaline) and fluid replacement. After a week of the above-mentioned treatment, the clinical condition of the patient was improved and at the seventh day after the surgery, the patient was transferred from the ICU to another hospital division. Then, the result of the histopathological exams of samples collected during surgery showed: "chronic granulomatous inflammation, granulomas, extensive caseous necrosis and Langhans giant multinucleated cells; Ziehl-Neelsen (ZN) stain for Acid Fast Bacilli (AFB) negative", and a diagnosis of abdominal TB was made ( Figures 1- 3). Based on this result quadruple anti-tuberculous treatment (isoniazid 5 mg/kg, rifampicin 10 mg/kg, ethambutol 20 mg/kg, pyrazinamide 25 mg/kg) was initiated in concordance with Peruvian and international guidelines.  ,   Subsequently, the diagnosis was confirmed by a polymerase-chain reaction (PCR) for Mycobacterium tuberculosis in peritoneal fluid . The tuberculin skin test (Mantoux or PPD test) was negative. Serial ZN smears for AFB in urine, sputum, secretion of both pelvic drains, were negative; adenosine deaminase test in peritoneal fluid 292.7 U/L (reference value < 40 U/L). Blood cultures, and cultures for common pathogens, fungi, and M. tuberculosis in urine and peritoneal fluid were negative. Before discharge, the patient was evaluated by an oncologist who suggested some other exams: serum tumor markers (CEA, CA 125, AFP, CA19.9, beta-HCG), esophagogastroduodenoscopy, and colonoscopy with ileoscopy, all of which were within normal ranges. In addition, contrast-enhanced chest-abdomen-pelvis computed tomography (CT) and magnetic resonance imaging (MRI) showed "multiple nodular implants in spleen, gut, and peritoneal cavity; but no hepatosplenomegaly or abnormal lymph nodes enlargement" ( Figure 4). One week after the start of the antituberculosis treatment, the patient was discharged from hospital because of clinical improvement.