A 22-year-old Hispanic male who recently emigrated from Guatemala within the last six months, without any previous medical history presented with a chief complaint of rectal and abdominal pain. Onset of the pain was four days before; however, he had been experiencing other symptoms for approximately three months. He reported productive cough, pyrexia, chills, night sweats, fatigue, and weight loss. He denied nausea, vomiting, diarrhea, melena, hematochezia, and rectal manipulation. Vital signs revealed temperature of 99.8 F, blood pressure 105/67 mmHg, pulse 91 bpm, respiratory rate 20 bpm, and oxygen saturation 99%. Labs revealed sodium 136 mEq/L, potassium 4.5 mEq/L, chloride 99 mEq/L, bicarbonate 22 mEq/L, creatinine 0.54, WBC 9.3 k/mul, hemoglobin 11.0 g/dl, and platelet 416 k/mul.
On physical examination, there was palpable right lower quadrant tenderness accompanied by abdominal rigidity and involuntary guarding. The patient was not amenable to digital rectal examination due to reported pain. However, illuminated visual examination of the rectum did not reveal any abnormalities. Due to the constellation of travel history, cough, and constitutional symptoms, a chest X-ray (CXR) was performed. It revealed biapical pleural thickening associated with parenchymal scarring, bronchiectasis, nodularity, and superimposed infiltrates (Figure 1). Pulmonary tuberculosis (TB) was highly suspected, and the patient was placed in an isolation room. Further imaging was accomplished with computed tomography (CT) of the abdomen and pelvis with intravenous and oral contrast. This revealed acute appendicitis in the right lower quadrant congruent with earlier physical examination findings (Figure 2). It also revealed a 3.1 x 1.9 cm dumbbell-shaped loculated fluid collection anterior to the anus consistent with perirectal abscess (Figure 3) confirming the etiology of his rectal discomfort. Finally, CT gave more insight into suspected pulmonary TB as it revealed nodular and patchy consolidation in both lung bases along with dense consolidation, fluffy airspace infiltrates, distended, and distorted bronchi (Figure 4).
The patient was taken to the operating room expeditiously where he underwent diagnostic bronchoscopy with bronchoalveolar lavage (BAL), laparoscopic appendectomy, and incision and drainage of the perirectal abscess. By postoperative day one, cultures from BAL, sputum, and perirectal abscess were positive for acid-fast bacilli (AFB). Cultures from the perirectal abscess were also positive for beta-hemolytic group C streptococcus. Gross pathology of the appendix revealed a dusky, congested, red-brown serosa. When sectioned, we appreciated a dilated lumen measuring approximately 0.5 cm in diameter and an appendiceal wall thickness averaging at 0.3 cm. The mucosa was noted to be tan-pink, glistening, and congested. The lumen of the appendix contained abundant gray-pink semisolid contents. A discrete perforation was not appreciated. Histologic analysis revealed a focally effaced mucosa albeit where present, the epithelium was without atypia. Foci of acute and granulomatous inflammation were appreciated (Figure 5) along with epithelioid histiocytes and multinucleated giant cells (Figure 6). Initial acid-fast staining was negative, but a repeat stain revealed the presence of acid-fast bacilli in the cytoplasm of a multinucleated giant cell (Figure 7).
The patient was started on antitubercular drugs that included a combination of rifampin, isoniazid, pyrazinamide, and ethambutol. Based on sensitivities, he was also started on antibiotics for management of the streptococcal infection. The patient did well postoperatively and tolerated both antibacterial and antitubercular treatments without complication.