We report a case of a 41-year-old married, nonsmoker man who brought to the hospital with the major complaint of abdominal pain, accompanied by nausea and vomiting since ten days prior to admission. Three months earlier, he had experienced shortness of breath which exacerbated when lying on his right side (Trepopnea). The patient had productive cough and fever during the hospital stay. No chest pain, paroxysmal nocturnal dyspnea, and lower extremity edema were detected. Our patient tested negative for SARS-CoV-2 with Polymerase Chain Reaction (PCR). Electrocardiogram (ECG) was unremarkable. Ultrasound study at the time showed minimal free fluids in the abdominal cavity and dilated hypo peristaltic bowel loops in favor of partial bowel obstruction. In chest radiography, consolidation in the right lung and right side pleural effusion was detected. Thoracentesis was performed and about 120 ml of exudative pleural fluid was extracted. Bronchoscopy and biopsy confirmed the pulmonary TB diagnosis. The medication was started for the treatment of pulmonary TB, and the patient was discharged. The patient was relatively in good condition for two months when he developed abdominal pain, nausea, and vomiting. After ten days, he visited the hospital and admitted for better evaluation. He described his Abdominal pain as generalized, intermittent, and his vomit as massive, non projectile and bilous. He also had a positive history of constipation and obstipation. Initial vital signs were stable with a body temperature of 37oC, respiratory rate 18/min, pulse rate of 80/min, arterial blood pressure of 116/80 mmHg, and arterial oxygen saturation of 98%. We detected mild generalized abdominal tenderness without abdominal distention, guarding, or rebound tenderness in physical examination. The patient did not have any dyspnea in the course of hospitalization. Laboratory results reported mild anemia (hemoglobin was 12.7 gr/dl (normal range 13.5-17.5 gr/dl for men)), No leukocytosis (white blood cell count was 9.7x103 /mul (normal range 4.5-11x103/mul)), or thrombocytosis (platelet count was 377x103 /mul (normal range 150-450x103 /mul)). Renal function test showed slightly increased creatinine (1.55 mg/dl (normal range 0.7-1.2 mg/dl)) and normal blood urea nitrogen (16 (normal range 7-30 mg/dl)). He had mildly decreased estimated glomerular filtration rate(eGFR) (66.53 ml/min (normal range 90-120 ml/min)), Which was calculated by the Cockroft-Gault formula. Electrolyte levels were within the normal range. Liver enzymes were normal. Alkaline phosphatase was elevated (316 U/L (normal range 40-150 U/L)) and hypoalbuminemia was also detected (2.9 gr/dl (normal range 3.5-5 g/dl)).
Chest X-ray showed right upper lobe pulmonary consolidation and infiltration (Figure 1) in favor of pneumonitis and possibly due to the previous TB infection. Abdominal radiography also demonstrated several air-fluid levels (Figure 2) suggestive of bowel obstruction. Ultrasound study reported several echogenic wall thickenings, largest 11x12 mm. Computed tomography scan revealed right-sided pleural effusion and subsegmental atelectasis in the right lower lobe of the lung (Figure 3). In the abdominal cavity, significant dilatation of jejunal and proximal ileal bowel loops associated with a transitional zone in mid ileal bowel loops in the pelvic cavity was detected, suggesting mechanical obstruction (Figure 4). In liver, several hypodense lesions were seen in the right and left lobe of the liver, suggestive for visceral TB (Figure 5).
On the 2nd day of hospitalization, the patient was transferred to the operating room for exploratory laparotomy. During the surgical exploration of the abdominal cavity, severe adhesion was noted, and adhesiolysis was done. The cause of mechanical obstruction seemed to be an adhesion band about 20 cm prior to the ileocecal valve, which was released. Due to severe inflammation of the appendix, appendectomy was also performed with double ligation method. Another finding was TB-like lesions all along with the small bowel, colon, omentum, and liver surface. We sent excised tissues to the pathology laboratory for further evaluation. Pathology reports were consonant with the diagnosis of PTB as all the samples had caseating granuloma formation despite negative acid-fast staining. After the operation, anti TB medications (Ethambutol 500mg and Rifampicin 150 mg once daily) resumed. Three days later, after complete recovery, he was discharged with follow-up of a general surgeon, and infectious specialist.