Case Report: A Rare Case of Abdominal Tuberculosis
Revealed by Complicated Diverticular Disease

Prakash Shashi; Kumari Laxmi

Case Report

Case Report: A Rare Case of Abdominal Tuberculosis Revealed by Complicated Diverticular Disease

Prakash Shashi¹* and Kumari Laxmi²

¹Nursing Faculty, College of Nursing, S. N. Medical College, Agra, Uttar Pradesh, India

²B.Sc. Nursing Student, College of Nursing, S. N. Medical College, Agra, Uttar Pradesh, India

Corresponding Author

Received Date:July 31, 2024; Published Date:August 08, 2024

Abstract

Background: Diverticular disease, marked by the formation of diverticula in the colon, is prevalent in industrialized countries and often asymptomatic. However, complications such as diverticulitis can lead to severe outcomes like perforation or abscess formation. This report describes an unusual case where diverticular disease was complicated by abdominal tuberculosis in a 19-year-old female, highlighting the diagnostic and therapeutic challenges encountered.
Case Presentation: A 19-year-old female presented with abdominal distension, pain, nausea, and vomiting for eight months. Initial diagnosis revealed diverticular disease with a significant mass. An exploratory laparotomy was performed, and pus fluid analysis confirmed abdominal tuberculosis through the detection of Mycobacterium tuberculosis. Histopathological examination also identified Streptococci and Klebsiella species in the colon.
Management: The patient underwent right hemicolectomy with colostomy and the creation of an ileostomy stoma. Antitubercular therapy was initiated following the Directly Observed Treatment Short-course (DOTS) regimen. Postoperative care included broad-spectrum antibiotics and nutritional support with protein supplements and vitamins.
Follow-up and Outcomes: The patient was discharged with instructions for home care and continued DOTS therapy. Six months later, she was readmitted for the closure of the surgical site. Her condition resolved due to interdisciplinary management and adherence to tuberculosis treatment.
Conclusion: This case highlights the rarity of abdominal tuberculosis presenting as a complication of diverticular disease. It underscores the need for thorough diagnostic evaluation and a multidisciplinary approach in managing complex gastrointestinal conditions. Accurate diagnosis and tailored treatment are crucial for effective management and recovery.

Keywords: Diverticular disease; abdominal tuberculosis; typhoidal perforation; DOTS therapy; right hemicolectomy

Introduction

Diverticular disease is prevalent in industrialized nations and poses a significant health burden due to its complications. The condition is characterized by diverticulosis, where mucosal and submucosal herniations, or diverticula, form in the colon wall. Although diverticulosis is frequently asymptomatic, approximately 4% of individuals with diverticula will develop diverticulitis, an inflammatory complication [1]. Diverticulitis can progress to severe complications such as perforation, abscess formation, and fistulas [2]. This case report describes an unusual presentation of diverticular disease complicated by abdominal tuberculosis in a 19-year-old female, demonstrating significant diagnostic and therapeutic challenges.

Case Presentation

Patient Information

A 19-year-old female was admitted to our hospital in October 2023 with abdominal distension, non-passage of feces and flatus, abdominal pain, nausea, and vomiting, symptoms that had persisted for eight months. Initial diagnostic imaging and clinical examination suggested diverticular disease complicated by a significant mass. Due to the severity of her symptoms and diagnostic findings, an exploratory laparotomy was deemed necessary.

Initial Management and Diagnosis

Exploratory laparotomy revealed extensive damage consistent with diverticular disease. During the procedure, a significant amount of pus fluid was observed. Analysis of this fluid confirmed the presence of Mycobacterium tuberculosis, establishing the diagnosis of abdominal tuberculosis. This diagnosis was supported by microbiological culture and histopathological examination. Histopathological examination also revealed inflammatory lesions in the colon, with Streptococci and Klebsiella species isolated [3]. These findings required a comprehensive management plan involving both surgical intervention and targeted medical therapy.

Surgical Interventions

Given the severity of the disease and associated complications, the following surgical procedures were performed:
a. Right Hemicolectomy and Colostomy: Due to extensive colonic damage, a right hemicolectomy was performed along with the creation of a colostomy. This intervention was necessary to manage the diverticular disease and its complications [4].
b. Ileostomy Stoma Creation: An ileostomy stoma was created to manage bowel function and facilitate the healing process. This procedure is often required in cases where the colon is severely affected [5].

Postoperative Course

Post-surgery, the patient experienced a challenging recovery period. Initial biochemical and haematological parameters were closely monitored:

A. Haematology:

• Haemoglobin: 9.3 g/dL
• Total Leukocyte Count (TLC): 5300 cells/mm³
• Platelet Count: 305,000 cells/mm³
• Red Blood Cells (RBCs): 2.91 million cells/mm³
• Packed Cell Volume (PCV): 26.5%

B. Biochemistry:

• Serum Bilirubin (Total/Direct/Indirect): 0.50 mg/dL / 0.29 mg/dL / 0.21 mg/dL
• Serum Protein: 5.46 g/dL
• Serum Albumin: 2.61 g/dL
• Serum Globulin: 1.85 g/dL
• Serum Urea: 10.84 mg/dL
• Serum Sodium: 135.1 mg/dL
• Serum Creatinine: 0.66 mg/dL
• Serum Potassium: 2.52 mmol/L

DOTS Therapy and Home Care

Following surgery, the patient was started on the Directly Observed Treatment Short-course (DOTS) regimen for abdominal tuberculosis. The DOTS regimen, a standard protocol for tuberculosis treatment, emphasizes adherence to a multi-drug regimen [6]. In addition to antitubercular therapy, the patient received extensive nutritional and supportive care:

a) Antimicrobials:

 Levofloxacin 750 mg IV OD
 Meropenem 2 g IV TDS
 Colistin 3 MIU in 100 mL NS TDS
 Amikacin 750 mg IV OD

b) Supportive Care:

 IV Fluid DNS 1000 mL with 4 KCL ampoules
 RL 500 mL
 Pantoprazole 40 mg IV OD
 Emset 4 mg IV TDS
 Paracetamol 100 mL IV TDS
 Perinorm 1 amp. IV TDS
 Calcium Gluconate 1 amp. with 100 mL NS IV TDS
 Ointment Heparin Sodium and Benzyl Nicotine for thrombophlebitis
 Magnesium Sulphate Urea Sulphacotamide Sodium Sulphur for skin reactions

c) Nutritional Support:

 Prtiken Protein Powder
 A2Z Multivitamin, Multimineral, and Antioxidants Syrup

Follow-up and Closure of Surgical Site

The patient was discharged with detailed home care instructions and continued DOTS therapy. Six months later, in May 2024, she was readmitted for the closure of the surgical site. The decision for site closure was based on her stable condition and successful response to tuberculosis treatment.

Discussion

This case report details a rare and complex instance of diverticular disease complicated by abdominal tuberculosis in a young patient. The intersection of these conditions presents significant diagnostic and therapeutic challenges.

Diverticular Disease and Its Complications

Diverticular disease, characterized by diverticulosis, involves the formation of diverticula—sac-like protrusions in the colon wall. While diverticulosis is common in industrialized countries, affecting a significant portion of the population, it is often asymptomatic [1]. Diverticulitis, the inflammation of diverticula, can lead to severe complications such as perforation, abscess formation, and fistulas [2]. The progression from diverticulosis to diverticulitis is influenced by dietary habits, genetic factors, and colonic motility [4]. In this case, the patient’s diverticular disease advanced to a severe form, necessitating surgical intervention.

Abdominal Tuberculosis as a Rare Complication

Abdominal tuberculosis is uncommon but can be a serious condition, particularly in areas with high tuberculosis prevalence [6]. Tuberculosis affecting the gastrointestinal tract can mimic or exacerbate other conditions, including diverticulitis. Symptoms such as chronic abdominal pain, weight loss, and abdominal masses complicate diagnosis [7]. In this case, the presence of Mycobacterium tuberculosis in pus fluid and the identification of Streptococci and Klebsiella species further complicated the clinical picture. This combination of infections underscores the necessity for a broad differential diagnosis in patients with complicated diverticular disease.

Diagnostic Challenges and Management

The presence of abdominal tuberculosis in a patient with diverticular disease presented significant diagnostic challenges. Tuberculosis can be overlooked in differential diagnoses due to its rarity and the potential overlap with other gastrointestinal disorders [8]. This case emphasizes the importance of considering tuberculosis in patients with atypical diverticulitis symptoms, especially in regions with known tuberculosis prevalence. Effective management required a comprehensive approach. Surgical interventions, including right hemicolectomy and ileostomy stoma creation, were crucial for managing diverticular complications and ensuring adequate bowel function [5]. Postoperative care involved a rigorous antitubercular regimen following the DOTS protocol and tailored antibiotic therapy to address the mixed bacterial infections [6,9].

Implications for Clinical Practice

This case highlights the need for thorough diagnostic evaluation in patients with complex gastrointestinal conditions. Clinicians should be vigilant for rare complications such as abdominal tuberculosis, which can present alongside common gastrointestinal disorders like diverticulitis [3]. An interdisciplinary approach, involving gastroenterologists, surgeons, and infectious disease specialists, is essential for managing such cases effectively. This collaborative care ensures comprehensive management from diagnosis to postoperative care [7]. Additionally, increased awareness and education among healthcare providers about rare infections complicating common conditions can improve diagnostic accuracy and treatment outcomes [8].

Recommendations

a. Enhanced Diagnostic Vigilance: Maintain a high index of suspicion for tuberculosis in patients with severe or atypical gastrointestinal symptoms, especially in areas with known tuberculosis prevalence. Evaluation for tuberculosis should be part of the diagnostic workup for diverticular disease with complications [8].
b. Comprehensive Diagnostic Evaluation: Utilize microbiological, histopathological, and imaging studies for definitive diagnosis. Analyze peritoneal fluid, perform biopsy, and use advanced imaging techniques like CT scans to identify fewer common infections [7].
c. Multidisciplinary Management: Engage a multidisciplinary team, including gastroenterologists, surgeons, infectious disease specialists, and pathologists, to ensure comprehensive care [9].
d. Tailored Treatment Strategies: Develop individualized treatment plans addressing both primary conditions and secondary complications. Adhere to the DOTS regimen for tuberculosis and manage secondary infections with appropriate antibiotics based on culture and sensitivity [6].
e. Patient Education and Follow-up: Provide thorough education on the condition, treatment regimen, and follow-up care. Regular monitoring is essential for adherence to treatment, addressing complications, and adjusting the treatment plan as needed.
f. Research and Awareness: Support research into the intersection of common gastrointestinal conditions and rare infections. Increased awareness and understanding of these complications can enhance diagnostic accuracy and treatment strategies

Conclusion

This case report underscores the complexity of managing diverticular disease complicated by abdominal tuberculosis. The presentation of diverticular disease alongside tuberculosis is uncommon and highlights critical aspects of diagnosis and treatment. The patient’s progression from diverticulosis to severe diverticulitis and subsequent abdominal tuberculosis demonstrates the necessity for a comprehensive and multidisciplinary approach in managing such complex cases.

Ethical Approval

An institution board of review is not required ethics committee approval for the case reports.

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Guarantor

As Corresponding Author, I confirmed that the manuscript has been read and approved by all named authors.

Declaration of Competing Interest

No conflicts of interest in this work.

References

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World Health Organization (2022) Global Tuberculosis Report 2022. Geneva: World Health Organization.
Khan MS, Ahmed M (2022) Tuberculosis in gastrointestinal disorders: Diagnostic and therapeutic challenges. World Journal of Gastroenterology 28(5): 585-598.
Hsieh YH, Wu SH, Hsu CM (2021) The clinical significance of abdominal tuberculosis and its treatment. Journal of Clinical Gastroenterology 55(3): 230-237.
Singh P, Rao M, Sharma A (2019) Mixed infections in the abdomen: Case studies and review. Infectious Diseases in Clinical Practice 27(2): 149-155.

Article Details

Citation

Prakash Shashi* and Kumari Laxmi. Case Report: A Rare Case of Abdominal Tuberculosis Revealed by Complicated Diverticular Disease. Acad J Gastroenterol & Hepatol. 3(5): 2024. AJGH.MS.ID.000575.

Keywords

Diverticular disease; abdominal tuberculosis; typhoidal perforation; DOTS therapy; right hemicolectomy; Iris Publishers; Iris Publishers Indexing Sites