A case of Ileocecal Tuberculosis in a resource limited community

hospital in Pakistan

Initial History/Presentation
A child named Muneer Ahmed . age 7 years, presented in paediatrics outdoor patient
department, with chief complaint of abdominal pain ,distention and mild bloody
diarrhea. Low-grade fever and anorexia is present.
Abdominal pain is from 2 months and is generalized, gradual on onset, associated
with vomiting and relieved with IV antibiotics and Fluid administration from a local
quack. Low grade fever is present since 2-3 months,no specific pattern,documented
100 F, rises in the evening, associated with fatigue and weight loss. Blood in stool is
present since last week , dark in color and defecation is not associated with any pain.
Child was born via SVD at 39 weeks with good immediate cry and no need of
resuscitation and fed on cows milk and weaning started 10th month of age. Child is
vaccinated only one time and parents don't remember the vaccine or the month.

General Physical Examination

Weight=18kg, Height= 90 cm
Body pallor with slight jaundice, pale sclera, normal eye vision, Lymphadenopathy
not present. JVP not raised. On abdominal palpation , Liver 4 finger in size felt below
costal margins. Pain on right iliac fossa when deep palpated. No ascites .
CVS= Normal S1 and S2,GCS= 15/15

Diagnostic Evaluation
CBC, along with Hepatitis and TB tests are ordered because TB is a common diagnosis
in our country.
X ray abdomen=No free air under diaphragm
Ultrasound=Normal appearing appendix with some with suspected inflammation at
ileocecal junction. Ruled out intussusception.
CBC=Hb 9 mg/dl , Leukocytes 12,000
Barium study= Narrowing of terminal ileum
PPD test =Positive
IGRA test=Positive
Chest xray=Normal
Sputum staining and culture for 3 morning samples was negative

Treatment/Conclusion
Due to frequent cases and tuberculosis and because it is endemic in the area, it is
always in the back of the mind of the physician while making the diagnosis.
Endoscopic guided biopsy is taken that showed caseous necrosis. Initial treatment
with pain killers and IV fluids and Antibiotics started until the results came. Initial
phase ATT stated for2months. And then INH and Rifampin for 4 months. Child started
to feel well in a week. Colonoscopy is done after the treatment finished to find no
issues.

Learning Points
1-Mycobacterium tuberculosis may show a preference for this site due to the
presence of static, plentiful lymphoid tissue.
2-When examining a patient from a developing country or an overseas camp, always
bear this diagnosis in mind.
3-Additionally, it is prudent to research and discuss local diseases with doctors in the
area.