Ileocecal Perforation with Tuberculous Sclerosing Encapsulating Peritonitis Complicated by Splenic Infarction and Enterocutaneous Fistula in a Young Immunocompetent Man: A Case Report

Author

Sandhiya V, Harineshwari V, Sneha Y, Prathap A

Abstract

Abdominal tuberculosis most often involves the ileocecal region; free perforation is uncommon and highly lethal, and its coexistence with tuberculous sclerosing encapsulating peritonitis, splenic infarction and enterocutaneous fistula is rarely reported. A 26-year-old immunocompetent man with untreated interferon-gamma release assay–positive tuberculosis and 25 days of oral deflazacort presented with one day of abdominal pain, vomiting, fever and obstipation, in septic shock (blood pressure 80/60 mmHg, creatinine 2.1 mg/dL, procalcitonin 27.01 ng/mL). Computed tomography showed small-bowel perforation. At emergency laparotomy the abdomen was entirely plastered, with 1.5 L of faeculent fluid, a 5 × 3 cm ileocecal perforation and a separate 3 × 3 cm caecal perforation; segmental resection with end ileostomy was performed. Recovery was complicated by refractory shock, acute kidney injury, wound dehiscence, thrombocytosis peaking at 1,029,000/mm³, a splenic infarct involving 50–70% of the parenchyma with hilar arterial thrombus, and a low-output enterocutaneous fistula. Histopathology showed necrotising granulomatous inflammation at four sites. Antitubercular therapy began on postoperative day 17; the fistula and infarct were managed conservatively and the patient was discharged ambulant on day 24. Corticosteroids given for untreated tuberculous infection can precipitate perforation, and within an abdominal cocoon resection with proximal diversion is safest.

Keywords

abdominal tuberculosis, ileocecal perforation, sclerosing encapsulating peritonitis, abdominal cocoon, splenic infarction, enterocutaneous fistula, septic shock

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