DOUBLE INFECTIOUS CHALLENGE; WHEN TUBERCULOSIS MEETS THE PUERPERIUM: LATE PUERPERAL ENDOMETRITIS WITH INTRAUTERINE GAS ASSOCIATED WITH PULMONARY AND ABDOMINAL TUBERCULOSIS - A CASE REPORT

Puerperal sepsis is a major cause of maternal morbidity and mortality, especially after cesarean section. Puerperal endometritis is usually polymicrobial in origin; however, persistent fever and the appearance of atypical respiratory or intra-abdominal manifestations should prompt investigation for concomitant infections. Tuberculosis during the puerperium can present with nonspecific manifestations and simultaneously affect pulmonary and extrapulmonary organs. We present the case of a 29-year-old woman from a rural area, ten days postpartum after a cesarean section due to breech presentation, with a history of prolonged rupture of membranes of approximately 20 hours, who developed persistent fever, chills, neutrophilic leukocytosis, abdominopelvic pain, and progressive respiratory deterioration. The chest CT scan revealed cavitary lesions and ground-glass opacities, while the abdominopelvic CT scan showed abundant intra-abdominal fluid, a subinvoluted uterus , and intrauterine gas. Given the suspicion of puerperal endometritis complicated by sepsis, an exploratory laparotomy and obstetric hysterectomy were performed. Peritoneal fluid was positive for Mycobacterium tuberculosis by Xpert MTB/RIF, with sensitivity to rifampicin, while the respiratory molecular study was also positive, confirming pulmonary tuberculosis. The patient did not have HIV infection, diabetes mellitus, was not on immunosuppressive therapy, or had any other known condition associated with immunosuppression. Clinical progress was favorable after surgical control of the focus of infection, antimicrobial treatment, and antituberculosis therapy. This case highlights the diagnostic complexity of the coexistence of puerperal sepsis and pulmonary and abdominal tuberculosis. Intraoperative sampling allowed for the identification of extrapulmonary tuberculosis during the management of a complicated puerperal infection. Persistent fever or the presence of atypical respiratory and intra-abdominal findings should prompt a broader differential diagnosis, particularly in regions with a high burden of tuberculosis. The demonstration of peritoneal tuberculosis alone does not establish a tuberculous etiology for endometritis; therefore, it is essential to integrate clinical, radiological, surgical, and microbiological findings to establish a complete diagnosis.