The great imitator, perforated intestinal tuberculosis during the Puerperium: An atypical presentation: Case Report

Abdominal tuberculosis is a rare form of extrapulmonary tuberculosis that presents a diagnostic challenge due to its nonspecific clinical manifestations. Intestinal involvement, especially of the terminal ileum, can progress to serious complications such as obstruction, hemorrhage, or intestinal perforation. During the puerperium, the immunological changes of pregnancy and postpartum can alter the clinical presentation of the disease, leading to initial misdiagnoses. We present the case of a 39-year-old woman in the postpartum period, 30 days postpartum, who presented with unquantified fever, pelvic pain, abnormal vaginal discharge, and diarrhea of three days' duration. Initially diagnosed with complicated puerperal endometritis, she underwent uterine curettage and empirical antibiotic therapy. However, she developed progressive abdominal pain and distension. Computed tomography revealed abundant free fluid and intrauterine gas, prompting a total abdominal hysterectomy. During the procedure, granular lesions were observed in the uterus, peritoneum, and intestine.
Given the persistent clinical deterioration and suspected perforation, an exploratory laparotomy was performed, revealing a perforation of the terminal ileum with fecal contamination. The Xpert MTB/RIF assay in peritoneal fluid and intestinal tissue was positive for Mycobacterium tuberculosis. Intestinal resection, ileostomy, and peritoneal lavage were performed. The patient required ICU management for severe intra-abdominal sepsis and subsequently began antituberculosis treatment with the HRZE regimen, with a favorable outcome. This case highlights the importance of considering intestinal tuberculosis in the differential diagnosis of acute abdomen in the postpartum period and underscores the value of rapid molecular tests for timely diagnosis.