Stillbirth as the primary manifestation of disseminated tuberculosis in a young immunocompetent mother with multiple perforations of the ileum

Background

Tuberculosis (TB) is the second-leading cause of death globally among all communicable diseases. The prevalence of TB, especially extrapulmonary TB (EPTB), is increasing worldwide. TB, directly and indirectly, affects female reproductive health and can present in different ways resembling other diverse disorders to tax the best diagnostician’s ingenuity. Pregnancy usually does not influence the course of pulmonary or EPTB but may aggravate the condition. Although pulmonary TB in pregnant women poses risk for their infants, EPTB outcomes are not well known during the pregnancy. Congenital TB though rare, resulting in either due to haematogenous spread or by ingestion and aspiration of infected amniotic fluid, is associated with high perinatal mortality.

Case presentation

A 21-year-old female postpartum state (first pregnancy), without comorbidity and any significant medical history, presented to the emergency department with acute abdomen and respiratory distress of 5 days duration, developing after full-term stillbirth delivery at home. There was no history of fever, cough, weight loss or altered bowel habits. Menstrual history before the pregnancy was unremarkable.

Pallor, dry tongue and bilateral pedal oedema were the positive findings on general physical examination. Her recorded vitals at presentation were: Pulse 100 beats/min; Blood pressure 100/60 mm Hg; Respiratory rate 24 breaths/min; Oxygen saturation (SpO₂) 93% on room air. Abdominal examination revealed fullness over the lower abdomen associated with tenderness and auscultable bowel sounds. No guarding or rebound tenderness could be elicited. The patient was admitted and intravenous fluids, analgesics, empirical antibiotics and moist oxygen were initiated.

Investigations

Because of the ongoing COVID-19 pandemic and the patient having breathing difficulty, nasal and oropharyngeal swabs were taken which reported negative for coronavirus on real-time reverse transcription-polymerase chain reaction (RT-PCR) testing. Routine laboratory workup done on the morning of the day of admission revealed haemoglobin: 0.8 g/L, leucocytes: 16×10⁹/L, platelet count: 90×10⁹/L, serum albumin: 25 g/L, international normalised ratio: 1.2 and serum creatinine: 123 µmol/L. An abdominal radiograph showed dilated small bowel loops but no evidence of free air under the right dome of the diaphragm. Both lung fields showed basal opacities on the radiograph. Ultrasound abdomen showed an extensive pelvic collection. After initial fluid bolus resuscitation and lowering of creatinine value to within normal range, contrast-enhanced computed tomography (CECT) of the torso was planned. CT scan of the chest done on the night of admission showed few solid centrilobular nodules giving tree-in-bud pattern with extensive consolidation involving bilateral lung parenchyma suggestive of active infection likely tubercular (figure 1). Abdominal tomography demonstrated gross hydropneumoperitoneum and bulky uterus postpartum state (figure 2).

Differential diagnosis

The patient had no routine prenatal laboratory tests. For evaluation of the antecedent stillbirth, hepatitis panel, human immunodeficiency virus (HIV) and venereal disease research laboratory (VDRL) tests were ordered that turned out to be negative. Various differentials thought of included puerperal sepsis, appendicular perforation, abdominal TB and complicated enteric fever. Widal test was also negative. As the patient gave no history of fever, acute illnesses were ruled out. CT abdomen findings pointing towards hollow viscous perforation augmented by chest sections suggesting a tubercular infection strongly favoured the possible diagnosis of disseminated TB.

Treatment

An emergency exploratory laparotomy under high-risk consent was performed during the early morning hours of the subsequent day following admission. It revealed around one litre of fecopurulent contamination with multiple perforations (figure 3), a total of 20 in number, spanning almost the whole of the ileum for which resection of the involved segment was done (figure 4), and two viable ends of small bowel exteriorised. Intraoperatively, the patient landed into refractory hypotension. The anaesthetist started dual ionotropic support: inj. norepinephrine 8 mg @ 12 mL/hour and inj. vasopressin @ two units/hour and one unit of packed red blood cells was transfused. Second-line injectable antitubercular drugs (levofloxacin 500 mg/100 mL intravenous 12 hourly and amikacin 750 mg intravenous 24 hourly) were started postoperatively and the patient shifted to the intensive care unit on ventilatory support.

Outcome and follow-up

The patient had a stormy postoperative period and remained on ionotropic support in the intensive care unit. Oliguria ensued progressively over subsequent 48 hours leading to a rise in serum creatinine level to 250 µmol/L. She underwent haemodialysis for the same but urine output did not improve. Her requirement of ionotropic support gradually increased and the stoma remained oedematous and non-functional even on the third postoperative day. She subsequently developed acute respiratory distress syndrome and finally succumbed to multiorgan dysfunction on postoperative day five. The histopathological examination of the resected bowel revealed granulomatous inflammation and extensive serositis (figure 5). Ziehl-Neelsen staining of the tissue demonstrated acid-fast bacilli (figure 6).