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Dr.Rithwik Sunil, Dr.Praveena N.B, Dr. C Jayakumar
A 17-year-old male presented with a two-week history of fever, loose stools, and vomiting.
He reported an evening rise in temperature, with a maximum recorded spike of 101 °F. The patient experienced significant abdominal pain, primarily localized to the right lumbar and iliac regions, accompanied nausea and vomiting. He is noted having 2 to 3 episodes of loose stools daily, without any blood present. Additionally, he experienced a weight loss of 2 kg over the same period.
There were no reported symptoms of skin rash, joint pain, cough, dyspnea, headache, hematuria, or frothy urine. He had previously sought care at a near hospital, where elevated inflammatory markers were noted.
PERSONAL HISTORY :
Appetite reduced, increased Bowel Movement frequency, sleep adequate
Past history
Child is a known case of IgA Vasculitis with Nephritis and persistent proteinuria (diagnosed 2018). He was on Mycophenolate mofetil 750 mg, Envas 7.5mg
Birth History:
1st child of non consaginous marriage
Antenatal: uneventful
Natal: 3kg/NVD/Term/CIAB
Postnatal: uneventful
Developementally normal child
Immunized for age as per NIS schedule
CLINICAL EXAMINATION :
Vitals: PR 88/min , BP 130/86mm Hg, Temp:100F
Left supraclavicular lymph node 1x1cm, non-tender , no pallor, icterus, cyanosis,edema
Auxology:
P/A – Soft, right iliac and lumbar tenderness + Bowel sounds +
RS – Normal vesicular breath sounds, no added sounds
CVS – S1, S2 normal
CNS – No focal deficit
MSK – Normal
Differential Diagnosis considered
• Typhoid fever
• EBV
• HIV(as he was on immunisuppression)
• Clostridium difficile
• Tuberculosis
• Inflammatory Bowel disease
• Malignancy
Investigations done
Hb:10g/dl
PLT:340
Tc:22
N/L:88%/3.8%
CRP;56
LFT: mild TransaminitisAST/ALT (77/65)
EBV IgM : Negative
Anti HCV :Non Reactive HIV – Emergency Screen:Non Reactive
LDH: 337.0 U/L Lipase : 29.8 U/L
Amylase: 75.0 U/L GGT: 288.0 U/L
C.diff assay: Negative
Stool Cultures: sterile
USG abdomen was done, which showed extensive retro-peritoneal LNs with inflammatory thickening of the small bowel
IBD workup done was negative
Tuberculosis was suspected, and IGRA was done, which turned out to be positive.
Upper and lower GI scopies were done under GA, which showed a duodenal ulcer and swollen IC valve with terminal ileal nodularity and surface ulcerations. These findings were highly suggestive of tuberculosis, and hence ATT was started.
Immunosuppressive drugs were discontinued during the start of AT
Discussion
Abdominal TB is a rare form of TB. Abdominal tuberculosis comprises 0.3–4% of all cases of childhood tuberculosis.Abdominal tuberculosis has been reported mainly from developing countries and is relatively rare in children. The commonest age group that is affected is 9–14 years.
Common symptoms of abdominal tuberculosis are fever, loss of weight, reduced appetite, distension and pain in abdomen. Some children with abdominal tuberculosis can have diarrheaor constipation. Occasionally, children with abdominal tuberculosis can have bleeding in stools. Many children with abdominal tuberculosis can also develop jaundice
Abdominal tuberculosis is treated with a combination of four medicines namely, Rifampicin, Isoniazid, Pyrazinamide and Ethambutol. The duration of treatment for a period of six to nine months. Some children with fluid in the abdomen or ascites also require additional steroids for two months.