Atypical Presentation of Extra-Pulmonary Tuberculosis—A Case Report, Diagnostic Challenges and Importance of Frequent and Repeated Testing

Author

Dr. Renu Yadav, Dr. Praveen Kumar Pandey, Dr. Subhadeep Saha

Abstract

 Tuberculosis (TB), caused by Mycobacterium tuberculosis, remains one of the leading infectious causes of morbidity and mortality worldwide as well as in India. India bears the highest global burden of tuberculosis. Although newer molecular tests has significantly strengthened case detection, diagnosis remains uncertain in a specific group of cases especially in extra pulmonary cases. Early diagnosis and prompt initiation of anti-tubercular therapy are essential not only for improving patient outcomes but also for interrupting disease transmission within the community.

Pulmonary tuberculosis typically presents with chronic cough, fever, weight loss, night sweats, and hemoptysis. But presentation of extra pulmonary tuberculosis can be atypical, more so in case of abdominal tuberculosis.

Severe intra-abdominal infections can have a prolonged and complicated clinical course, particularly when accompanied by respiratory failure, persistent intra-abdominal collections, and recurrent infections. Such patients may require prolonged intensive-care support, mechanical ventilation, repeated bronchoscopy, percutaneous drainage, and surgical intervention. The presence of persistent or recurrent wound infection despite conventional management should prompt consideration of less common infectious etiologies, including tuberculosis.

Despite the widespread availability of rapid molecular assays such as Xpert MTB/RIF Ultra, establishing the diagnosis in atypical cases remains difficult. Low bacillary burden, false-negative microbiological tests, difficulties in obtaining representative tissue specimens, and overlapping radiological or histopathological findings frequently necessitate repeated sampling and a multidisciplinary diagnostic approach. Delayed diagnosis not only increases patient morbidity and the risk of irreversible organ damage but also prolongs infectivity and places an additional burden on healthcare resources.

Abdominal tuberculosis may involve the peritoneum, abdominal wall, surgical wounds, and other sites. Diagnosis can be challenging because clinical manifestations may overlap with bacterial or fungal infections, and conventional histopathology may be inconclusive. Molecular testing such as GeneXpert MTB can provide important diagnostic information, particularly when specimens are obtained from a clinically involved site.

We describe a complex clinical course involving abdominal pain, vomiting, ascites and suspected peritonitis, respiratory failure requiring prolonged ventilatory support, recurrent intra-abdominal collections requiring drainage and laparoscopic lavage, and subsequent detection of Mycobacterium tuberculosis from wound pus by molecular testing. 

Keywords

Extrapulmonary Tuberculosis, Mycobacterium tuberculosis, Atypical Presentation, Case Report, Diagnostic Challenges

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References

The case underlines the importance of re-evaluating the diagnosis when infection persists or recurs despite conventional treatment, and of considering tuberculosis in patients with chronic or recurrent abdominal/wound disease. Appropriate specimen collection and targeted molecular and microbiological testing can be crucial in establishing the diagnosis when routine investigations are inconclusive.

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