S2775 Use of Intravenous Antitubercular Therapy to Combat Intestinal Malabsorption in Disseminated Abdominal Tuberculosis

Abstract

INTRODUCTION: Tuberculosis (TB) is a malicious disease with an estimated annual incidence of 10 million cases and about 1.5 million deaths. TB has the potential to spread to any organ system, including the gastrointestinal tract, by direct ingestion or hematogenous spread. Abdominal TB can be managed with typical medical therapy. However, some cases may require escalation of therapy if poor intestinal absorption is suspected. Intravenous (IV) anti-TB therapy is an option, but there are currently no guidelines with sufficient data to aid providers. We report a case of a young immunocompetent female with abdominal TB that required urgent exploratory laparotomy with ileostomy followed by IV anti-tuberculosis therapy. CASE DESCRIPTION/METHODS: An 18-year-old Philipino female with a 2-month history of subacute respiratory complaints, diarrhea, abdominal pain, and 20-pound weight loss was admitted for septic shock. She had lived in the United States for the past 8 years. Examination showed a frail, severely malnourished female. Computed tomography of her abdomen and pelvis showed multiple small hypodense lesions throughout the liver and a larger complex gas containing fluid collection in the pelvis. Exploratory laparotomy for abscess drainage revealed extensive metastatic appearing lesions involving the small bowel and small bowel mesentery. Her perforation was near the ileocecal junction and ileostomy was performed. Chest imaging showed bilateral infiltrates, most severe in the upper lobes. AFB smears of her sputum and surgical biopsies returned positive. Her respiratory status became tenuous after initiation of oral 4-drug therapy and there was concern for malabsorption of antitubercular medication given her malnourished state. IV Rifampin and Levaquin were added and continued during hospitalization. Her nutritional status was optimized over the course of 2 weeks and she was discharged on oral therapy. DISCUSSION: Disseminated TB which has spread to the abdomen can be difficult to diagnose and challenging to treat. Treatment for abdominal TB begins with standard oral therapy. Current guidelines do not address the implementation of IV therapy for individuals who are unable to take or absorb oral medications. This case represents an immunocompetent 18-year-old presenting critically ill from complications of abdominal TB ultimately requiring intravenous therapy. Further research and reports in this field could enrich provider knowledge and allow for appropriate treatment in similar patients.Figure 1.: Computed tomography of abdomen and pelvis demonstrating multiple hypodense lesions scattered throughout the liver representing disseminated tuberculosis.Figure 2.: Computed tomography of abdomen and pelvis demonstrating large 6 × 11 × 9 cm complex gas containing fluid collection in the pelvis representing abscess formation due to perforation at the ileocecal junction.