Barriers to Care Leading to Fatal Consequences: A Case of Tuberculosis Sepsis Amid Policy Change

Mycobacterium tuberculosis is an acid-fast bacterium with a diverse range of clinical manifestations and is considered rare in Western countries. Tuberculosis (TB) remains a global health concern and can pose several challenges in diagnosis and treatment. Paired with changing immigration policies, immigrant populations can face several barriers to healthcare. This case illustrates the impact of immigration policy on clinical outcomes and how government policies can act as a barrier to care. We present a case of a 26-year-old Guatemalan man with no known past medical history who came to the emergency department hemodynamically unstable with the presentation of abdominal perforation. He was urgently taken for an exploratory laparotomy, which revealed two perforations in the terminal ileum, extensive fibrinous exudate in the peritoneal cavity, and significant lymphadenopathy in the mesentery and retroperitoneum. The specimens collected intraoperatively were sent for evaluation and showed necrotizing granulomatous inflammation with transmural necrosis, and mesenteric lymph node biopsy revealed necrotizing granulomatous lymphadenitis, findings consistent with TB lymphadenitis. A sputum acid-fast bacilli (AFB) test further confirmed Mycobacterium tuberculosis. Given the concern for disseminated TB and ongoing ventilator and pressor support, this case required a multidisciplinary critical care course. The patient was started on antimycobacterial therapy with plans to transition to RIPE (rifampin, isoniazid, pyrazinamide, and ethambutol) therapy plus vitamin B6. The patients' hospital course was further complicated by loculated ascites with peritonitis and necrotizing pneumonia. Despite aggressive multidisciplinary medical therapy, the patient ultimately expired. The treatment of sepsis due to disseminated TB depends heavily on the ability to identify the causal infection, in addition to providing hemodynamic and organ support. The research stressing the timeliness of treatment and its impact on mortality in sepsis and miliary TB is well documented across medical literature. In this case, it is critical to analyze the political climate that may have prevented the patient from presenting to a healthcare provider when he first experienced symptoms.