Paradoxical ileocecal perforation during early anti-tuberculosis therapy: A rare case report

Tuberculosis remains a global health challenge, with extrapulmonary forms accounting for a significant proportion of cases. Intestinal tuberculosis, though uncommon, can present with nonspecific gastrointestinal symptoms and lead to severe complications, including intestinal perforation.

We report a 24-year-old male with a two-year history of right lower quadrant abdominal pain, weight loss, and anorexia. Imaging and colonoscopy revealed ileocecal thickening with ulceration and stenosis; biopsies confirmed tuberculous enteritis. Six days after starting anti-tubercular therapy, he developed generalized peritonitis due to an ileocecal perforation. Right hemicolectomy with ileotransverse anastomosis was performed. He received postoperative antibiotics, analgesics, and continued anti-tubercular therapy, with good recovery on follow-up.

Paradoxical intestinal perforation during anti-tubercular therapy is a rare but serious complication, likely due to a delayed hypersensitivity reaction to mycobacterial antigens, particularly in the ileocecal region. It may mimic treatment failure, delaying intervention. Prompt surgical management, continued anti-tubercular therapy, and high clinical suspicion during early treatment are vital to reduce morbidity and improve patient prognosis.

This case highlights the importance of recognizing paradoxical reactions, such as intestinal perforation, as potential complications during the early phase of anti-tubercular therapy. Maintaining early vigilance and a high index of suspicion is essential for timely diagnosis and appropriate intervention. Clinicians should consider paradoxical perforation in patients who deteriorate shortly after initiating anti-TB treatment, even when adherence is confirmed. Early surgical intervention, guided by a high index of suspicion, is crucial to reducing morbidity and improving outcomes in intestinal tuberculosis.