Coinfection of Typhoid Fever With Tuberculosis: A Challenge to Surgical Management

Ileal perforation is one of the most dreaded complications of abdominal tuberculosis. It is more common in immunodeficient patients, where ulcerative type of intestinal tuberculosis predominates. Various factors play role in the outcome of these patients, such as age and comorbid illness, though the lag period (advent of symptoms to time of admission to hospital) correlated directly to the mortality in these patients. Herein we present a 28-year-old male who had a coinfection of typhoid fever along with intestinal tuberculosis. The patient presented with abdominal pain and fever for one-week duration. On examination, he had diffuse tenderness of his abdomen with guarding. X-ray revealed free air under diaphragm. The patient underwent limited resection of terminal ileum and cecum with end ileostomy for ileal perforation. The patient's serum Widal test was positive and blood culture grew Salmonella Typhi, and the patient was started on intravenous (IV) antibiotics based on culture and sensitivity. The patient's general condition worsened after two weeks with bile leak from the surgical site. The patient succumbed to severe sepsis. Postoperative histopathology of the resected ileo-cecal segment showed features of ileo-cecal tuberculosis. As typhoid is a common cause of ileal perforation in the developing countries, the co-existence of typhoid fever in this patient lead to the delay in the diagnosis and appropriate management of tubercular ileal perforation. Knowledge about various causes of typhoid perforation is essential for treating surgeons.

Keywords: anastomosis; ileostomy; lag period; non-traumatic perforation; resuscitation; small bowel.