An Unusual Presentation of Disseminated Tuberculosis

Abstract Introduction: Disseminated tuberculosis (TB) caused by Mycobacterium tuberculosis (MTB) occurs when the organism spreads through the bloodstream, affecting multiple organs throughout the body. The presentation of disseminated TB is commonly associated with significant respiratory symptoms. This is a rare presentation of disseminated TB without respiratory symptoms at the time of admission illustrating the importance of clinical history. Case Report: A 28-year-old man who immigrated from Kenya 10 years prior presented with night sweats and severe rectal pain. On arrival he was febrile, tachycardic, and hypotensive. Diffuse purulent drainage was noted from his perianal skin. His labs revealed neutrophil-predominant leukocytosis and lactic acidosis. His qSOFA score was 2. Computed Tomography (CT) of the abdomen and pelvis revealed a right perianal abscess/fistula extending to the anal canal. Incidentally, chest imaging showed extensive tree-in-bud nodularities throughout the left upper and lower lobes as well as consolidations of the lingula with regions of cavitation. He was treated for sepsis with early antimicrobial therapy and surgical drainage of the perirectal and ischioanal abscesses. His operative cultures grew E.Coli, Lactobacillus, and Bacteroides. The patient was negative for sexually transmitted infections however, he had a positive Quantiferon-TB result. Approximately 10 days after admission, he developed progressive respiratory failure requiring intubation and mechanical ventilation. His respiratory culture grew acid fast bacilli, and he was started on treatment for MTB. His respiratory failure progressed to ARDS, and he was cannulated for venovenous ECMO, 16 days after presentation. Cultures and sensitivities confirmed the diagnosis and treatment regimen. Notably, MTB was later isolated from his rectal tissue as well. Despite aggressive management, repeat CT chest showed significant progression of multifocal necrotizing pneumonia and miliary pulmonary nodules, consistent with MTB with superimposed infection. He died 45 days after admission (29 days on ECMO). Discussion: While this patient demonstrated some of the classic signs of MTB infection, his initial presentation of perirectal disseminated TB with absence of significant respiratory symptoms was rare. Recognizing and mitigating cognitive biases can improve diagnostic accuracy and treatment outcomes.