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

INTRODUCTION AND IMPORTANCE: 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.

PRESENTATION OF CASE: 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.

DISCUSSION: 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.

CONCLUSION: 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.