Description
Tuberculosis of the appendix is a rare finding despite the high frequency of intestinal tuberculosis. Even in areas where tuberculosis is common, it is difficult to make the right diagnosis because of the clinical picture mimicking acute appendicitis, when there are no definitive signs of any system infected with tuberculosis [1]. A 37-year-old female presented with severe pain in the right iliac fossa. On clinical examination, she had fever and tachycardia with guarding and rigidity in the right iliac fossa. The patient underwent contrast-enhanced computed tomography (CT) scan of the abdomen, which revealed a distended retrocaecal appendix with thick enhancing walls (arrow in Figure 1A) and adjacent fat stranding. Incidentally, thickening of the uterine cervix was noted, for which she underwent magnetic resonance imaging (MRI) evaluation. The MRI depicted findings of chronic cervicitis and helped to confirm appendicitis (arrow in Figure 1B). There was gross effusion also noted in the right pleural cavity (star in Figure 1B).
The patient underwent appendicectomy and a reddish swollen angry-looking appendix was found intra-operatively (arrow in Figure 1C). The patient had uncomplicated post-operative period.
On histopathology, there were multiple granulomatous lesions and areas of caseous necrosis surrounded by Langerhan’s giant cells and epithelioid cells (arrow in Figure 1D). The patient started on anti-tubercular drugs and kept on follow-up. She is doing fine till the last follow up. Patients present with vague clinical symptoms in gastrointestinal TB. Severe abdominal pain, weight loss, intermittent constipation and diarrhoea associated with worsening of the pain [2]. Acute tubercular appendicitis being a very rare condition, a contrast-enhanced CT scan is the ideal imaging modality for the evaluation of such cases.
Figure 1. A. Axial section of contrast-enhanced CT scan shows distended retro-caecal appendix, measuring 10 mm in diameter with adjacent fat stranding. B. Coronal T2 weighted MR image shows inflamed appendix in the right paracolic gutter. C. Intra-operative image shows distended appendix having a reddish serosa. D. Histopathology image show caseous necrosis and infiltration of the Langerhan’s giant cells and epithelioid cells.
Learning Points
1. Tubercular appendicitis being a rare condition should be kept in considered while making the diagnosis because of the condition mimicking acute appendicitis.
2. A contrast enhanced CT scan helps in detailed assessment of the entity with proper visualization of other involved organs if any.
References
2. Maharjan S. An Uncommon Case of Chronic Tubercular Appendicitis. Case Rep Pathol. 2015;2015:534838.