• M G Bani-Hani, A Al-Nowfal, and S Gould.
• North West London Hospitals NHS Trust, Northwick Park Hospital, Harrow, Middlesex, UK. mgbh76@hotmail.com
• J. Gastrointest. Surg. 2009 Jul 1; 13 (7): 1373-5.

BackgroundTuberculosis (TB) peritonitis is a rare presentation of TB that is typically insidious, presenting with systemic symptoms and nonspecific abdominal pain. In the majority of the cases, this leads to bowel obstruction and rarely causes abdominal cocoon. The disease process predominantly affects the small bowel with a tendency to involve the terminal ileum, leading to perforation on rare occasions.MethodsWe are presenting a case report of multiple small-bowel perforations in immune-competent male patient complicating a TB cocoon and discuss clinical course and therapeutic options.DiscussionTB cocoon is a rare form of TB peritonitis presenting usually in the form of bowel obstruction. However, TB can cause multiple bowel perforations, particularly in children and immune-compromised patients. Such presentation carries a high rate of mortality. With the global increase in TB infections and the emergence of aggressive, multidrug-resistant strains, more severe manifestations are expected to increase. We presented a case of such severe acute manifestation on a background of insidious TB cocoon in a fit immune-competent male. Although primary repair of TB perforation is considered hazardous, it could not be avoided on this occasion. Nevertheless, proximal defunctioning jejunostomy and the early use of anti-TB drugs seemed to facilitate healing in such scenario.ConclusionsTB should be considered in all cases of atypical bowel perforations. Proximal jejunostomy and early use of anti-TB drugs can facilitate primary repair in aggressive TB infection with multiple bowel perforations.

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