Intestinal tuberculosis is a challenging diagnosis due to its nonspecific symptoms and similarities with other abdominal conditions. This case is unique due to the rarity of intestinal tuberculosis (TB) in a region where pulmonary TB is more common.
It underscores the diagnostic challenges posed by the disease’s vague abdominal symptoms and fever, which can easily be mistaken for more prevalent conditions. This case highlights the critical importance of a detailed patient history, including family and past medical history, in guiding the diagnostic process and considering rare diagnoses.
CASE SUMMARY – The patient presented with a one-week history of fever, headache, body pains, and localized abdominal pain. Important clinical findings included severe sweating, episodes of watery, offensive semisolid stools, and a high oral temperature.
Physical examination revealed localized tenderness in the right iliac region. These symptoms and the patient’s history of exposure to her aunt with pulmonary TB were pivotal in considering and eventually diagnosing intestinal TB. The prescription of homoeopathic medicine petroleum 30c, based on the symptomatology and with reference to the old literatures on tabes mesenterica, led to a significant improvement.
THE BEGINNING: FEVER AND ABDOMEN PAIN
A 53-year-old female was admitted in our In-Patient department (IPD) on 24 May 2023, with the following complaints-
- Fever for the past 1 week
- Fever associated with vague abdominal pain and loose stools of a semisolid, offensive nature.
- Pain around the umbilicus before stool.
- Pain worse after eating or drinking.
- Extreme weakness, unable to sit up, better by lying down.
HISTORY OF PRESENTING COMPLAINTS
Fever initially started suddenly associated with body aches, headache, and abdomen pain. Patient did not take any treatment for 5 days. She had episodes of severe sweating – especially in the head, neck and face, and loose stools.
After 5 days, she consulted with a nearby allopathic physician and she was prescribed antibiotics. In spite of that fever persisted, so she came to us. Patient had history of recurrent episodes of excessive sweating in the past 6 months with weight loss.
PHYSICAL GENERALS
Appetite – total loss of appetite for the past 1 week
Thirst – increased thirst with dryness of lips and throat.
Desire – cold drinks
Sleep – disturbed sleep for the past 1 week.
Dreams – nothing specific
Intolerance – beetroot, cabbage, turnip, snake gourd, watery vegetables in general which Causes fever and cold.
Urine – no difficulties. Urine yellowish and hot in nature.
Stool – pain in the umbilical region before stool, during urge for stool. Offensive semi solid dark stool.
Sweat – no sweat in the last 4 days. But before she used to have episodes of excessive sweating for the past 6 months. After taking antibiotics sweating was checked.
Breathe – no complaints.
Discharges – nothing specific.
Thermals – ambi thermal towards chilly.
EXAMINATION – A KEY TO DIAGNOSIS
Oral temperature – 103F. Other vitals under normal limits.
Continuous type of fever.
Respiratory system – BAE+. No added sounds.
GIT – Inspection – abdomen distended/ no scar marks on inspection
Palpation – Tenderness in right iliac fossa and umbilical region. No tenderness in the McBurney’s point. No organomegaly. Percussion – tympanic sounds heard. Dullness in the liver region. Liver spans normal. Auscultation – Hyperactive bowel sounds heard around the umbilicus.
THE FIRSTLINE INVESTIGATIONS AND PROVISIONAL DIAGNOSIS
As the fever persisted more than a week, blood tests were done for typhoid, dengue, and malaria. All reports came out to be negative. Her CBC revealed low haemoglobin levels – 10.8g/dl. Other parameters were found to be normal.
So, the patient was provisionally diagnosed to have acute gastroenteritis.
REPERTORISATION AND FIRST PRESCRIPTION
Based on the Repertorisation – Bryonia alba 30c was started in aqua Arsenicum album 30, and Nux vomica 30 was prescribed after the failure of bryonia.
AFTER THE PRESCRIPTION…
After Bryonia alba 30c, Arsenicum album 30 and Nux vomica 30 there was no improvement in the patient’s condition. Fever persisted – oral temp – 103F. Abdominal complaints also persisted. It was already a fever of more than 7 days and in spite of carefully selected remedies, symptoms persisted.
LOOKING CLOSER: THE IMPORTANCE OF PATIENT HISTORY
No history of travel, no history of contact with animals or birds.
- Past Medical History –
- She had episodes of sweating for the past 6 months on and off.
- History of Recurrent colds
- Obstetrical History – No children.
Husband died in 2004 – at an early age due to HIV/ cancer – details not available. - Family History –
Her paternal aunt had pulmonary tuberculosis
Father, mother – died due to ageing.
1 elder sister – alive and healthy.
At present she is living with her elder sister.
THE KEY TO DIAGNOSIS: LISTENING TO THE PATIENT’S STORY
The patient revealed that she doesn’t like to visit her aunt’s house, because she used to spit her expectoration here and there without any hygienic measures. On enquiring further, she revealed that her paternal aunt had been diagnosed with pulmonary tuberculosis. Patient had frequent visits and stays at her aunt’s house. This personal history of our patient, led us to the provisional diagnosis of intestinal tuberculosis, with ingestion being the possible route of spread.
FINDING THE ANSWER: DISCOVERING INTESTINAL TB
She was then sent for CT abdomen. Impression – diffuse wall thickening in the terminal ileum, ileo-cecal junction and cecum with mild narrowing of the lumen and regional lymphadenitis -? Koch’s few enlarged regional mesenteric lymph nodes are seen in the right iliac fossa. Post hysterectomy status.
CHOOSING THE TREATMENT: WHY WE USED PETROLEUM 30C
Repertory – Knerr repertory
Abdomen – pain eating – After, in tabes mesenterica: – Petr.
Abdomen – bloated – Pains, with, worse after eating or drinking, from accumulation of gas, lying down, and from menses (tabes mesenterica): – Petr.
Abdomen – Pains, with, worse after eating or drinking, from accumulation of gas, lying down and in afternoon (tabes mesenterica): – Petr.
Generals – Tired feeling – tabes mesenterica in- petr
Eating – abdomen colic – tabes mesenterica in – petr
Based on all these rubrics, Petroleum 30c, was started in aqua on 25/5/2023, 9pm.
Along with that Calcarea hypophosphorica 3x – 2-2-2AF was given.
Materia medica of Calcarea hypophosphorica – Scrofulosis, chlorosis and phthisis. anemias after acute diseases and chronic wasting diseases. Abdomen -At every attempt to eat, colicky pain in abdomen. Sunken and flabby. Colic, soreness and burning around navel. There was emaciation, loss of appetite, and he was as pale as a corpse. The appetite returned at once in great force.
Generalities.- Limbs perfectly powerless; unable to rise from chair or move either arms or legs in the least; generally unable to speak except in a low monotone. -Total loss of all desire to move or make any muscular exertion, with inability to do so.
AFTER THE REMEDY
Temperature gradually started to reduce from 103F to 102.6F then gradually returned to normal within 1 day. The offensive nature of the stool gradually reduced, the frequency of stools reduced, abdomen pain reduced gradually. Tiredness reduced, patient was able to sit up and walk about. Her appetite returned. She was then discharged within 3 days, on 27 May 2023.
At a follow up after 2 weeks, on June 10, 2023, she was healthy apparently, and had no complaints, no recurrence of fever nor any gastrointestinal symptoms. Rx – sac lac TDS for 1 month.
Follow up after 1 month on – July 7, 2023 – Better. No new complaints.
Due to financial constraints from the patient’s side, we were not able to take a repeat CT abdomen.
Temperature chart after homoeopathic medications
What we learnt from this case
- Diagnosis is important – Many say that homoeopathy doesn’t require diagnosis for choosing the remedy but in this case the simillimum was arrived at only after proper diagnosis of the underlying pathology. Our Materia medica and repertories contain a vast number of pathological conditions, which definitely guides us in the selection of the remedy.
- Importance of history – past/family/personal – Only upon deep interrogation of the patient’s history, we came to a provisional diagnosis of intestinal tuberculosis.
Literature review of tabes mesenterica
You can find a short-compiled repertory of intestinal TB here below.
Pdf link – short repertory of intestinal tuberculosis
References
- Cheng, W. et al. (2023). Case report: a case report and literature analysis on intestinal tuberculosis. BMC Infectious Diseases, 23, 559. https://doi.org/10.1186/s12879-023-08550-z[3] Recent advances in the diagnosis of intestinal tuberculosis. BMC Gastroenterology.
- Recent advances in the diagnosis of intestinal tuberculosis. BMC Gastroenterology. https://bmcgastroenterol.biomedcentral.com/articles/10.1186/s12876-022-02171-7
- Intestinal tuberculosis: a diagnostic challenge – PubMed. https://pubmed.ncbi.nlm.nih.gov/28609809/
a very instructive and inspiring case; without the words “in tabes mesenterica”, many of the rubrics would be rather non-specific, showing the importance of really understanding the case and not just adding up symptoms.