TUBERCULOSIS IN DISGUISE: JEJUNAL TUBERCULOSIS PRESENTING AS PROTEIN-LOSING ENTEROPATHY WITH ANASARCA — A RARE CASE REPORT

Abstract

Background: Intestinal tuberculosis accounts for a substantial share of extrapulmonary tuberculosis, but its distribution across the gastrointestinal tract is uneven and isolated jejunal disease is uncommon. Protein-losing enteropathy, defined by excessive enteric loss of serum protein leading to hypoalbuminemia, is a rare and easily overlooked mode of presentation of intestinal tuberculosis. Case presentation: A 63-year-old man presented with a six-month history of abdominal pain, recurrent vomiting, bilateral lower-limb swelling and weight loss, without fever, cough, dyspnea or diarrhea. Examination revealed pitting pedal edema without abdominal distension. Investigations showed severe hypoalbuminemia (1.5 g/dL), low serum-ascites albumin gradient (0.5), and markedly elevated ascitic adenosine deaminase (65.4 U/L). Ultrasonography demonstrated free intraperitoneal fluid, and contrast-enhanced computed tomography showed diffuse mural thickening and mucosal edema of the jejunum and proximal ileum with mesenteric haziness. Ascitic cytology was negative for malignancy. Mini-laparotomy with mesenteric lymph node biopsy revealed caseating granulomatous inflammation, confirming a tuberculous etiology. Conclusion: Jejunal tuberculosis presenting as protein-losing enteropathy is rare and can mimic cardiac, hepatic or renal causes of edema. A high index of suspicion, supported by ascitic fluid SAAG and adenosine deaminase, cross-sectional imaging, and tissue biopsy, allows timely diagnosis. Anti-tubercular therapy combined with nutritional rehabilitation resulted in resolution of edema and normalization of albumin.