Vol.1, No.3, 37-39 (2013) Journal of Tubercul osis Resear ch
Appendicular tuberculosis presenting as
enterocutaneous fistula over thighA rare case
report with review of literature
Vaibhav Pandey*, Ajay Narayan Gangopadhyay, Shiv Prasad Sharma, Vijayndar Kumar
Department of Pa e d ia t r ic Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India;
*Corresponding Author: sunny.imsbhu@gmail.com
Received 23 July 2013; revised 11 September 2013; accepted 24 September 2013
Copyright © 2013 Vaibhav Pandey et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abdominal tuberculosis is a significant cause of
morbidity and mort ality in children in developing
countries. Primary involvement of appendix is
very rare. Presentation is usually non specific
and diagnosis is made in most cases on histo-
pathlogical examination following appendicec-
tomy. This to our knowledge is the first case of
appendicular tuberculosis presenting primarily
as spontaneous enterocutaneous fistula over
front of right thigh. Barium meal follow-through
was diagnostic. Appendicectomy was perform-
ed followed by anti-tubercular treatment which
was curative.
Keyw ords: Tubercular Appendicitis; Abdominal
Tuberculosis; Enterocutaneous Fistula
Abdominal tuberculosis continues to be a significant
cause of morbidity and mortality in children in develop-
ing countries. Ileocaecal region is most common site of
involvement and accoun ts for 75% of the gastrointestinal
tuberculosis; primary involvement of appendix is very
rare and accounts for only 0.6% to 2.9% [1]. Here we
report a case of primary appendicular tuberculosis in a
child presented with enterocutaneous fistula in front up-
per part of right thigh.
A 4-year-old female child presented with pain com-
plaints of pain and swelling over front of right thigh as-
sociated with high grade fever. A diagnosis of a suppura-
tive abscess was made and incision and drainage was
done outside, following which she developed fecal dis-
charge from the incision site (Figure 1). Patient had also
mild pain in right iliac fossa. On examination there was
guarding and mild tenderness in the right iliac fossa. Ul-
trasonogram of abdomen showed localized collection in
the right iliac fossa. Barium meal follows through show-
ed spillage of dye from Ileocaecal region and presence of
fistulous tract towards right thigh. Exploratory laparo-
tomy was performed, intraoperatively appendix was in-
flammed and there was a perforation over the tip of ap-
pendix (Figure 2) with purulent fluid in the right iliac
fossa. Terminal ileum, rest of the bowel, peritoneum and
other abdominal organs were normal. On further explo-
ration, fistulous tract was found in the iliac fossa going to
the front of thigh. Appendectomy followed by curettage
of the tract with minimal debridement of the edge was
done. Appendectomy specimen and the biopsy from the
edge of the tract were sent for histopathological exami-
nation. Histological picture of the appendix showed fea-
tures of tuberculosis. Investigations for pulmonary and
extrapulmonary tuberculosis were negative. Anti tuber-
cular treatment (ATT) was started and patient was dis-
charged on 10th post operative day. On 6 months fo llow-
up patient w as asymptomatic with healed fistula.
Abdominal tuberculosis is a major cause of morbidity
and mortality in children. Ileocaecal region is most
common site with involvement in about 40% of cases.
Appendicular tuberculosis is very rare as primary in-
volvement of appendix is found only in 1% of cases [1].
The minimal contact of appendix with intestinal contents
has been implicated as cause of this rare involvement.
Direct haematogenous spread is the cause of isolated
appendicular involvement, though some authors believe
that appendicular involvement is always secondary to
Copyright © 2013 SciRes. OPEN A CCESS
V. Pandey et al. / Journal of Tuberculosis Re search 1 (2013) 37-39
Figure 1. Enterocutaneous Fistula over front of right thigh.
Figure 2. Barium spillage seen from ileocaecal region towards
the right thigh.
primary caecal involvement [2]. In most cases diagnosis
is made postoperatively following histopathlogical ex-
amination. The prevalence of tuberculosis in the appen-
dectomy specimens removed surgically for appendicitis
is up to 2.9% in the reported studies [3]. In symptomatic
cases recurrent episodes of right iliac fossa pain, vomit-
ing and diarrhea are commonest presentation [4]. Though
Spontaneous enterocutaneous fistula over scar of a pre-
vious appendicectomy has been reported [5], this is to
our knowledge first case presenting primarily as sponta-
neous enterocutaneous fistula over front of right thigh.
Barium studies and CECT can show the actual tract of
the fistula and also locate any associated pathology [6].
In our case barium meal follow-through was able to
diagnose the site of fistula preoperatively. In most cases
evidence of primary tuberculosis is not found [7]. Histo-
pathlogical examination showed lymphoid hyperplasia
with associated caseating granulomas [8].
Enterocutaneous fistula on right thigh in a case of ap-
pendicitis should raise the high suspicion of underlying
appendicular tuberculosis. Barium meal follow-through
is very useful for preoperative diagnosis. Appendicec-
tomy followed by anti tubercular treatment is required
for cure.
[1] Chou Rasheed, S., Zinicola, R., Watson, D., Bajwa, A.
and McDonald, P.J. (2007) Intra-abdominal and gastroin-
testinal tuberculosis. Colorectal Disease, 9, 773-783.
http:// dx.doi.o rg/1 0.1111/j.1463-1318.2007.01337.x
[2] Singh, M.K., Arunabh and Kapoor, V.K. (1987) Tuber-
culosis of the appendix—A report of 17 cases and a sug-
ges te d aetiopathological classification. Postgraduate Med-
ical Journal, 63, 855-857.
[3] Pujari, B.D., Jeyaramaiah, M. and Deodhar, S.G. (1981)
Tubercular appendicitis. Journal of the Association of
Physicians of India, 29, 1025-1028.
[4] Agarwal, P., Sharma, D., Agarwal, A., Agarwal, V., Tan-
don, A., Baghel, K.D., et al. (2004) Tuberculous appendi-
citis in India. Tropical Doctor, 34 , 36-38.
[5] Singh, O., Gupta, S., Moses, S. and Jain, D.K. (2009)
Spontaneous tubercular enterocutaneous fistula develop-
ing in the scar of a surgery done 14 years earlier. Saudi
Journal of Gastroenterology, 15, 261-263.
[6] Chintamani, Badran, R., Daniel, R.K., Singhal, V. and
Bhatnagar, D. (2003) Spontaneous entrocutaneous fistula
27-years following radiotherapy in a patient of carcinoma
penis. World Journal of Surgical Oncology, 1, 23-26.
[7] Bhansali, S.U. (1977) Abdominal tuberculosis: Experi-
ence with 300 cases. The American Journal of Gastroen-
terology, 67, 324-327.
Copyright © 2013 SciRes. OPEN A CCESS
V. Pandey et al. / Journal of Tuberculosis Re search 1 (2013) 37-39
Copyright © 2013 SciRes. OPEN A CCESS
[8] Gupta, S.C., Gupta, A.K., Keswani, N.K., Singh, P.A.,
Tripathi, A.K. and Krishna, V. (1989) Pathology of tropi- cal appendicitis. Journal of Clinical Pathology, 42, 1169-
1172. http://dx.doi.org/10.1136/jcp.42.11.1169