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An unusual cause of biliary peritonitis.

A 39 year old epileptic, non-smoking, Caucasian male presented with abdominal pain, pyrexia and generalized abdominal tenderness. He had had episodes of diarrhoea during the week prior to his admission. Investigations including chest X-ray were unremarkable apart from a leucocytosis of 13.2 x 109/1 and plasma albumin of25 g/l. A working diagnosis of acute appendicitis was made, and at laparotomy, an inflamed retro-caecal appendix was removed. The ileum was normal and no Meckel's diverticulum was detected. Histology revealed welldeveloped granulomatous appendicitis with widespread epitheloid granuloma becoming confluent in the submucosa and mucosa. Scattered acid-fast bacilli were present. The serosa showed only mild chronic inflammation with no granulomas. In retrospect he admitted to being unwell for the past year with abdominal pain, night sweats and a weight loss of 7 kg. On review after 4 months of drug treatment he was asymptomatic. This case illustrates many features of a disease rarely encountered in Great Britain. Weight loss, abdominal pain, diarrhoea and fever are typical symptoms of gastrointestinal tuberculosis, although the differential diagnosis should primarily include lymphoma, Crohn's and Yersinia enterocolitis. It is usual to find a normal chest X-ray and no signs of tuberculosis elsewhere in the body.2 Three types of clinical presentation of tuberculous appendicitis have been described. The most common is chronic disease with mild to moderate intermittent right iliac fossa pain indistinguishable from ileocaecal tuberculosis, acute obstructive appendicitis as in our patient, and a latent type discovered incidentally.' It is interesting that the patient had presented 9 months earlier with a non-traumatic right knee effusion. This was thought to be Rieter's syndrome and was successfully treated with non-steroidal anti-inflammatory drugs. However, it is probable that he had a peripheral arthritis which is a well-described manifestation of tuberculosis,3 the mechanism of which is poorly understood, although an immune complex arthritis has been suggested.4 A year after his initial illness no other symptoms ofarthritis have occurred. In the UK, isolated tuberculous appendicitis in a Caucasian is certainly unusual and according to our search has not been documented before. It seems that tuberculosis has replaced syphilis as the great mimicker of other diseases, and the diagnosis should be actively sought in view of ease of treatment with modern drug regimes.