Postoperative Diagnosis of Miliary Tuberculosis Masquerading as Acute Surgical Abdomen in an Immunocompromised Child: A Case Report

Miliary tuberculosis (TB) is a severe, life-threatening form of disseminated disease. In the postoperative setting, particularly among immunocompromised patients, its diagnosis is frequently delayed because its non-specific clinical presentation can easily masquerade as routine surgical complications. We report the case of an eight-year-old female with juvenile idiopathic arthritis, managed with chronic immunosuppressive therapy (methotrexate and adalimumab), who presented with acute abdominal symptoms. Over a one-month period, she underwent three major surgical interventions for a suspected appendiceal abscess and subsequent adhesive bowel obstruction, complicated by multiple intra-abdominal abscesses. In the immediate postoperative period following her third surgery, she developed severe acute respiratory distress. High-resolution computed tomography revealed a diffuse bilateral micronodular pattern alongside an ileocecal phlegmon. An interferon-gamma release assay (IGRA) was positive. Rather than relying on a single test, the diagnosis of active miliary TB was established based on the compelling overall clinicoradiologic picture, specifically the setting of severe immunosuppression, the characteristic diffuse pulmonary and intra-abdominal findings, and the patient's positive response to targeted therapy. Following prompt admission to the intensive care unit and the initiation of first-line antitubercular therapy combined with broad-spectrum antibiotics and respiratory support, the patient achieved a full clinical recovery. This case highlights the critical necessity for heightened diagnostic vigilance. Miliary TB must be included in the differential diagnosis of unexplained postoperative systemic failure or respiratory distress, particularly in immunocompromised patients or those originating from endemic regions. Early thoracic imaging and rapid therapeutic intervention are crucial determinants of patient survival.