The present case report describes the diagnostic approach in a middle-aged, immunocompetent male with risk factors for tuberculosis who presented with chronic, nonspecific abdominal symptoms that culminated in intestinal perforation secondary to undiagnosed abdominal tuberculosis.

Given the clinical and pathological findings, a comprehensive review of similar cases and diagnostic challenges is warranted. Reports in the literature have documented similar presentations of intestinal tuberculosis in immunocompetent adults, often involving chronic, vague abdominal symptoms that mimic other gastrointestinal pathologies. The review article by Debi et al (16) indicated that the ileocecal region is the most commonly affected site, with perforation occurring in <5% of cases, typically in advanced or undiagnosed disease. In the study by Ahmed et al (17), patients with intestinal tuberculosis presented with abdominal pain, altered bowel habits, fever and weight loss, features that overlap with malignancies or inflammatory bowel diseases, such as Crohn's disease. Moreover, the majority of cases required surgical exploration for definitive diagnosis, as preoperative imaging and laboratory tests often failed to confirm the etiology (17).

In the case series by Chan and Lee (18), several patients without HIV or other known causes of immunosuppression presented with perforation due to intestinal tuberculosis, with diagnosis achieved only postoperatively via histopathology. These findings align with the present case, where the lack of specific clinical indicators, the gradual onset of symptoms, and a non-specific response to initial symptomatic treatment delayed appropriate intervention. This underscores the necessity of considering abdominal tuberculosis in the differential diagnosis of chronic abdominal pain, even in the absence of clear immunosuppressive factors, particularly in regions with an intermediate or high prevalence of tuberculosis.

Additionally, the increasing incidence of atypical and extrapulmonary tuberculosis in younger populations without classic risk factors highlights the evolving epidemiological landscape of this disease (19). This reinforces the importance of a multidisciplinary diagnostic strategy and heightened clinical suspicion, particularly when non-specific gastrointestinal symptoms are accompanied by weight loss, systemic signs, or a suggestive family or epidemiological background.

Tuberculosis is an infectious disease known since antiquity; its causative agent was identified in the 19th century, a period marked by significant disease spread. Due to its predominant respiratory manifestations, tuberculosis was soon recognized as one of the first major global public health challenges (20). Although its incidence has declined in recent decades, tuberculosis remains one of the leading causes of mortality from infectious diseases. Currently, up to 15% of all cases are extrapulmonary, with abdominal tuberculosis being the most common form, prompting the WHO to prioritize its early identification (21).

Abdominal tuberculosis may result from the direct ingestion of the pathogen or hematogenous dissemination from a primary pulmonary focus, mediated by immune cells (22). Once in the abdominal cavity, Mycobacterium tuberculosis can affect the gastrointestinal tract, peritoneum, solid abdominal organs and mesenteric lymph nodes. Although it shares risk factors with pulmonary tuberculosis, it also presents distinct characteristics, being more commonly observed in women and in patients with chronic conditions that induce a pro-inflammatory state, even in the absence of overt immunosuppression (23).

In the case presented herein, the identified risk factors did not fully align with those typically described for abdominal tuberculosis. The absence of prolonged, specific symptoms and the abrupt clinical worsening hindered the initial diagnosis. This aligns with previous reports highlighting the difficulty of establishing an etiologic diagnosis in immunocompetent individuals, where confirmation is achieved only after a thorough clinical history is obtained (24,25). Similar cases have been described in patients of comparable age and immune status, without evident risk factors, who developed acute disease following nonspecific constitutional and gastrointestinal symptoms. In such instances, diagnosis was only reached after comprehensive imaging, serologic testing and histopathologic evaluation (26).

Beyond clinical features, the patient in the present study exhibited unconventional, yet relevant risk factors, such as high-risk behaviors and a history of poor hygiene (27,28). Additionally, prior epidemiological research has reported that in northern and northeastern regions of Mexico, where the patient was originally from, latent or oligosymptomatic tuberculosis is prevalent, particularly among young and middle-aged males, possibly explaining the primary infection in this case (29).

Although the patient described herein did not present with respiratory symptoms, imaging analyses revealed a pulmonary cavitation, consistent with latent tuberculosis. This finding may contribute to the development of extrapulmonary forms of the disease (30). Household exposure, particularly the history of a sister who succumbed due to pulmonary tuberculosis, supports the hypothesis of prior latent infection (31). Notably, a number of young patients discontinue prophylactic treatment or follow-up, even when a direct family history is present, particularly in contexts lacking support networks or with gaps in epidemiologic surveillance (32).

It is also worth noting that the onset of symptoms in this patient coincided with the COVID-19 pandemic in Mexico. In this context, it is reasonable to consider that the tuberculosis diagnosis may have been delayed due to prioritization of COVID-19 cases and the suspension of screening programs in high-risk populations (33). While the pandemic highlighted the importance of infectious diseases, it also negatively affected the care of other conditions, particularly respiratory illnesses (34). The strain placed on epidemiological surveillance systems led to under-diagnosis and clinical deterioration in patients with tuberculosis, which may have influenced the outcome in the case described herein (35).

The present case report is subject to several limitations. First, the diagnosis of intestinal tuberculosis was only confirmed post-operatively through histopathology, as microbiological cultures or PCR testing were not performed. Second, the clinical course of the patient was documented over a limited follow-up period, which restricts the evaluation of a long-term treatment response. Additionally, healthcare disruptions during the COVID-19 pandemic may have contributed to diagnostic delays. As with all single-case reports, generalizability to broader populations is limited.

Although detecting latent tuberculosis could aid in identifying non-specific clinical presentations and preventing extrapulmonary forms, its diagnosis remains challenging. The wide variability in the sensitivity of available tests, compounded by diverse immunological and inflammatory conditions in the Mexican population, limits the feasibility of mass screening strategies (36). Nevertheless, the complex interaction between Mycobacterium tuberculosis and its host promotes mutations that confer antimicrobial resistance (37). The rising prevalence of multidrug-resistant strains has renewed interest in the follow-up and treatment of latent tuberculosis infections (38). In this context, case reports, such as the present one underscore the need to strengthen adherence to therapeutic and prophylactic regimens among contacts of diagnosed patients, and to consider tuberculosis in the differential diagnosis of acute abdominal syndromes, even in young, immunocompetent men with no specific clinical history (39). The present case report serves as a valuable reminder of the varied presentations of tuberculosis and the need for vigilance even in non-immunocompromised individuals.

In conclusion, intestinal tuberculosis remains a diagnostic challenge, particularly in immunocompetent patients presenting with non-specific abdominal symptoms and no clear history of recent exposure. The case described in the present study highlights the importance of maintaining a high index of clinical suspicion in atypical abdominal presentations, particularly in endemic regions and among individuals with unconventional risk factors, such as poor hygienic conditions or a family history of tuberculosis. The surgical outcome resulting from an advanced form of abdominal tuberculosis underscores the need to strengthen early detection systems, particularly in settings where epidemiologic surveillance has been weakened, such as during the COVID-19 pandemic. The timely identification of latent tuberculosis and adherence to prophylactic treatment protocols could help prevent severe complications, including intestinal perforation. The present case report emphasizes the value of a multidisciplinary approach and the combined use of clinical, radiological and histopathological tools for the comprehensive diagnosis of this condition.