Intestinal perforation due to paradoxical reaction during treatment for miliary tuberculosis

A 61-year-old man was being treated for poor nutritional status. He had been on weekly methotrexate 6 mg and daily tacrolimus 1 mg and prednisolone 18 mg for 8 years due to dermatomyositis. On further workup, he was initially detected to have ileocecal ulcer with subsequent development of diffuse miliary shadows on chest radiograph. He was diagnosed as having ileocecal with miliary tuberculosis (TB). While receiving anti-tuberculous therapy, there was initial improvement of TB-related symptoms and he had no conditions that interfered with the efficiency of the anti-tuberculous therapy. However, he developed intestinal perforation. Emergency surgery for resection of the ileocecal ulcer and ileocolostomy led to improvement and he was finally discharged. Recently, cases of intestinal TB have been rare and perforation due to TB is extraordinary. In this case, paradoxical reaction and poor nutritional status may have contributed to the intestinal perforation.