How can my cousin’s health be improved?

Q: My 15 years old cousin underwent an ileotransverse anastomosis five months back to get the perforation in his terminal ileum corrected. The ultrasonography report indicated enlarged mesenteric nodes. The doctor told us that the perforation was due to typhoid. But two months after surgery he again developed the similar symptoms with fever between 100-104 degree F. The doctor did some tests and told us that his ESR is 50 and haemoglobin level is 9.4. He suspected it to be tuberculosis (TB) and started the medication for the same. My cousin’s health has deteriorated a lot in the last 15 days. He has lost almost 7-8 kg and his weight is 50 kg. Now, he again underwent ultrasonography and the same mesenteric nodes were found enlarged. The x-ray report is normal, Mantoux test is negative and the blood report is normal too. What else should we do in order to diagnose the root cause of his ailment? Please advise.

A:What does he have now? The likely possibilities are:

• Collection of pus in the abdomen, following surgery for perforation. This can only be properly diagnosed by a CT scan of the abdomen. Has this been done?
• A disease that causes fever, lymph node enlargement, and weight loss. The main causes are tuberculosis and lymphoma. The negative Mantoux goes against a diagnosis of tuberculosis (but does not completely rule out tuberculosis). If he has tuberculosis, the fever should respond within two weeks, almost definitely within three weeks. If not ask the doctors to think of a lymphoma.
• During surgery for perforation the doctors may have taken a biopsy from the edge of the ulcer. Get this biopsy reviewed. Tuberculosis (a common cause of perforation) would show up in the biopsy in most cases. Lymphoma rarely causes perforation, but would show up. Some other diseases show up as well, but not typhoid. If the histology report says "typhoid" this is only suggestive, not confirmatory. So if the doctors have taken a biopsy, get this reviewed.

Lastly, note that a positive PCR for tuberculosis is only indicative. It confirms that he has tubercle bacilli in the body, but does not prove that his fever and weight loss are caused by tuberculosis.

In summary: suggest to the doctors –

1. A CT scan to look for pus in the abdomen
2. Review biopsy, if any, taken during surgery
3. Get an evaluation for lymphoma.