A CASE OF INTESTINAL TUBERCULOSIS MASQUERADING AS CROHN'S DISEASE IN A PATIENT TREATED WITH HIGH DOSE PREDNISONE.
Belissa M. Ramos Chaves*, Juan Ricardo, Ijeoma Eccles-James, Olesya Petrenko, Wilhelmine Wiese-Rometsch, Roberto A. Mercado, Kenneth Hurwitz
Sarasota Memorial Hospital - Florida State University Internal Medicine Residency, Sarasota, FL
Introduction: Extra pulmonary tuberculosis constitutes about 15 to 20% of all TB cases in immunocompetent patients. Intestinal TB is a rare disease in the United States and comprises of only 3-5% of all reported cases, a small fraction.
Case: A 52 y/o Colombian male who emigrated to the US 19 years ago, with a PMH of pneumonia with pleural effusions 3 years ago prior, presented to the ED with generalized fatigue, fever of 103°F, chills, intermittent watery non-bloody diarrhea, dry cough and resting dyspnea for a week. ROS was positive for 30lb unintentional weight loss over the past 3 months. The patient was diagnosed with septic shock. Two weeks prior to admission, he had been treated with high dose prednisone with a taper, after being diagnosed with Crohn's disease by a community gastroenterologist. Of note, the patient had a documented negative skin PPD and received the BCG vaccine at birth.
Vital Signs: BP 76/58 mmHg, RR 20, Temp 99°F, HR 126 bpm, and O2 saturation of 98% on 3L of supplemental O2.
Physical exam: HEENT: Oropharynx clear, ear canal intact, PULMONARY: rhonchi bilaterally, bibasilar crackles. ABDOMEN: soft, BS +, mild RLQ tenderness to deep palpation, no palpable mass. SKIN: No lesions.
LABORATORY AND IMAGING STUDIES : Hgb 10.4 g/dL, Na+ 126 mmol/dl, CRP 29.4 mg/dL, ESR 99 mm/hr. CT abdomen/pelvis with IV contrast showed moderate to severe mucosal thickening and enhancement involving the RUQ small bowel, distal and terminal ileum up to the ileocecal junction, with reactive mesenteric nodes.
Outpatient colonoscopy two weeks prior presentation showed severe diffuse inflammation with erythema, friability, serpentine ulcerations, at the terminal ileum, ileocecal valve, cecum, and distal sigmoid colon. Pathology results were consistent with severe inflammatory bowel disease (IBD); moderate to severely active Crohn's Disease in the terminal ileum, ileocecal valve, and sigmoid colon. Pathology was resent during patient's hospitalization which was positive for Acid Fast Bacilli (AFB). Prometheus serologic, genetic, and inflammatory markers were negative thus inconsistent with IBD however. The patient was placed on 60mg of Prednisone with a taper. CT of the chest showed diffuse airspace disease, predominately in the upper lobes, with a miliary pattern to the lung parenchyma extending inferiorly. Bronchial alveolar lavage was positive for pan-sensitive Mycobacterium TB complex, as were blood cultures. Quantiferon Gold testing for MTB was negative.
Discussion: Intestinal tuberculosis has non-specific features and often involves the same anatomic intestinal areas of other more commonly diagnosed abdominal pathologies such as Crohn's Disease. This may lead to diagnostic and treatment delays, further promoting the development of life-threatening complications.
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