1514 Intestinal Tuberculosis Presenting as GI Bleed and Cecal Mass

Abstract

INTRODUCTION: Abdominal tuberculosis (TB) is rare and comprises only 5% of all cases of TB. Lower GI bleeding occurs in 5-15% of patients with intestinal TB, with the ileocecal region is the most common site of hemorrhage. We present a case of disseminated TB with intestinal involvement, presenting as a GI hemorrhage and cecal mass. CASE DESCRIPTION/METHODS: A 72-year-old female of Vietnamese origin with PMH of dementia and chronic hepatitis C presented to our hospital with a chief complaint of increased somnolence and melena. She was febrile, hypotensive, and tachycardic. Labs showed a hemoglobin of 6.2 and hematocrit of 20.3. She was admitted to the ICU for presumed sepsis due to a UTI, and was initiated on broad spectrum antibiotics. She was transfused packed red blood cells, and treated with IV pantoprazole and IV octreotide. Ultimately she underwent an EGD which was unremarkable. Subsequent workup with a chest CT revealed innumerable non-calcified bilateral lung nodules concerning for granulomatous disease. She underwent a bronchoscopy, and BAL was positive for AFB on cultures. Anti-TB therapy with rifampin, isoniazid, pyrazinamide and ethambutol was initiated. Due to ongoing encephalopathy an MRI of the brain was performed and showed multiple enhancing nodules suggestive of disseminated or metastatic disease. Ultimately a CT abdomen pelvis was performed showing a possible cecal and ascending colon mass with ileal thickening in the R pelvis. Subsequently a colonoscopy was performed which revealed an ulcerated non-obstructing mass at the ileocecal valve, with oozing and stigmata of recent bleeding. Biopsies showed granuloma formation with necrosis, with acid-fast bacilli confirmed on AFB stain. DISCUSSION: Intestinal TB is rare in Western countries and has a higher incidence in migrant populations. Its nonspecific features make establishing a diagnosis difficult. It should be considered in the differential diagnosis of GI hemorrhage in the appropriate clinical setting. As the presentation of colonic TB often mimics that of a neoplasm, colonoscopy with tissue biopsy remains the main stay of diagnosis.