1526 Abdominal Tuberculoma in a Cirrhotic Patient With Disseminated Tuberculosis

Abstract

INTRODUCTION: Disseminated tuberculosis (TB) is defined as two or more noncontiguous sites due to lymphohematogenous spread by Mycobacterium tuberculosis. Diagnosis is made through isolation of the organism from blood, bone marrow, or from two or more non-contiguous organs. Lymphocytopenia is a risk factor for dissemination. The incidence of disseminated TB is unclear, but of the cases reported in the United States in 2016, both pulmonary and extrapulmonary sites were reported in less than 10% of cases. We present a rare case of an abdominal tuberculoma in cirrhotic patient with disseminated tuberculosis. CASE DESCRIPTION/METHODS: 72 year old Vietnamese female with a history of hepatitis C cirrhosis who presents with altered mentation concerning for stroke. CT head without contrast was negative. She subsequently developed melena with an associated hemoglobin of 6.2 overnight. She underwent upper endoscopy without significant findings. CT chest without contrast showed numerous noncalcified nodules bilaterally as well as the apices concerning for military tuberculosis. BAL positive with AFB stain. Lumbar puncture did not show significant pleocytosis, normal glucose and protein. CSF culture was negative for AFB, cocci, Cryptococcus. Blood cultures, HIV 1/2 Ag/Ab screen 4th generation and serum cocci were negative. CEA was 2.7. MRI head with and without contrast showed multiple enhancing lesions concerning for infection versus malignancy. CT abdomen/pelvis showed a colonic mass in the cecum and ascending colon with thickening in the ileum. Colonoscopy showed a non-obstructing large mas in the cecum. Biopsies of the ileum and cecum were consistent with granuloma formation with necrosis, acid-fast bacilli with confirmation on AFB stain. The patient was started on RIPE therapy. Unfortunately, her encephalopathy did not improve despite 2 weeks of treatment and she was placed on hospice. DISCUSSION: Abdominal tuberculosis (TB) is reported in less than 5% of all cases of TB worldwide. It can present with non-specific symptoms such as fever, weight loss and abdominal pain. Endoscopic findings of intestinal TB vary from ulcers, strictures, nodules to deformed ileocecal valves and fistulas. Patients typically improve within weeks of initiating antituberculous therapy. One case report demonstrated correlation with carcinoembryonic antigen (CEA) pre -and post antituberculous therapy in a patient with multivisceral tuberculosis suggesting it could be a marker to trend response to therapy.