3208 Small Bowel Obstruction Due to Tuberculous Lymphadenopathy

Abstract

INTRODUCTION: Mycobacterium tuberculosis is estimated to infect 1.7 billion people worldwide. When untreated, disseminated tuberculosis can occur through hematogenous seeding from primary infection or reactivation of latent disease. Abdominal tuberculosis can be seen in 5% cases of tuberculosis worldwide, with complications such as bowel obstruction resulting from localized infection or tuberculous lymphadenopathy. We present a patient with a history of latent tuberculosis who presented with bowel obstruction secondary to calcified mesenteric lymphadenopathy. CASE DESCRIPTION/METHODS: An 82-year old woman was initially seen in Pulmonology clinic regarding latent tuberculosis. Testing was notable for a positive interferon gamma release assay and a chest CT showed calcified lymphadenopathy in the neck and chest. She was started on isoniazid but was unable to tolerate the medication due to dizziness, headaches, and gastrointestinal upset. Over the next year, she developed intermittent abdominal discomfort and was eventually hospitalized for severe abdominal pain, nausea and vomiting. Physical examination revealed stable vital signs and a mildly distended abdomen. Laboratories were notable for a sodium of 129 mmol/L and hemoglobin 11.3 g/dL. An abdominal CT revealed a dilated stomach and duodenum with a transition point in the distal duodenum. There were multiple new calcified mesenteric and retroperitoneal lymph nodes compressing the distal duodenum, causing partial small bowel obstruction (Figure A). Subsequent esophagogastroduodenoscopy demonstrated white plaques in the distal esophagus, consistent with candida esophagitis (Figure B). The stomach and duodenal mucosa appeared endoscopically normal, with exception of narrowing at the second portion of the duodenum. This was suggestive of extrinsic compression and correlated with the area seen on the CT scan (Figure C). Duodenal biopsies were unremarkable. Her presentation was attributed to progressive calcific tuberculous lymphadenopathy and she improved with conservative management. Due to her other comorbidities and intolerance of prior therapy, anti-tubercular treatment was not pursued. DISCUSSION: Bowel obstruction is a common complication of abdominal tuberculous. Calcified tuberculous lymphadenopathy should be considered in the differential as a cause for bowel obstruction in patients with a history of untreated latent tuberculosis. Most cases clinically improve with medical therapy; however, in some cases, surgical management is needed.