A CASE OF PULMONARY TB AND PERSISTENT INTESTINAL INFLAMMATION AND HEMORRHAGE: TB OR NOT TB?

Abstract

SESSION TITLE: Chest Infections SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/23/2019 8:45 AM - 9:45 AM INTRODUCTION: We present a case of pulmonary tuberculosis with intestinal hemorrhage initially thought to be due to tuberculous enteritis. CASE PRESENTATION: A 68 year-old man presented to the emergency department with two months of productive cough, anorexia, and weight loss. His medical history included untreated latent tuberculosis (TB) infection and nasal NK/T-cell lymphoma, which recurred after chemoradiation and required autologous hematopoietic stem cell transplantation 12 years prior to presentation. He took no medications. He was afebrile and hemodynamically stable with oxygen saturation of 97% breathing room air. He was cachectic and weighed 49 kg. Leukocyte count was 5.9 x 10ˆ9/L and hemoglobin 5.0 g/dL. Renal and liver function tests were normal. Computed tomography of the chest revealed extensive consolidations with cavitation and tree-in-bud opacities (Figure 1). Empiric treatment for TB was initiated with isoniazid, rifampin, pyrazinamide and ethambutol. Shortly after, sputum smear for acid-fast bacilli and GeneXpert were positive, and culture grew M. tuberculosis. Over the next two weeks, the patient developed hematochezia with a drop in hemoglobin to 6.1 g/dL. Computed tomography revealed a 40-cm segment of jejunum with wall thickening, mucosal enhancement, and ulceration (Figure 2). Stool cultures grew M. tuberculosis. Endoscopy revealed gastritis and a duodenal ulcer without bleeding and colonic diverticulosis. Pathology revealed acute inflammation without acid-fast bacilli or dysplasia. Several weeks later, he developed recurrent hematochezia with hemorrhagic shock. Repeat endoscopy revealed a new ulcerated mass in the stomach and several smaller ulcers in the jejunum. Pathology of the gastric lesion revealed diffuse large B-cell lymphoma (positive for CD20, BCL6, and CD10; negative for CD3, CD5, CD7, and CD56) while jejunal lesions revealed acute inflammation and large cells with inclusion bodies consistent with CMV enteritis. Smears and cultures for TB were negative. With chemotherapy and valgancyclovir treatment the patient improved, with weight gain and cessation of bleeding. DISCUSSION: Intestinal TB is difficult to diagnose because of non-specific signs and symptoms. In a patient with pulmonary TB, the presence of TB in the stool is not diagnostic because this may occur as a result of swallowed infected sputum. In this case, intestinal inflammation on imaging with pulmonary TB supported a diagnosis of TB enteritis. However, gastrointestinal hemorrhage necessitating transfusion is unusual in intestinal TB and its persistence for several weeks despite treatment suggested an alternative diagnosis. Eventually, two alternative diagnoses were found: CMV enteritis and lymphoma involving the gastrointestinal tract. CONCLUSIONS: This case underlines the importance of considering a broad differential for gastrointestinal signs and symptoms, even in the presence of pulmonary TB. Reference #1: Debi U, et al. Abdominal tuberculosis of the gastrointestinal tract: revisited. World J Gastroenterol. 2014;20(40):14831-40. Reference #2: Rahman SMM, et al. Evaluation of Xpert MTB/RIF assay for detection of Mycobacterium tuberculosis in stool samples of adults with pulmonary tuberculosis. PLoS One. 2018;13(9):e0203063. DISCLOSURES: Consultant relationship with Cohero Health Please note: $1-$1000 Added 03/14/2019 by Caralee Caplan-Shaw, source=Web Response, value=stock My spouse/partner as a Speaker/Speaker's Bureau relationship with Cook Incorporated Please note: $1001 - $5000 Added 08/05/2019 by Caralee Caplan-Shaw, source=Web Response, value=Consulting fee No relevant relationships by Andrew DeMaio, source=Web Response No relevant relationships by Imran Sulaiman, source=Web Response