A Case of Tuberculous Enteritis Mimicking Crohnʼs Disease

Abstract

Purpose: A 20-year-old Guatemalan male with no significant past medical history presented with complaints of one week of abdominal pain, nausea and vomiting. Labs were unremarkable. A CT scan of the abdomen and pelvis revealed evidence of a small bowel obstruction. After the patient showed no improvement in symptoms with bowel rest and decompression, a small bowel enteroscopy was performed. The enteroscopy showed a stricture within the proximal jejunum, ulcerations distal to the stricture, and diverticulae proximal to the stricture. Biopsies of the ulcerations revealed noncaseating granulomas. Acid fast bacilli (AFB) and fungal stains were negative. Based on the biopsy, there was a concern for the possibility of Crohn's disease so the patient was started on steroids and antibiotics. When the patient did not improve over the next 48 hours, he was referred for a surgical evaluation. A laparotomy revealed the presence of multiple peritoneal nodules, and lysis of adhesions was performed without bowel resection. Biopsies showed caseating granulomas with positive AFB stains. The patient's PPD, HIV test, and chest X-ray were all negative. The patient was started on rifampin, ethambutol, pyrizinamide, and levofloxacin. He showed an improvement in symptoms within six weeks. This case highlights the need for a high index of suspicion for tuberculous enteritis when evaluating patients with possible Crohn's disease, especially HIV patients and immigrants from areas where TB is endemic. Tuberculous enteritis rarely causes a small bowel obstruction. However, in cases where it causes strictures, obstruction is a common complication. Tuberculous enteritis is the most common extrapulmonary manifestation occurring in 25% of patients with pulmonary TB. Although our patient presented with proximal small bowel involvement, the majority of patients (75%) have distal small bowel and ileocecal involvement. As highlighted in this case, diagnosis is often difficult because common screening methods and microbiological diagnostics often fail to detect gastrointestinal TB. However, a prompt diagnosis can help prevent the development of serious complications such as intestinal fistulas, obstruction, and perforations.Figure: Small Bowel Enteroscopy described above