An Unexpected Diagnosis of Tuberculosis Colitis

Abstract

Introduction: Tuberculosis (TB) remains one of the world’s deadliest diseases. The diagnosis of gastrointestinal TB, an extra pulmonary manifestation, poses a diagnostic challenge to health care providers due to its non-specific symptoms and varied presentation. Herein, we report a case of TB colitis. Case Report: A 71-year-old male with a history of hypertension, chronic kidney disease, and ischemic cardiomyopathy with recent implantation of a left ventricle assist device (LVAD) was found anemic with hemoglobin (Hgb) of 6.9g/dL from baseline of 12g/dL at a routine clinic visit. His only complaint was “low energy” for few weeks. He denies sweats, weight loss, chest pain, dyspnea, cough, hemoptysis, hematochezia, melenic stools, jaundice, or recent illness. There are no known sick contacts, new or recent medication changes, or history of supratherapeutic INR. He traveled to Vietnam about 2 years ago and is up to date on his immunizations. Physical examination was unremarkable except for conjunctival and skin pallor. Rectal exam was unremarkable and stool was negative for occult blood. Laboratory findings were consistent with iron-deficiency anemia (Hgb 6.6g/dL, Iron 18 μg/dL, ferritin 14ng/mL, TIBC 370, and saturation 4.9%). LFTs and LDH were within normal limits. Colonoscopy was performed with removal of a solitary 6-mm cecum ulcer and biopsies of ulcerated area of terminal ileum. He received red cell transfusions, anticoagulation agent was adjusted with a conservative INR goal, and he was started on iron-supplements with out-patient follow-up. Three weeks later, the patient returned with a near-syncopal event and Hgb of 8 gm/dL. He reported an episode of melena, bloody bowel movements, and vague abdominal discomfort. Infectious, auto-immune and malignancy work-up was initiated. Repeat colonoscopy was significant for increased ulceration of terminal ileum. Fungal (GMS), mycobacteria (Fite) and AFB-Kinyoun’s special stain again did not identifying an organism. The presence of inflammatory changes and caseating granulomas on pathology raised suspicion for TB. TB quantiferon and AFB cultures from biopsy specimen during second colonoscopy was positive for mycobacterium tuberculosis. He was started on RIPE therapy and continues to improve. Discussion: TB occurs worldwide. In 2012, the largest number of new cases occurred in Asia, accounting for 60% of new cases globally. Up to 3% of cases are extra-pulmonary. The GI tract is the sixth most common extra-pulmonary site of TB and most commonly involved is the ileocecal region due to the preponderance of lymphoid tissue, stasis of gut flow, and increased rate of fluid and electrolyte absorption. A high index of suspicion is required to make the diagnosis.