Intestinal Tuberculosis in an HIV-Infected Patient With Advanced Immunosuppression

Abstract

s e A homosexual man was admitted to our hospital with a 1-month history of fever, diarrhea, and anorexia. He as diagnosed with HIV infection 11 years earlier and since then, ad been treated with highly active antiretroviral therapy. On dmission, the patient was alert with a body temperature of 9.5°C. Laboratory tests on admission showed a low CD4 count 48 cells per L) and elevated C-reactive protein (13.88 mg/dL). Colonoscopy showed a few giant ulcers at the terminal ileum and a shallow ulcer at Bauhin’s valve (Figure A). A biopsy and aspiration of intestinal fluid from the lesions were then performed endoscopically. The biopsy specimen revealed numerous acid-fast bacilli on auramine staining (Figure B). Both biopsy and intestinal uid sample showed Mycobacterium tuberculosis with the polymerase hain reaction method. Computed tomography showed bilateral ulmonary miliary tuberculosis and a thickened ileum (Figure C). esults of acid-fast staining and polymerase chain reaction of the putum were positive. The acid-fast bacilli cultures of biopsy, ntestinal fluid, sputum, and blood were positive. Based on these ests, the final diagnosis was pulmonary tuberculosis, miliary tuerculosis, and intestinal tuberculosis. Treatment with oral isonizid, rifampicin, pyrazinamide, and ethambutol was started. After month of treatment, the patient’s clinical symptoms were much mproved, and colonoscopic appearance was changed to ulcer scar. There are various pathogens responsible for HIV-related diarhea,1 and it is difficult to predict the pathogen based on clinical features alone. Endoscopy not only is useful for obtaining an image, but it is also useful to biopsy the mucosal lesion and aspirate intestinal fluid.2 This diagnostic method was quite useful n this case because intestinal tuberculosis was not initially susected on macroscopic appearance alone. This is a rare case report ecause the diagnoses of intestinal, pulmonary, and miliary tuberulosis were reached owing to the examination of chronic diarrhea. Identical endoscopic findings, such as round, irregular-shaped, nd small ulcers have been reported in intestinal tuberculosis cases,3 but a giant deep ulcer is extremely rare. Cellular immunouppression may lead to the growth of M tuberculosis and the xpansion of the lesion, such as a giant, deep ulcer. Jones et al4 reported that extrapulmonary tuberculosis is more common in those with low CD4 cell counts in HIV patients. In this case, the patient, who had a low CD4 count (48 cells per L), showed pulmonary tuberculosis, miliary tuberculosis, and intestinal tuberculosis presenting as a giant deep ulcer. These manifestations of tuberculosis might be related to low CD4 cell counts.