Intestinal Tuberculosis Mimicking Inflammatory Bowel Disease as an Initial Presentation of AIDS

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Purpose: A 44-year-old African-American male presented with three months of right-sided abdominal pain and two weeks of bloody diarrhea, fevers and 20-pound weight loss. CT showed necrotic mesenteric lymphadenopathy and reactive thickening of the mid-small bowel; patient preferred workup as an outpatient. Three months later, he presented with pancytopenia and was diagnosed with HIV and CD4 count of 54. After six months of HAART, the mesenteric lymphadenopathy improved. Infection, neoplasm and inflammatory bowel disease were considered, but the patient was reluctant to undergo further workup. He eventually developed progressive abdominal pain and small bowel obstruction. Colonoscopy revealed friable, edematous mucosa in the terminal ileum and a fungating, ulcerated mass at the ileocecal valve with multiple ulcers throughout the ascending colon and cecum. Pathology of the mass showed poorly formed granulomas with multinucleated giant cells. Testing for CMV, HSV, AFB, Yersinia, and fungal organisms were negative. Mesenteric lymph node biopsy showed necrotizing granulomatous inflammation, but culture was negative. One month later, ileocecal AFB culture grew Mycobacterium tuberculosis (MTB). He was started on 4-drug MTB therapy with improvement in his symptoms and imaging. MTB is a rare cause of colitis in the industrialized world. In countries where the disease is endemic, MTB colitis is common and often indistinguishable from Crohn's Disease. Both disorders cause similar granulomatous change, mucosal erythema, ulceration, and nodularity. Abdominal MTB can involve the peritoneum, intestines, intraabdominal lymph nodes, and liver. Ninety percent of cases in the GI tract affect the ileocecal region. Pulmonary involvement is present in up to 50% of patients with GI MTB. In patients with HIV/AIDS, immune reconstitution after initiation of anti-retrovirals is associated with worsening of MTB infection in up to 40% of cases, and worsening can be seen after initiation of anti-MTB therapy as well. Though rare, TB colitis should be considered in patients with symptoms and imaging suggestive of colonic ulceration and inflammation. A high index of suspicion is essential in timely diagnosis and management of GI MTB.Figure: [1194]