INTESTINAL TUBERCULOSIS PRESENTING WITH SEVERE LOWER GI BLEEDING

Abstract

A 28-year-old Vietnamese woman who immigrated to the US in 1993 presented to the ED with 5 days of LLQ abdominal pain and 5 bloody bowel movements in the past day. She felt feverish and had some nausea and vomiting. She lost several pounds in the past few weeks. She had no prior history of GI bleeding or abdominal pain or diarrhea. Her only medical history was a vaginal delivery one year ago and possible reactive PPD in the past. She smoked, drank 2 beers a month, and denied illicit drug use. She had no travel since 1993, but did have food items shipped from Vietnam. Her only family history was a brother who had a renal transplant in 1993. On exam, she had a temperature of 99.6° F, pulse of 108, and blood pressure of 91/51. She was awake and alert. Pertinent findings of physical exam included tachycardia, a clear chest, hyperactive bowel sounds, mild upper abdominal tenderness, and streaks of dark red blood on rectal exam. Labs included a hemoglobin of 9.1 that dropped to 4.9 over 6 hours and normal liver injury tests, coagulation factors, white cell count, and platelet count. Obstruction series showed mildly dilated loops of distal small bowel and reticular opacities in the upper lung fields. Stool culture and O&P were normal. A colonoscopy was performed and showed nodular, erythematous mucosa with ulcerations around the ileocecal valve. The remainder of the cecum and terminal ileum appeared normal. Biopsies were obtained. The endoscopic findings were suggestive of Crohn's disease, but given the abnormal chest radiography and possible history of reactive PPD, TB was also considered. Biopsies were sent for pathology and bacterial and AFB stains and cultures. The histology showed chronic inflammatory changes, submucosal noncaseating granulomas, and crypt abscesses. Pulmonary evaluation for underlying TB included a CT of the Chest showing cavitary areas in upper lobes. Bronchoscopy was normal and bronchial washings had negative AFB staining and culture. Colonic tissue staining for AFB was negative. Colonic tissue culture grew Mycobacterium tuberculosis by nuclear hybridization. Cases of TB have risen in the US in the past 15 years, but intestinal tuberculosis remains very uncommon, and massive lower GI bleeding is an uncommon presentation for intestinal tuberculosis. It is often difficult to distinguish from Crohn's disease. The diagnosis requires high clinical suspicion and diligent evaluation with multiple biopsies.