Primary Intestinal Tuberculosis Presenting as Crohn's Disease

Abstract

17 y.o. female, who had undergone a laparoscopic appendectomy two weeks prior to presenting with RLQ pain, weight loss, fevers and hematochezia. Pathology from the appendectomy was significant for multiple granulomas. Fungal and AFB stains were negative. An UGI with SBFT revealed 8 cm of abnormal terminal ileum, consistent with Crohn's disease. She was not evaluated endoscopically because of the recent appendectomy but was started on oral steroids and mesalamine. She clinically improved and underwent an EGD and colonoscopy six weeks later revealing Helicobacter pylori gastritis and mild inflammatory changes in the rectum and cecum. She was then lost to follow up for several months until she came into the ER with hematochezia, anemia, fever, and weight loss. CT scan of the abdomen and pelvis revealed thickening of the terminal ileum and cecum with some free fluid in the pelvis, her stool studies were negative. She was transfused with PRBCs and started on IV steroids, after a week without improvement she was given a dose of Infliximab with good clinical response. She was discharged home on a tapering dose of prednisone and sulfasalazine. She did well for several weeks until her return to the ER with similar symptoms. A repeat CT scan revealed mesenteric lymphadenopathy without any other new findings. She then underwent a repeat colonoscopy with gross evidence of ileitis, colitis and pseudo polyp formation. Biopsies revealed acute and chronic colitis with granuloma formation. A PPD placed prior to restarting steroids was negative. She was then started on a two week course of IV steroids and broad spectrum antibiotics without clinical improvement. A second dose of Infliximab was given without response. Her poor clinical progression led to an exploratory laparotomy for an ileocecal resection followed by an uncomplicated post operative course. The resected specimen was reviewed by our pathologist, who thought this could be an infectious process. It was also reviewed by a GI pathologist, who felt the specimen represented either Wegener's granulomatosis or Crohn's disease with post Infliximab histologic changes. After 37 days, however, Mycobacterium tuberculosis DNA was found via PCR from a lymph node, and a lymph node culture grew Mycobacterium tuberculosis. This patient had no risk factors for tuberculosis and her chest radiographs were negative at the time. She was subsequently treated with anti-Tb medications, but because of noncompliance, disease progression was noted on serial chest films. Once compliant and after completion of therapy, all of her symptoms resolved.