Cases Of Intestinal Tuberculosis Research Articles

Successful Management of Complex Intestinal Tuberculosis with Ileal Perforation: A Case Report

Background: Intestinal tuberculosis (ITB) with ileal perforation represents a formidable challenge in the realm of extrapulmonary tuberculosis. This case report underscores the complexities inherent in managing such cases, highlighting the critical need for a multidisciplinary approach that integrates pharmacological and surgical interventions. Case presentation: A 57-year-old male presented with a history of both pulmonary and intestinal tuberculosis, complicated by ileal perforation. He had previously undergone a six-month course of anti-tuberculosis treatment and a laparotomy for ileal perforation repair. The patient's current presentation included abdominal pain, nausea, and vomiting, indicative of obstructive ileus. Diagnostic assessments revealed elevated inflammatory markers and imaging confirmed partial obstructive ileus and active pulmonary tuberculosis. The patient was managed with extended anti-tuberculosis therapy and intravenous antibiotics, resulting in significant clinical improvement and enhanced quality of life. Conclusion: This case report emphasizes the importance of early detection, comprehensive assessment, and individualized treatment plans in managing complex ITB cases. The successful outcome achieved in this case underscores the efficacy of a multidisciplinary approach that combines pharmacological and surgical interventions.

A meta-analysis of the accuracy of Xpert MTB/RIF in diagnosing intestinal tuberculosis.

A detection method with high efficiency and accuracy is urgently needed in clinical work. The purpose of our study was to determine the diagnostic accuracy of the Xpert MTB/RIF assay for intestinal tuberculosis (ITB). We searched PubMed and 4 other databases from their establishment to July 19, 2022, for published essays of diagnostic performance in which Xpert MTB/RIF was used to test patients with clinically suspected ITB. An assessment of the quality of the selected literature was conducted using QUADAS-2. We built forest plots by MetaDiSc software. The pooled Xpert MTB/RIF sensitivity was 48%, and the specificity was 99%. Moreover, the positive likelihood ratio for ITB diagnosis was 21.61. The negative likelihood ratio was 0.54. There were substantial variations between the study estimates of sensitivity (I2 = 87.6%) and specificity (I2 = 82.4%). Intestinal TB is detected with limited diagnostic sensitivity by Xpert MTB/RIF but with high specificity. An Xpert-positive result may facilitate the rapid identification of ITB cases. Nevertheless, a negative result has less certainty in excluding the disease.

Role of cytokines in Granulomatous Colitis

Background: Intestinal tuberculosis (ITB) have significant immunological similarity with Crohn’s disease (CD). T helper cells and various cytokines secreted by them play a very crucial role in the pathogenesis of both the diseases. It is of great clinical relevance in a country like India to perform a comparative study between CD and ITB with respect to pathogenesis.
 Objectives: To study the levels of four cytokines(IL-4,IL-17, IFN-ϒ & TGF-β1 ) s in serum of patients with CD & ITB which indirectly reflects the levels of CD4+ T cells.
 Material and method: An observational, cross-sectional study was done on patients, attending Gastroenterolory clinic in a tertiary care hospital, with features of ileitis, colitis or ileo-colitis due to CD or ITB.12 cases of Crohn’s disease & 13 cases of intestinal tuberculosis were taken( control-20 cases). 5 biopsies were taken from the ulcerated mucosa & 3 biopsies were taken from normal mucosa. H & E study & serum levels of four cytokines(IL-4,IL-17, IFN-ϒ & TGF-β1 ) were estimated.
 Results & analysis: In CD & ITB we found marginal increase of IFN-ϒ & TGF-β1 compared to control. IL17 level was found decreased in ITB compared to control (p=0.001).CD4+ T cells study by ELISA also showed significant increase in the concentration of IFN-γ (p=0.007) in ITB. There was no change in IL4 levels.
 Conclusion: Cytokines have an important role in the pathogenesis of grannulomatuos inflammatory bowel diseases. The identification of cytokines & their role in the pathogenesis might be helpful for future therapy based on cytokines, and anti-cytokine antibodies.
 Bangladesh Journal of Medical Science Vol.20(4) 2021 p.784-789

Ten Cases of Intestinal Tuberculosis Which Were Initially Misdiagnosed as Inflammatory Bowel Disease.

Objective Intestinal tuberculosis (ITB) and inflammatory bowel disease (IBD) frequently present with similar clinical, endoscopic and pathological features, therefore it is difficult to differentiate between them. The aim of this study was to elucidate the diagnostic delay and prognosis of ITB cases, initially misdiagnosed as IBD. Methods ITB cases were selected from the hospitalized patient list between April 2004 and March 2017 in a tuberculosis center in Japan. We retrospectively evaluated the initial diagnosis, clinical characteristics, endoscopic and pathological findings, bacterial examinations, treatment and prognosis. Results Among 66 ITB patients, ten patients were initially misdiagnosed as IBD. Seven patients were male and the median age was 60.5 years (23-74 years). After the diagnosis of IBD, all the patients were treated with mesalazine, in addition to corticosteroids in two patients and sequential azathioprine and infliximab in one. The median duration of diagnostic delay was 5.5 months (range 0.5-17 months). Eight patients had active pulmonary tuberculosis at the diagnosis of ITB. Acid-fast bacilli were confirmed in four of seven patients by reevaluation of the pathological specimens at the IBD diagnosis. Two patients needed intestinal resection and one with erroneous corticosteroid use for IBD died due to respiratory failure in spite of receiving appropriate treatment for tuberculosis. Conclusion ITB patients were frequently misdiagnosed and treated as IBD, thus resulting in a poor clinical outcome even after finally making a correct diagnosis and administering appropriate treatment. On diagnosis of IBD and/or treatment failure, chest radiograph and acid-fast bacilli of the pathological specimens should be carefully evaluated in order to rule out tuberculosis.

Development and Validation of a Novel Diagnostic Nomogram to Differentiate Between Intestinal Tuberculosis and Crohn's Disease: A 6-year Prospective Multicenter Study.

Differentiating Crohn's disease (CD) from intestinal tuberculosis (ITB) remains a diagnostic challenge. Misdiagnosis carries potential grave implications. We aimed to develop and validate a novel diagnostic nomogram for differentiating them. In total, 310 eligible patients were recruited from 6 tertiary inflammatory bowel disease centers. Among them, 212 consecutive patients (143 CD and 69 ITB) were used in the derivation cohort for the establishment of diagnostic equation and nomogram; 7 investigative modalities including clinical manifestations, laboratory results, endoscopic findings, computed tomography enterography features, and histology results were used to derive the diagnostic model and nomogram. Ninety-eight consecutive patients (76 CD and 22 ITB) were included for validation of the diagnostic model. Eight out of total 79 parameters were identified as valuable parameters used for establishing diagnostic equations. Two regression models were built based on 7 differential variables: age, transverse ulcer, rectum involvement, skipped involvement of the small bowel, target sign, comb sign, and interferon-gamma release assays (for model 1) or purified protein derivative (for model 2), respectively. Accordingly, 2 nomograms of the above 2 models were developed for clinical practical use, respectively. Further validation test verified the efficacy of the nomogram 1 with 90.9% specificity, 86.8% sensitivity, 97.1% PPV, 66.7% negative predictive value (NPV), and 87.8% accuracy for identifying CD, and the efficacy of the nomogram 2 with 100% specificity, 84.2% sensitivity, 100% positive predictive value, 64.7% NPV, and 87.8% accuracy for diagnosing CD. The derivation and validation cohorts identified and validated 2 highly accurate and practical diagnostic nomograms for differentiating CD from ITB. These diagnostic nomograms can be conveniently used to identify some difficult CD or ITB cases, allowing for decision-making in a clinical setting.

CD73 expression in tissue granulomas in distinguishing intestinal tuberculosis from Crohn’s disease in a South African cohort

Introduction: Overlap of clinical, endoscopic and radiographic features, coupled with a poor microbiological yield makes differentiating Crohn’s disease (CD) from intestinal tuberculosis (ITB) challenging. A potential histological differentiating mechanism is the use of immunohistochemical staining for the mesenchymal stem cell marker CD73, as a pilot study showed ITB but not CD granulomas stained positive for this marker. The aim of this study was to assess the value of CD73 in differentiating ITB from CD granulomas in a South African cohort.Methods: Patients with confirmed CD or ITB were identified from a pathology database. Tissue sections were reviewed by a pathologist to confirm the presence of granulomas. These were then stained with a mouse monoclonal anti-CD73 antibody. The slides were examined together by a pathologist and gastroenterologist in a blinded manner for anti-CD73 staining around granulomas.Results: Ninety six cases were available for analysis; 50 cases of ITB and 46 cases of CD. Thirty percent of CD granulomas (14/46) stained positive for CD73, whereas CD73 positivity was seen in 52% (26/50) of cases of ITB. This was statistically significant (OR 2.48, 95% CI 1.1–5.72, p = .03). The area under the curve (AUC) was 0.61. Sensitivity of CD73 in predicting ITB was 52% and specificity was 70%. Overall CD73 staining of granulomas correctly classified only 60% of cases.Conclusions: In our study we have shown that significantly more patients with ITB express CD73 in their granulomas than those with CD. However the relatively poor sensitivity, specificity and AUC make this test unlikely to be of value in our clinical practice.

Diagnostic classification of endosonography for differentiating colorectal ulcerative diseases: A new statistical method.

AIMTo establish a classification method for differential diagnosis of colorectal ulcerative diseases, especially Crohn’s disease (CD), primary intestinal lymphoma (PIL) and intestinal tuberculosis (ITB).METHODSWe searched the in-patient medical record database for confirmed cases of CD, PIL and ITB from 2008 to 2015 at our center, collected data on endoscopic ultrasound (EUS) from randomly-chosen patients who formed the training set, conducted univariate logistic regression analysis to summarize EUS features of CD, PIL and ITB, and created a diagnostic classification method. All cases found to have colorectal ulcers using EUS were obtained from the endoscopy database and formed the test set. We then removed the cases which were easily diagnosed, and the remaining cases formed the perplexing test set. We re-diagnosed the cases in the three sets using the classification method, determined EUS diagnostic accuracies, and adjusted the classification accordingly. Finally, the re-diagnosing and accuracy-calculating steps were repeated.RESULTSIn total, 272 CD, 60 PIL and 39 ITB cases were diagnosed from 2008 to 2015 based on the in-patient database, and 200 CD, 30 PIL and 20 ITB cases were randomly chosen to form the training set. The EUS features were summarized as follows: CD: Thickened submucosa with a slightly high echo level and visible layer; PIL: Absent layer and diffuse hypoechoic mass; and ITB: Thickened mucosa with a high or slightly high echo level and visible layer. The test set consisted of 77 CD, 30 PIL, 23 ITB and 140 cases of other diseases obtained from the endoscopy database. Seventy-four cases were excluded to form the perplexing test set. After adjustment of the classification, EUS diagnostic accuracies for CD, PIL and ITB were 83.6% (209/250), 97.2% (243/250) and 85.6% (214/250) in the training set, were 89.3% (241/270), 97.8% (264/270) and 84.1% (227/270) in the test set, and were 86.7% (170/196), 98.0% (192/196) and 85.2% (167/196) in the perplexing set, respectively.CONCLUSIONThe EUS features of CD, PIL and ITB are different. The diagnostic classification method is reliable in the differential diagnosis of colorectal ulcerative diseases.

Clinical presentations, diagnosis and pattern of intestinal tuberculosis, our experience, Nishtar Hospital Multan, Pakistan

Objective: To discuss clinical presentations, diagnosis and pattern of intestinal tuberculosis of the patients presenting in surgical department. Design. Retrospective study. Place and duration of study. Nishtar Hospital Multan, Pakistan during the period of January 2002 to August 2004. Patients and methods. 109 diagnosed cases of intestinal tuberculosis were included in this study. Patients with intercurrent illness and patients proved to have other diagnosis after full work up were excluded from the study. A detailed history and full physical examination of all patients was recorded. Later on various investigations, operative findings were also noted. Results. The ages of patients were in range of 12-54 years. Male to female ratio was approximately 1:2. Clinical presentation was quite variable ranging from abdominal pain present in 100 patients (91.74%) to weight loss noted in 54 patients (49.54%). Endoscopic biopsy and PCR analysis were most useful in diagnosing intestinal tuberculosis in elective ca ses. Strictures of the small bowel were commonest pattern noted. Past history of pulmonary tuberculosis was present in 8 patients (7.33%) while 18 patients (16.51%) had previous history of intestinal tuberculosis. 35 patients (32.11%) had positive family history of tuberculosis. 18.34% of the patients had secondary tuberculosis. Conclusion. Intestinal tuberculosis is a common disease in third decade in the developing countries. Females are more affected than males. Primary tuberculosis is more common than secondary tuberculosis. Intestinal tuberculosis may present with a variety of abdominal symptoms and signs. Endoscopy and PCR analysis can be considered as reliable investigation in elective cases. Strictures, mass abdomen and intestinal perforation are the most common pattern observed.

Intestinal Tuberculosis in Surgical Pathology - Experience from a Tertiary Care Hospital

Background: Intestinal tuberculosis (ITB) represents the most common type of abdominal TB. Definitive diagnosis of intestinal tuberculosis is made on the basis of morphological examination of surgical specimens in majority of cases as clinico-radiological features are non-specific in initial stages of the disease. Aims: To analyze the surgical pathology data on intestinal tuberculosis of the hospital and to document findings of morphological examination. Setting: A descriptive study of intestinal tuberculous lesions encountered in surgical specimens received during a period of three years in the histopathology section of a tertiary care hospital. Materials and Methods: 40 cases of intestinal tuberculosis out of 250 consecutive, surgically excised specimens of small and large bowel were included in this study. One year retrospective and two years prospective data is included in the study. Results: Intestinal obstruction was the most frequent clinical presentation followed by perforation peritonitis in ITB cases in this series.9 patients had past history of pulmonary and/or intestinal tuberculosis. Out of 31patients without past history of TB, 25.80% were suspected of having TB preoperatively on the basis of clinical and imaging findings. Ileal and ileo-caecal region was most frequently involved. The three gross morphological forms of tuberculous enteritis seen were ulcerative in 82.5%, ulcero-hypertrophic in 15% and hypertrophic in 2.5 %cases. Characteristic caseating granulomas were seen in 60% cases. Conclusion: Changes in clinical presentation of Intestinal TB are being observed. High index of suspicion is needed at every step of diagnosis of intestinal TB as many non-tuberculous lesions share same clinical and radiological findings.

Granulomas as the Most Useful Histopathological Feature in Distinguishing between Crohn's Disease and Intestinal Tuberculosis in Endoscopic Biopsy Specimens.

The incidence of Crohn's disease (CD) is increasing in Chinese populations in whom intestinal tuberculosis (ITB) is prevalent.This study aimed to identify differential diagnostic microscopic and endoscopic characteristics of CD from those of ITB.Patients with CD (N = 52) and patients with ITB (N = 16) diagnosed between 2010 and 2013 were identified. Specimens obtained via endoscopy were analyzed microscopically by a pathologist. The relationship between endoscopic appearance and histopathological features was analyzed. The χ2 test, Fisher's exact probability test, and the Mann-Whitney U test were used.Granulomas were present in 81.3% of ITB cases and in 67.3% of CD cases (P = 0.36). Granulomas in ITB cases were denser than those in CD cases (mean 5.29 ± 4.30 vs. 2.46 ± 3.50 granulomas per 10 low power fields; each low power field = 3.80 mm2; P = 0.005). Granulomas in ITB cases were larger (mean widest diameter, 508 ± 314 μm; range, 100–1100 μm) than those in CD cases (mean widest diameter, 253 ± 197 μm; range, 50–800 μm). Basal plasmacytosis was more common in CD cases than in ITB cases (77.0% vs. 37.5%, P = 0.000). Endoscopy findings such as longitudinal ulcer, aphthous ulcer, and cobblestone appearance were only seen in CD cases (34.6%, 21.2%, and 23.1%, respectively). Granulomas were detected in the majority of cases with longitudinal ulcers (88.9%). Basal plasmacytosis was exclusively detected in cases with longitudinal ulcer and a cobblestone appearance.Characteristics of granulomas maybe the most important distinguishing features between CD and ITB. However, the histopathological characteristics of both diseases may overlap on endoscopic biopsy specimens. An accurate diagnosis should be made that considers clinical, endoscopic features, and pathologic findings.

Genome-wide gene expression analysis for target genes to differentiate patients with intestinal tuberculosis and Crohn's disease and discriminative value of FOXP3 mRNA expression.

Background and aims: Crohn’s disease (CD) and intestinal tuberculosis (ITB) are both chronic granulomatous conditions with similar phenotypic presentations. Hence, there is need for a biomarker to differentiate between both these two diseases. This study aimed at genome-wide gene expression analysis of colonic biopsies from confirmed cases of ITB and CD in comparison with controls. To evaluate the role of T regulatory cells, forkhead box P3 (FOXP3) mRNA expression was quantified in serum as well as in colonic biopsies from patients with ITB and with the controls.Methods: Paired samples, including serum and colonic biopsies, were taken from 33 study subjects (CD, ITB and controls), and total RNA was extracted. Human whole genome gene expression microarray analysis was performed using the Illumina HumanWG-6 BeadChip Kit with six total RNA samples of the three groups in duplicates. Real-time PCR for FOXP3 mRNA expression was analyzed in serum samples and colonic biopsy samples (4-CD, 5-ITB, 4-controls).Results: In CD and ITB there was 1.5-fold upregulation of 92 and 382 genes and 1.5-fold downregulation of 91 and 256 genes, respectively. Peroxisome proliferators via the PPARγ pathway were most significantly downregulated (P < 0.005) in CD. Additionally, the IL4/5/6 signaling pathways and Toll-like receptor signaling pathway were identified as significantly differentially regulated (P < 0.005) at > 2-fold change. In ITB, the complement activation pathway, specifically the classical pathway, was the most significantly upregulated. FOXP3 mRNA expression was significantly elevated in colonic biopsies obtained from ITB patients as compared with CD cases (4.70 ± 2.21 vs 1.48 ± 0.31, P = 0.016).Conclusions: FOXP3 mRNA expression in colonic mucosa could be a discriminatory marker between ITB and CD. Upregulation of the complement activation pathway in ITB suggests that pathogenetic mechanisms for ITB are similar to those of pulmonary tuberculosis. In CD, downregulation of PPARγ was seen in colonic tissue, suggesting that restoration of PPARγ-dependent anti-microbial barrier function may be a therapeutic target.

Fluorescent quantitative PCR of Mycobacterium tuberculosis for differentiating intestinal tuberculosis from Crohn's disease

Intestinal tuberculosis (ITB) and Crohn's disease (CD) are granulomatous disorders with similar clinical manifestations and pathological features that are often difficult to differentiate. This study evaluated the value of fluorescent quantitative polymerase chain reaction (FQ-PCR) for Mycobacterium tuberculosis (MTB) in fecal samples and biopsy specimens to differentiate ITB from CD. From June 2010 to March 2013, 86 consecutive patients (38 females and 48 males, median age 31.3 years) with provisional diagnoses of ITB and CD were recruited for the study. The patients' clinical, endoscopic, and histological features were monitored until the final definite diagnoses were made. DNA was extracted from 250 mg fecal samples and biopsy tissues from each patient. The extracted DNA was amplified using FQ-PCR for the specific MTB sequence. A total of 29 ITB cases and 36 CD cases were included in the analysis. Perianal disease and longitudinal ulcers were significantly more common in the CD patients (P<0.05), whereas night sweats, ascites, and circumferential ulcers were significantly more common in the ITB patients (P<0.05). Fecal FQ-PCR for MTB was positive in 24 (82.8%) ITB patients and 3 (8.3%) CD patients. Tissue PCR was positive for MTB in 16 (55.2%) ITB patients and 2 (5.6%) CD patients. Compared with tissue FQ-PCR, fecal FQ-PCR was more sensitive (X2=5.16, P=0.02). We conclude that FQ-PCR for MTB on fecal and tissue samples is a valuable assay for differentiating ITB from CD, and fecal FQ-PCR has greater sensitivity for ITB than tissue FQ-PCR.

Granulomas of Intestinal Tuberculosis and Crohn's Disease Can Be Differentiated by CD73 Cell Surface Marker Expression: A Pilot Study

Intestinal tuberculosis (ITB) and Crohn's disease are similar granulomatous disorders. Granulomas are present in both and difficult to differentiate on histopathology alone. A recent study demonstrated recruitment of mesenchymal cells (MSCs) at the periphery of granulomas in lymph node tuberculosis which suppressed T cell responses. We hypothesized that granulomas of ITB would also recruit MSCs to evade host immune response. The purpose of this study was to demonstrate MSC markers in granulomas of ITB and evaluate whether distribution of MSC markers could differentiate between granulomas of Crohn's and ITB. We initially retrospectively enrolled 17 patients with confirmed ITB (8) or Crohn's (9) with granulomas on histopathology. Tissues were evaluated by immunofluorescence for MSC markers CD29, CD90, CD73 and absence of haematopoietic markers CD31, CD34, CD45 and CD14. Double-staining was done to confirm presence of MSCs. Subsequently, 23 postoperative specimens of Crohn's (18) and ITB (5) were analyzed for validation. Overall, 27 Crohn's and 13 ITB cases were assessed. CD29 and CD90 positive cells were noted around both ITB and Crohn's granulomas. MSC marker CD73 was expressed around the granulomas of ITB alone and was completely absent in the Crohn's. The subsequent assessment of granulomas in postoperative specimens of Crohn's and ITB also showed similar results. Granulomas of ITB and Crohn's disease can be differentiated by CD73 MSC surface marker expression. The differential CD73 expression around ITB granuloma indicates that Mycobacterium tuberculosis evades host immunity by recruiting MSCs with CD73 expression. MSCs with increased CD73 expression could be the future for therapeutic intervention in Crohn's.

Intestinal Tuberculosis in an HIV-Infected Patient With Advanced Immunosuppression

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.

The clinical analysis of 34 cases of intestinal tuberculosis in China’s big city hospitals

Intestinal tuberculosis is not uncommon in developing countries. The diagnosis of this disease is quite difficult. The purpose of our research was to recall the clinical, colonoscopic, and histopathological features of this disease. The clinical, colonoscopic, and histopathological findings were retrospectively analyzed in 34 patients with intestinal colonic tuberculosis in recent 5 years. The mean age of the patients was 34.7 ± 10.5 years. There were 18 males and 16 females in this group. Abdominal pain, fever, diarrhea, weight loss, and fatigue were the commonest symptoms. Extraintestinal tuberculosis was present in 14 patients. Colonoscopy revealed ulcers in 18 patients, nodules in 11, a deformed cecum and ileocecal valve in 17, strictures in five, polypoid lesions in four, and fibrous bands forming mucosal bridges in three. The cecum and ascending colon were the commonest sites involved. Segmental tuberculosis was seen in five of the 34 patients in whom full-length colonoscopy could be performed. Two or more sites were involved in 18 patients. Histopathology revealed well-formed granulomas in 23 patients. Fourteen of the above patients had caseation and 11 had confluence of the granulomas. Ill-formed granulomas were seen in seven patients and chronic inflammatory changes in 13. Both caseation granulomas and stain for acid-fast bacilli in the biopsies positive were from four patients. We divided the patients into groups I (definitive intestinal tuberculosis, 27 cases) and II (suspected intestinal tuberculosis, seven cases). Despite the various histopathological findings, all of the patients responded to antitubercular treatment and continued to remain asymptomatic during the follow-up period. Colonoscopy with biopsy is essential for diagnosing colonic tuberculosis. Even in the absence of the classic histopathological features, a therapeutic trial may be indicated in a given clinical and colonoscopic setting. Follow-up is important.

Erratum to: Predictors of Clinical and Endoscopic Findings in Differentiating Crohn’s Disease from Intestinal Tuberculosis

Background There are many similarities and overlaps in clinical manifestations and ileocolonoscopic features between Crohn’s disease (CD) and intestinal tuberculosis (ITB). Differentiation between CD and ITB is of great importance. Aim To investigate the values of clinical and endoscopic findings in differential diagnosis between CD and ITB. Methods Clinical and endoscopic features of a cohort of 130 cases of CD and 122 cases of ITB from June 2003 to February 2009 were retrospectively reviewed following predetermined criteria. Parameters were screened by logistic regression analysis. Furthermore, the diagnostic efficacy of screened parameters was analyzed by regression equation (mathematical model) and receiver operating characteristic curve (ROC curve). Results The clinical features helpful in differentiating CD from ITB are hematochezia, intestinal surgery, perianal diseases, pulmonary tuberculosis, ascites, and positive of PPD skin test; the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of regression mathematical model established by clinical features were 90.3, 76.8, 83.8, 80.7, and 88.0%, respectively. The endoscopic features helpful in differentiating CD from ITB were rectum involved lesions, longitudinal ulcer, cobblestone appearance, fixed-open ileocecal valve, transverse ulcer, and rodent ulcer; the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of regression mathematical model established by endoscopic features were 82.9, 82.0, 82.5, 82.9, and 82.0%, respectively.

Predictors of Clinical and Endoscopic Findings in Differentiating Crohn’s Disease from Intestinal Tuberculosis

There are many similarities and overlaps in clinical manifestations and ileocolonoscopic features between Crohn's disease (CD) and intestinal tuberculosis (ITB). Differentiation between CD and ITB is of great importance. To investigate the values of clinical and endoscopic findings in differential diagnosis between CD and ITB. Clinical and endoscopic features of a cohort of 130 cases of CD and 122 cases of ITB from June 2003 to February 2009 were retrospectively reviewed following predetermined criteria. Parameters were screened by logistic regression analysis. Furthermore, the diagnostic efficacy of screened parameters was analyzed by regression equation (mathematical model) and receiver operating characteristic curve (ROC curve). The clinical features helpful in differentiating CD from ITB are hematochezia, intestinal surgery, perianal diseases, pulmonary tuberculosis, ascites, and positive of PPD skin test; the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of regression mathematical model established by clinical features were 90.3, 76.8, 83.8, 80.7, and 88.0%, respectively. The endoscopic features helpful in differentiating CD from ITB were rectum involved lesions, longitudinal ulcer, cobblestone appearance, fixed-open ileocecal valve, transverse ulcer, and rodent ulcer; the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of regression mathematical model established by endoscopic features were 82.9, 82.0, 82.5, 82.9, and 82.0%, respectively. It was proposed that a diagnostic algorithm based on available clinical and endoscopic regression equation could improve the current sensitivity, specificity, and accuracy in differentiating between CD from ITB.

Histopathology and TB-PCR kit analysis in differentiating the diagnosis of intestinal tuberculosis and Crohn’s disease

To compare the histopathologic features of intestinal tuberculosis (ITB) and Crohn's disease (CD) and to identify whether polymerase chain reaction for Mycobacterium tuberculosis (TB-PCR) would be helpful for differential diagnosis between ITB and CD. We selected 97 patients with established diagnoses (55 cases of ITB and 42 cases of CD) who underwent colonoscopic biopsies. Microscopic features of ITB and CD were reviewed, and eight pathologic parameters were evaluated. Nine cases of acid fast bacilli culture-positive specimens and 10 normal colonic tissue specimens were evaluated as the positive and negative control of the TB-PCR test, respectively. PCR assays were done using two commercial kits: kit <A> detected IS6110 and MPB64, and kit <B> detected IS6110 only; a manual in-house PCR method was also performed on formalin-fixed, paraffin-embedded colonoscopic biopsy specimens. Statistically significant differences were noted between ITB and CD with regard histopathologic criteria: size of granulomas (P = 0.000), giant cells (P = 0.015), caseation necrosis (P = 0.003), confluent granulomas (P = 0.001), discrete granulomas (P = 0.000), and granulomas with lymphoid cuffs (P = 0.037). However, 29 cases (52.7%) of ITB showed less than five kinds of pathologic parameters, resulting in confusion with CD. The sensitivities and specificities of the TB-PCR test by kit <A>, kit <B>, and the in-house PCR method were 88.9% and 100%, 88.9% and 100%, and 66.7% and 100% in positive and negative controls, respectively. The PCR test done on endoscopic biopsy specimens of ITB and CD were significantly different with kit <A> (P = 0.000) and kit <B> (P = 0.000). The sensitivities and specificities of TB-PCR were 45.5% and 88.1%, 36.4% and 100%, and 5.8% and 100%, for kit <A> and kit <B> and in-house PCR method on endoscopic biopsy specimens. Among the 29 cases of histopathologically confusing CD, 10 cases assayed using kit <A> and 6 cases assayed using kit <B> were TB-PCR positive. A combination of histologic findings and TB-PCR testing led to an increase of diagnostic sensitivity and the increase (from 47.3% to 58.2) was statistically significant with kit <B> (P = 0.000). The TB-PCR test combined with histopathologic factors appears to be a helpful technique in formulating the differential diagnosis of ITB and CD in endoscopic biopsy samples.

Experience with Two Cases of Intestinal Tuberculosis: Utility of the QuantiFERON-TB Gold Test for Diagnosis

Intestinal tuberculosis is rare in Western countries, with incidence rates of 35.7 and 0.43 per 100,000 per year for the immigrant and native populations, respectively. Despite a clear increase in the frequency of extrapulmonary tuberculosis in immunosuppressed patients, the clinical features of intestinal tuberculosis are seen rarely. A typical clinical presentation includes abdominal pain, weight loss, fever, weakness, nausea, vomiting, obstruction, and bleeding. Intestinal tuberculosis often mimics inflammatory bowel disease or malignant neoplasia, and its preoperative diagnosis is a challenge. Microbiologic diagnosis often is difficult because the causative microorganism requires a long incubation period. Two case reports and review of the pertinent literature. We report two cases of colonic tuberculosis mimicking cecal carcinoma in one patient and periappendiceal abscess in the other. A 75 year-old man underwent right hemicolectomy for a right colon mass. Preoperative laboratory, radiologic, and endoscopic evaluations were negative for tuberculosis and carcinoma. The QuantiFERON-TB Gold test was positive. Surgical specimen histologic review showed non-caseating granulomas and rare Ziehl-Neelsen-positive bacilli. A 35 year-old man, born in Sri Lanka but living in Italy for 10 years, came to our attention for a periappendiceal abscess. Multiple peritoneal micro-nodules were found at laparotomy. Their extemporaneous histologic examination showed granulomas and giant-cell inflammation. A right hemicolectomy was performed. The QuantiFERON-TB Gold test, performed on peritoneal fluid and blood, was positive in both. The QuantiFERON-TB Gold test may hold promise for use in intestinal inflammatory diseases when tuberculosis is suspected but conventional workup is not diagnostic.

A CASE OF ILEO-COLONIC FISTULA WHICH WAS ASSUMED TO BE CAUSED BY INTESTINAL TUBERCULOSIS

65-year-old woman was admitted to the hospital because of intractable lower abdominal pain which had been lasting for nearly two years. There was a history of pulmonary tuberculosis (Tbc) which was successfully treated with anti-Tbc agents at the age of twenty years old. Chest and abdominal X-ray examinations revealed calcified lesions which were presumed healed tuberculotic lesions. Barium enema showed shortening of the ascending colon, distorted cecum with pseudo-diverticula and a fistula formation between the stenotic terminal ileum and transverse colon. Right hemicolectomy including the fistula was performed. The patient recovered without any complications and was discharged from the hospital on 45th postoperative day. Although no histological evidence was obtained, intestinal tuberculosis was strongly suspected as a cause of ileo-colonic fistula in this case. Intestinal tuberculosis is liable to extend on the surface of the intestial wall, but does not tend to reach to the deep organs. It is very rare that the disease forms a fistula between organs. We reviewed previously reported six cases of intestinal tuberculosis with fistula formation in Japan.