Manifestation Of Tuberculosis Research Articles

Fever of unknown origin: evaluation of 110 classical and HIV-associated cases in the last decade

ABSTRACT Background Fever is one of the critical symptoms of collagen vascular diseases, malignancies, and infectious diseases. Patients with a fever of unknown origin (FUO) were evaluated to determine the etiology. Methods In this study, 110 cases with FUO who were admitted to two hospitals with a total of 800 beds, in which 5000 daily outpatient patients were admitted between 2006 and 2016 have been evaluated retrospectively. Anamnesis and the findings were obtained from hospital records. Patients with a temperature higher than 38.3°C and lasting three weeks or longer without diagnosis despite one week of investigation in the hospital were included as FUO cases in this study. Nosocomial and neutropenic cases were excluded from the present study. Results Fifty-seven patients were male (52%), and the mean age was 40.2 ± 17.2. The distribution of the classic and HIV-associated cases was 85 (77.3%) and 18 (16.4%). Tuberculosis (TB) was the most frequent disease in both groups. The etiology was infectious in 68.2%, autoimmune in 14.5%, and neoplastic in 5.4%. There was no case of collagen vascular disease in the HIV-associated FUO group. Conclusion As a result of our study, infectious diseases and TB were still the leading factors that caused FUO. TB has been notably found higher in the HIV-associated group than the classic group. FUO is usually either a rare cause or an unusual clinical presentation of a well-known infectious disease in Turkey. Therefore, it should be noted that various manifestations of extra-pulmonary tuberculosis may be considered a FUO case.

Standardized approaches for clinical sampling and endpoint ascertainment in tuberculous meningitis studies.

Tuberculous meningitis (TBM), the most severe manifestation of tuberculosis, has poorly understood immunopathology and high mortality and morbidity despite antituberculous therapy. This calls for accelerated clinical and basic science research in this field. As TBM disproportionally affects poorer communities, studies are often performed in resource-limited environments, creating challenges for data collection and harmonisation. Comparison of TBM studies has been hampered by variation in sampling strategies, study design and choice of study endpoints. Based on literature review and expert consensus, this paper provides firstly, practical recommendations to enable thorough diagnostic, pathophysiological and pharmacokinetic studies using clinical samples, and facilitates better data aggregation and comparisons across populations and settings. Secondly, we discuss clinically relevant study endpoints, including neuroimaging, functional outcome, and cause of death, with suggestions of how these could be applied in different designs for future TBM studies.

Therapies for tuberculosis and AIDS: myeloid-derived suppressor cells in focus

The critical role of suppressive myeloid cells in immune regulation has come to the forefront in cancer research, with myeloid-derived suppressor cells (MDSCs) as a main oncology immunotherapeutic target. Recent improvement and standardization of criteria classifying tumor-induced MDSCs have led to unified descriptions and also promoted MDSC research in tuberculosis (TB) and AIDS. Despite convincing evidence on the induction of MDSCs by pathogen-derived molecules and inflammatory mediators in TB and AIDS, very little attention has been given to their therapeutic modulation or roles in vaccination in these diseases. Clinical manifestations in TB are consequences of complex host-pathogen interactions and are substantially affected by HIV infection. Here we summarize the current understanding and knowledge gaps regarding the role of MDSCs in HIV and Mycobacterium tuberculosis (co)infections. We discuss key scientific priorities to enable application of this knowledge to the development of novel strategies to improve vaccine efficacy and/or implementation of enhanced treatment approaches. Building on recent findings and potential for cross-fertilization between oncology and infection biology, we highlight current challenges and untapped opportunities for translating new advances in MDSC research into clinical applications for TB and AIDS.

Evaluation of heterologous prime-boost vaccination strategies using chimpanzee adenovirus and modified vaccinia virus for TB subunit vaccination in rhesus macaques

Tuberculosis (TB) still is the principal cause of death from infectious disease and improved vaccination strategies are required to reduce the disease burden and break TB transmission. Here, we investigated different routes of administration of vectored subunit vaccines based on chimpanzee-derived adenovirus serotype-3 (ChAd3) for homologous prime-boosting and modified vaccinia virus Ankara (MVA) for heterologous boosting with both vaccine vectors expressing the same antigens from Mycobacterium tuberculosis (Ag85B, ESAT6, Rv2626, Rv1733, RpfD). Prime-boost strategies were evaluated for immunogenicity and protective efficacy in highly susceptible rhesus macaques. A fully parenteral administration regimen was compared to exclusive respiratory mucosal administration, while parenteral ChAd3-5Ag prime-boosting and mucosal MVA-5Ag boosting were applied as a push-and-pull strategy from the periphery to the lung. Immune analyses corroborated compartmentalized responses induced by parenteral versus mucosal vaccination. Despite eliciting TB-specific immune responses, none of the investigational regimes conferred a protective effect by standard readouts of TB compared to non-vaccinated controls, while lack of protection by BCG underpinned the stringency of this non-human primate test modality. Yet, TB manifestation after full parenteral vaccination was significantly less compared to exclusive mucosal vaccination.

Value of serum cytokine biomarkers TNF-α, IL-4, sIL-2R and IFN-γ for use in monitoring bacterial load and anti-tuberculosis treatment progress

Tuberculosis (TB) patient serum cytokine levels may be predictive of anti-tuberculosis treatment progress. Here, serum levels of cytokines TNF-α, IL-4, sIL-2R and IFN-γ were measured then correlated to clinical TB manifestations, bacterial burden, chest imaging findings and clinical course. Study subjects included 67 newly diagnosed pulmonary TB (PTB) patients with active disease admitted to Beijing Chest Hospital for anti-TB chemotherapeutic treatment. Blood was drawn at 0 months (pre-treatment), 1–2 months (at any time between 1 and 2 month) and after 6 months completion of treatment and serum TNF-α, IL-4, sIL-2R and IFN-γ levels were measured in duplicate using enzyme-linked immunosorbent assays (ELISAs). Correlation analysis was conducted to evaluate sensitivity and specificity of cytokine levels as predictors of disease activity and treatment progress. The results indicated that the pre-treatment serum TNF-α level of the smear-negative group was lower than that of the smear 1+ group, while serum TNF-α after 6 months completion of treatment and IFN-γ levels at 1–2 months and after 6 months completion of treatment were significantly lower, respectively, than at 0 months (before treatment) (P < 0.05). Using a cut-off value of 845 pg/ml, serum TNF-α level was predictive of treatment progress, with a sensitivity of 51%, specificity of 60% and AUC of 0.594 (P = 0.013). Meanwhile, using a cut-off value of 393 pg/ml, serum IFN-γ provided superior monitoring efficacy, with a sensitivity of 60%, specificity of 64% and AUC of 0.651 (P = 0.017). In conclusion, both serum TNF-α and IFN-γ levels might be useful biomarkers for monitoring treatment progress.

Intradural extramedullary tuberculoma of the spinal cord in patient of tubercular meningitis - an uncommon scenario

Intradural extramedullary tuberculoma of the spinal cord (IETSC) is a rare and unanticipated manifestation of CNS tuberculosis. A 28 years old female diagnosed case of tubercular meningitis (TBM), already on antitubercular therapy (ATT) for last nine months, developed sensory and motor weakness in lower limbs along with saddle anaesthesia. Magnetic resonance imaging (MRI) with contrast of the spine revealed the presence of multiple space occupying lesions in dorsal spinal cord. She received oral steroid therapy for six weeks with escalation of ATT after which neurological functions improved remarkably.

Treatment of ocular tuberculosis-an update

Tuberculous uveitis (TU) is initially usually not acute, accompanied by only slight visual disorders and affects otherwise healthy individuals so that the diagnosis is frequently primarily overlooked. This study was carried out to provide an update of the treatment options in suspected TU. APubMed search was undertaken using the key terms uveitis AND tuberculosis AND treatment for manuscripts published within the last decade. Cross-identified articles relevant to the topic were also evaluated regarding their evidence based on the authors' expertise. When the suspicion of a TU is not supported by further investigations, the decision has to weigh up the risks and benefits of treatment. Aresponse of the uveitis to antituberculous treatment (ATT) in 82% represents an important diagnostic indication. Based on this remarkably good response rate and an acceptable side effect profile of ATT, agenerous indication seems reasonable. Alack of response or aparadox worsening of uveitis under treatment for manifestations of extrapulmonary tuberculosis, probably represent ahypersensitivity reaction to mycobacterial antigens and require additional corticosteroid treatment. Eales' disease, an isolated retinal vasculitis, is associated with TU but does not respond to ATT and requires laser ablation of the ischemic area. TU typically affects otherwise healthy individuals without extraocular manifestations. Early consideration of TU and initiation of ATT ideally before the start of systemic corticosteroids is decisive for long-term functional recovery. Treatment success, defined as absence of new uveitic flares within 6 months of treatment cessation, is to be expected in at least 82%. In cases of paradox worsening or lack of response, additional anti-inflammatory treatment is required.

A case of tuberculosis during a period of transient immunodeficiency associated with HIV infection

The article describes a clinical case of a patient with tuberculosis that developed during the period of transient immunodeficiency of HIV infection (stage 2B of HIV infection). The main manifestation of tuberculosis was cervical lymphadenitis, for which several operations had to be performed; enlarged lymph nodes of the lung root, retroperitoneal and inguinal groups were visualized by X-ray. Based on the presence of tuberculosis, the patient was diagnosed with an advanced, 4B stage of HIV infection and, after 9 days, ART was started. The article speculates on whether tuberculosis should be considered as an unambiguous criterion for the last stage of HIV infection regardless of immunity indicators and duration of the course of HIV infection.

ERx – A technological advance to speed-up TB diagnostics

Abstract In 2016 an interdisciplinary collaborative research team started an ambitious project to assist the diagnosis of tuberculosis (TB) in areas with over-burdened and poor healthcare infrastructure in the outskirts of Lima, capital of Peru. Currently we have implemented an integrated system which connects nurses, physicians and scientists, in a network of cooperation to identify and report suspicious cases of pulmonary TB. Our Electronic Mobile system (called ‘eRx’) is a Computer Automated Diagnosis (CAD) tool that can be used by local TB nurses allowing them to send X-rays along with additional prospect patient information, directly to be remotely evaluated by a physician. The physician accesses a web-based system using a computer or a tablet which allows him/her to evaluate the data coming from the distinct healthcare centers. The physician may also be assisted by a Beta version of an automatic diagnostic software which uses Deep Learning to identify the presence of lung abnormalities as well as the possible manifestations for TB. The goal of our research is to increase the speed at which a diagnosis can be made by providing a CAD tool to health care providers to improve quality and efficiency of TB diagnosis. To support future developments of the automatic diagnostic software, we rely on another web-based platform which contains over 10,000 X-rays images which are being annotated by a specialist who provides the regions where the TB manifestations can be found, which will be used later to train a Region-Based Convolution Neural Network. The software for the eRx system covers the obtaining of high-quality data, artificial intelligence support and mobile technologies directly in hands of the healthcare professionals, each software has already been validated individually, and will be evaluated together during a pilot study working directly with local healthcare centers, physicians and nurses. Our study has approval from the the IRB Boards at the University of Massachusetts Lowell IRB, and the School of Medicine at the Peruvian University Cayetano Heredia.

Simultaneous Tuberculous Infection of Lung and Allograft in Renal Transplant

Tuberculosis is common infectious complication in kidney transplant recipients. In immunosuppressed patients, clinical manifestations of tuberculosis are varied and delayed diagnosis and poor clinical outcomes. Especially allograft involvement of tuberculosis can cause allograft loss. In this report, we present the case of 46-year-old man diagnosed disseminated tuberculosis involving allograft kidney successfully treated with maintenance of allograft function.

Disseminated tuberculosis associated with reactive arthritis of Poncet in an immunocompetent patient

Cutaneous tuberculosis is a rare extrapulmonary manifestation of tuberculosis which, like disseminated tuberculosis, commonly occurs in immunocompromised patients. Poncet reactive arthritis is a seronegative arthritis affecting patients with extrapulmonary tuberculosis, which is uncommon even in endemic countries. We report a previously healthy 23-year-old male patient with watery diarrhea associated with erythematous ulcers on the lower limbs and oligoarthritis of the hands. Histopathological examination of the skin showed epithelioid granulomatous process with palisade granulomas and central caseous necrosis. AFB screening by Ziehl–Neelsen staining showed intact bacilli, the culture was positive for Mycobacterium tuberculosis, and colonoscopy revealed multiple shallow ulcers. Disseminated tuberculosis associated with reactive Poncet arthritis was diagnosed, with an improvement of the clinical and skin condition after appropriate treatment.

Tracking down the White Plague: The skeletal evidence of tuberculous meningitis in the Robert J. Terry Anatomical Skeletal Collection.

Paleopathological diagnosis of tuberculosis (TB) essentially relies on the identification of macroscopic lesions in the skeleton that can be related to different manifestations of TB. Among these alterations, granular impressions (GIs) on the inner skull surface have been considered as pathognomonic features of tuberculous meningitis (TBM). GIs may be established by pressure atrophy of the tubercles formed on the outermost meningeal layer during later stages of TBM. Although GIs were used as diagnostic criteria for TBM in the paleopathological practice since the late 20th century, their diagnostic value has been questioned. To contribute to strengthening the diagnostic value of GIs, a macroscopic investigation-focusing on the macromorphological characteristics and frequency of GIs-was performed on skeletons of known cause of death from the Terry Collection. The χ2 analysis of our data revealed that GIs were significantly more common in individuals who died of TB than in individuals who died of non-TB causes. Furthermore, GIs were localized on the inner surface of the skull base and of the lower lateral skull vault. The localization pattern and distribution of GIs on the endocranial surface resemble that of the tubercles observed in the affected meninges during the pathogenesis of TBM. Our results strengthen the tuberculous origin of GIs and imply that they can be considered as specific signs of TBM. Therefore, GIs can be used as diagnostic criteria for TBM in the paleopathological practice, and the diagnosis of TBM can be established with a high certainty when GIs are present in ancient human bone remains.

Clinical and Epidemiological Study on Tubercular Uveitis in a Tertiary Eye Care Centre in Italy.

Purpose To describe frequency, clinical characteristics, and visual prognosis of tubercular uveitis (TBU) in a nonendemic country. Methods We retrospectively reviewed 3743 charts of patients with endogenous uveitis visited from 2008 to 2018 at a tertiary referral centre in Rome, Italy. We included immunocompetent patients with diagnosis of TBU. Patients were divided in two groups: patients with history of uveitis without a previous diagnosis of TBU (group A) and patients at their first episode of TB uveitis (group B). Results TBU was diagnosed in 28 (0.75%) out of 3743 patients. Twelve (42.9%) patients came from tuberculosis endemic areas. All patients received specific antitubercular treatment (ATT) and were evaluated for a mean follow-up of 3.2 ± 2.9 years. Group A showed a greater number of ocular complications when compared with group B. ATT was effective in reducing the frequency of recurrences of uveitis in patients of group B. Conclusion Intraocular inflammation can be the first manifestation of tuberculosis. Our data highlight that early diagnosis and specific treatment of TBU may allow to decrease recurrences and to improve visual outcomes.

Diagnostics and treatment of scrofuloderm

Scrofuloderm is a rare manifestation of cutaneous tuberculosis. The article describes a clinical case of secondary scrofuloderm in a 35-year-old man. The case demonstrates significant and irreversible cosmetic defects of scrofuloderm as well as importance of timely use of effective methods for diagnosis of tuberculosis (molecular genetic and histological tests, multi-slice computed tomography of the chest) and modern approaches to tuberculosis therapy based on the drug sensitivity pattern.

Mycobacterium tuberculosis bloodstream infection prevalence, diagnosis, and mortality risk in seriously ill adults with HIV: a systematic review and meta-analysis of individual patient data

SummaryBackgroundThe clinical and epidemiological significance of HIV-associated Mycobacterium tuberculosis bloodstream infection (BSI) is incompletely understood. We hypothesised that M tuberculosis BSI prevalence has been underestimated, that it independently predicts death, and that sputum Xpert MTB/RIF has suboptimal diagnostic yield for M tuberculosis BSI.MethodsWe did a systematic review and individual patient data (IPD) meta-analysis of studies performing routine mycobacterial blood culture in a prospectively defined patient population of people with HIV aged 13 years or older. Studies were identified through searching PubMed and Scopus up to Nov 10, 2018, without language or date restrictions and through manual review of reference lists. Risk of bias in the included studies was assessed with an adapted QUADAS-2 framework. IPD were requested for all identified studies and subject to harmonised inclusion criteria: age 13 years or older, HIV positivity, available CD4 cell count, a valid mycobacterial blood culture result (excluding patients with missing data from lost or contaminated blood cultures), and meeting WHO definitions for suspected tuberculosis (presence of screening symptom). Predicted probabilities of M tuberculosis BSI from mixed-effects modelling were used to estimate prevalence. Estimates of diagnostic yield of sputum testing with Xpert (or culture if Xpert was unavailable) and of urine lipoarabinomannan (LAM) testing for M tuberculosis BSI were obtained by two-level random-effect meta-analysis. Estimates of mortality associated with M tuberculosis BSI were obtained by mixed-effect Cox proportional-hazard modelling and of effect of treatment delay on mortality by propensity-score analysis. This study is registered with PROSPERO, number 42016050022.FindingsWe identified 23 datasets for inclusion (20 published and three unpublished at time of search) and obtained IPD from 20, representing 96·2% of eligible IPD. Risk of bias for the included studies was assessed to be generally low except for on the patient selection domain, which was moderate in most studies. 5751 patients met harmonised IPD-level inclusion criteria. Technical factors such as number of blood cultures done, timing of blood cultures relative to blood sampling, and patient factors such as inpatient setting and CD4 cell count, explained significant heterogeneity between primary studies. The predicted probability of M tuberculosis BSI in hospital inpatients with HIV-associated tuberculosis, WHO danger signs, and a CD4 count of 76 cells per μL (the median for the cohort) was 45% (95% CI 38–52). The diagnostic yield of sputum in patients with M tuberculosis BSI was 77% (95% CI 63–87), increasing to 89% (80–94) when combined with urine LAM testing. Presence of M tuberculosis BSI compared with its absence in patients with HIV-associated tuberculosis increased risk of death before 30 days (adjusted hazard ratio 2·48, 95% CI 2·05–3·08) but not after 30 days (1·25, 0·84–2·49). In a propensity-score matched cohort of participants with HIV-associated tuberculosis (n=630), mortality increased in patients with M tuberculosis BSI who had a delay in anti-tuberculosis treatment of longer than 4 days compared with those who had no delay (odds ratio 3·15, 95% CI 1·16–8·84).InterpretationIn critically ill adults with HIV-tuberculosis, M tuberculosis BSI is a frequent manifestation of tuberculosis and predicts mortality within 30 days. Improved diagnostic yield in patients with M tuberculosis BSI could be achieved through combined use of sputum Xpert and urine LAM. Anti-tuberculosis treatment delay might increase the risk of mortality in these patients.FundingThis study was supported by 10.13039/100010269Wellcome fellowships 109105Z/15/A and 105165/Z/14/A.

CLINICAL PARALLELS IN INFECTIOUS DISEASES OF THE CENTRAL NERVOUS SYSTEM IN PATIENTS WITH HIV

A retrospective analysis of medical records of 451 patients with HIV infection showed that the most common clinical manifestations of cerebral tuberculosis are as follows: headache, fever ≥ 38.0 °C, meningeal symptoms; in toxoplasmosis encephalitis these are headache, paresis of cranial nerves and extremities, incoordination, cognitive disorders, dysarthria, fever ≥ 38.0 °C and convulsions; in mycotic lesions of the CNS they are headache, coordination disorders, positive meningeal symptoms, disturbances of consciousness, cognitive disorders, visual disorders, cranial nerve deficiency, convulsions and dysarthria. The clinical picture of bacterial (exacted) meningitis was dominated by positive meningeal symptoms, headache, fever, impaired consciousness. At the same time, in such neurological manifestations of central nervous system lesions as cranial nerve paresis, mono− and hemiparesis, visual, coordination and speech disorders, which mostly accompany cerebral toxoplasmosis, cerebrovascular diseases, brain tumors, encephalitis of unspecified etiology. Thus, the analysis suggests that the clinical manifestations of various etiologies of lesions of the central nervous system are often nonspecific and probably are stipulated with common morphological changes in brain tissue, which may be associated with the neuropathological effects of HIV, as well as a large impact co−infection. Key words: HIV infection, opportunistic infections, central nervous system, main symptoms.

Evaluation of the Various Clinical Presentations of Adult CNS Tuberculosis

Background: Central nervous system (CNS) involvement is one of the most important extrapulmonary manifestations of tuberculosis (TB) causing considerable mortality and morbidity. Presentations of CNS TB are extremely variable. Treatments are generally more effective if the disease can be detected early. This study is to find out the various clinical patterns and investigation findings that might help in early detection of CNS TB.&#x0D; Objective: This study was conducted to detect various clinical manifestations of adult CNS TB at an earlier stage of evaluation.&#x0D; Methods: This was a hospital based observational study (cross sectional type) conducted on 30 patients of CNS TB who were admitted in Sir Salimullah Medical College Mitford Hospital, Dhaka during a period of 6 months from October 2013 to April 2014&#x0D; Results: Among the participants 53% were male and 47% were female, with a male female ratio of 1.13: 1. Mean age of the participants was 35.17±6.14 years. Tuberculosis involving brain (i.e. cranial TB) was most common (30.4%) in 15-24 years age group whereas spinal form of TB was most common (42.8%) in 25-34 years age group. Mean age of the participants having Brain TB was 36.46±6.90 years. Mean age of the participants having spinal TB was 32.36±12.52 years. Highest number of the cranial forms of TB was tuberculoma (52.2%) in this study and was found mostly in the young adults. Spinal TB was found in 25-34 years age group in highest number, all but one were Potts disease. Tuberculoma and tuberculous meningitis had an equal distribution in female sex while males had a higher (53.8%) occurrence of tuberculoma. On the other hand, spinal involvement was commoner in male sex (43.5%).Fever was the most common symptom noted in all forms of CNS TB patients (78.26% for brain and 71.43% for spinal cord TB patients) followed by headache and loss of consciousness representing 2nd and 3rd common symptom in brain TB patients. Most common clinical signs in brain TB were signs of meningeal irritation (65.22%), cranial nerve palsies and papillodema while spastic paraparesis with sensory level being the commonest in spinal cases. Tuberculoma was the most frequent neuro-radiologic findinds in case of brain TB patients and paraspinal soft tissue shadow with vertebral collapse was commoner in spinal TB patients.&#x0D; Conclusion: This study has highlighted the relative frequency of various types of brain and spinal TB lesions along with the symptoms, signs and laboratory findings in Bangladeshi adult patients. In Bangladesh, tuberculosis should be always an important differential diagnosis in patients of fever with headache as well as spastic paraplegia or quadriplegia for any duration in any sex group.&#x0D; J Dhaka Medical College, Vol. 28, No.1, April, 2019, Page 76-84

Current Study of the Detection and Treatment Targets of Spinal Tuberculosis.

Spinal tuberculosis is a common manifestation of extrapulmonary tuberculosis and osteoarticular tuberculosis. Common clinical manifestations include constitutional symptoms, back pain, spinal tenderness, paraplegia, and spinal deformities. They are the common causes of paralysis and could increase the mortality in patients. Most cases of spinal tuberculosis remaining undiagnosed, and early clinical symptoms and imaging manifestations lack specificity, which explained the reason why it is difficult to identify from atypical spinal metastases, brucellosis and other diseases. The rate of missed diagnosis and misdiagnosis for spinal tuberculosis is high. If spinal tuberculosis diagnostic targets could be early detected, the therapeutic targets can be effectively treated, which can not only control the progress of the disease and shorten the course of treatment, but also reduce the economic pressure and avoid spinal deformity. Therefore, early diagnosis should be our focus. Comprehensive use of a variety of diagnostic targets can improve the early diagnosis rate of spinal tuberculosis. Here, we review the progress of laboratory, imaging and gene detection in the diagnosis of spinal tuberculosis in recent years.

Hematologic parameters in pulmonary tuberculosis patients based on the microscopic sputum examination

This study aimed to analyze various hematological manifestations in tuberculosis (TB) patients using positive and negative smear sputum microscopy. This study was a retrospective study with cross-sectional design. The study subjects consisted of patients diagnosed with tuberculosis who were recruited consecutively at Rumah Sakit Islam Jakarta Sukapura hospital from 1st of January 2015 to 30 of June 2017. There were significant differences in hematological parameters, including leucocytes, erythrocytes, thrombocytes, and erythrocyte sedimentation rates between acid-fast Bacillus positive (+) and negative (-). Changes in the results from the hematological examination in pulmonary TB patients could be used as parameters for diagnosis, prognosis, and response to therapy.

A175 RECURRENT GASTROINTESTINAL BLEED – A LATE MANIFESTATION OF COLONIC TUBERCULOSIS TREATED CONSERVATIVELY

Abstract Background The incidence of active tuberculosis (TB) in Canada is 4.8 per 100000 persons. Globally, gastrointestinal (GI) TB is rare and accounts for 5% of all extra-pulmonary cases. Clinical manifestations of intestinal TB include weight loss (75%), abdominal pain (54%), and changes in bowel habits (50%). GI bleeding has been observed in 5–15% of confirmed cases of colorectal TB. The cecum is the most common site of involvement, with the most common gross finding on colonoscopy being ulcerations (88%), and the least common being polypoid lesions (10%). Intestinal TB is treated the same as pulmonary TB, with endoscopic healing observed in the majority of cases following 9 months of anti-TB therapy. Surgery is entertained in cases of non-resolving obstruction, perforation, or fistula formation. Aims Management of stable, recurrent, large volume GI bleeding in TB colitis is not well established. We report such a case that resolved solely by anti-TB regimen. Methods Case report Results A 56 year old man with chronic kidney disease presented with cachexia and 40 pound weight loss over 6 months after return from India. He underwent computerized tomography scan of his chest, abdomen and pelvis. Multiple, large, cavitary lesions in the right upper lung lobe were seen, and confirmed to be TB by bronchoalveolar lavage. Abdominal imaging identified moderate circumferential wall thickening at the cecum concerning for intestinal TB. These findings were also retrospectively noted on a review of an abdominal MRI 4 months prior. His course was complicated by episodes of large, alternating bright red blood per rectum and melena stools starting 5 days after initiation of anti-TB therapy. Colonoscopy revealed polypoid lesions in the cecum as well as blood throughout the colon, with no active source of bleeding. Surgery was considered for ongoing bleeding, however, because biopsies were negative for malignancy and positive on acid-fast stain, he continued conservative management with blood transfusions and anti-TB therapy. GI bleeding decreased significantly within the first 2 weeks, and resolved by day 25. He completed 1 year of anti-TB therapy, with no signs of colitis detected radiographically at the 6-month mark. Conclusions To our knowledge, this is the first report of GI bleeding as a very late manifestation of colonic TB, resolved with anti-TB therapy alone. Time from initial evidence of intestinal TB on imaging to the first bleed was 159 days, and time from initial symptoms was 6 months. As polypoid lesions are the least common gross finding on colonoscopy, a high degree of suspicion should be held in the right clinical setting. Surgical management should be considered only after conventional anti-TB therapy has failed. Funding Agencies None