Tuberculosis Colitis Research Articles

248.8: Mycobacterium tuberculosis Colitis and Cytomegalovirus in A Renal Transplant Recipient: An Infrequent Association

Introduction: Chronic diarrhea, infectious or inflammatory, is a frequent cause of consultation in transplant recipients. Immunosuppressants are the most common reason, but microorganisms like cytomegalovirus (CMV), clostridium difficile, campylobacter, are often reported. Tuberculosis can occur, but it has a low prevalence, described between 0.3 and 1.7%. Method: We described a 32-year woman with a history of membranoproliferative glomerulonephritis, recipient of a deceased-donor kidney transplant 12 years ago. She received basiliximab and steroids as induction therapy and maintenance with tacrolimus, mycophenolate and deflazacort. She consulted with a 7-day history of liquid diarrhea, no blood, nor mucus with abdominal pain, nausea, and fever up to 39°C. She manifested a 10kg loss of weight in a 6 month-period with no other symptoms. Upon admission, she had tachycardia, mild abdominal pain in left flank. Blood workup showed normal leukocytes and platelets, absolute lymphocyte count of 0.8x103/ L, hemoglobin 8.9g/dL, creatinine 1.51mg/dL, high C-reactive protein, and low level of albumin. Low iron, TSAT and high ferritin level. Normal folic acid and vitamin B12. Coproscopic showed blood, no leukocytes. Blood cultures, molecular panel identification of multiple gastroenterology pathogens (filmarrayTM), VIH, viral load with transcriptase-polymerase-chain-reaction (PCR) in blood for CMV were negative. Chest radiography was normal. Contrast abdominal tomography showed thickening and enhacement of the walls of the cecum, hepatic flexure, ileocecal valve and distal ileum. In ascending colon, a 4cm decreased of the lumen was seeing. Multiple round nodes smaller than 10mm after contrast were observed. Total colonoscopy showed colitis in transverse and left colon with 80% stenosis of the lumen. Biopsy documented active chronic colitis with a marked ulcerative component. No microorganisms, dysplasia or malignancy were observed. Real time-PCR was processed for CMV in colonic tissue and PCR for mycobacterium tuberculosis (MT) both reported positive. Co-infection with intestinal CMV and MT was diagnosed. She was treated with valganciclovir for 4 weeks and tetraconjugate with isoniazid(H), rifampicin(R), pyrazinamide(Z), ethambutol(E) and pyridoxine. During treatment, presented elevated transaminases and uric acid attributed to hepatotoxicity for H. It was switched to moxifloxacin with improved in hepatic profile. Moxifloxacin, R and Z were continued for 9 months. The patient had resolution of the diarrhea, recovery of weight, anemia and renal function. Conclusion: CMV is a common etiological agent in kidney transplant recipients with diarrhea, co-infection with other microorganisms, such as, MT can worsen the clinical course and without treatment can lead to death. Having a high index of suspicion is essential. A rigorous diagnostic approach is necessary and performing PCR on tissue can contribute to allow early diagnosis and timely treatment.

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

Validation of Administrative Big Database for Colorectal Cancer Searched by International Classification of Disease 10th Codes in Korean: A Retrospective Big-cohort Study.

BackgroundAs the number of big-cohort studies increases, validation becomes increasingly more important. We aimed to validate administrative database categorized as colorectal cancer (CRC) by the International Classification of Disease (ICD) 10th code.MethodsBig-cohort was collected from Clinical Data Warehouse using ICD 10th codes from May 1, 2003 to November 30, 2016 at Seoul National University Bundang Hospital. The patients in the study group had been diagnosed with cancer and were recorded in the ICD 10th code of CRC by the National Health Insurance Service. Subjects with codes of inflammatory bowel disease or tuberculosis colitis were selected for the control group. For the accuracy of registered CRC codes (C18–21), the chart, imaging results, and pathologic findings were examined by two reviewers. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for CRC were calculated.ResultsA total of 6,780 subjects with CRC and 1,899 control subjects were enrolled. Of these patients, 22 subjects did not have evidence of CRC by colonoscopy, computed tomography, magnetic resonance imaging, or positron emission tomography. The sensitivity and specificity of hospitalization data for identifying CRC were 100.00% and 98.86%, respectively. PPV and NPV were 99.68% and 100.00%, respectively.ConclusionsThe big-cohort database using the ICD 10th code for CRC appears to be accurate.

СЛУЧАЙ ТЯЖЕЛОГО РАСПРОСТРАНЕННОГО ВНЕЛЕГОЧНОГО ТУБЕРКУЛЕЗА

The article presents the clinical case when the patient was admitted to Novosibirsk Tuberculosis Research Institute, Russian Ministry of Health, in September 2013 from the territory supervised by the institute (Sakha Republic) with the advanced form of generalized urogenital tuberculosis, complicated by terminal renal failure and tuberculosis colitis. The patient had been treated for urogenital infections - veiled manifestations of tuberculosis, with no success for 10 years, he underwent a number of surgeries. Tuberculosis was diagnosed histologically when intestine fistula developed.

An Unexpected Diagnosis of Tuberculosis Colitis

Introduction: Tuberculosis (TB) remains one of the world’s deadliest diseases. The diagnosis of gastrointestinal TB, an extra pulmonary manifestation, poses a diagnostic challenge to health care providers due to its non-specific symptoms and varied presentation. Herein, we report a case of TB colitis. Case Report: A 71-year-old male with a history of hypertension, chronic kidney disease, and ischemic cardiomyopathy with recent implantation of a left ventricle assist device (LVAD) was found anemic with hemoglobin (Hgb) of 6.9g/dL from baseline of 12g/dL at a routine clinic visit. His only complaint was “low energy” for few weeks. He denies sweats, weight loss, chest pain, dyspnea, cough, hemoptysis, hematochezia, melenic stools, jaundice, or recent illness. There are no known sick contacts, new or recent medication changes, or history of supratherapeutic INR. He traveled to Vietnam about 2 years ago and is up to date on his immunizations. Physical examination was unremarkable except for conjunctival and skin pallor. Rectal exam was unremarkable and stool was negative for occult blood. Laboratory findings were consistent with iron-deficiency anemia (Hgb 6.6g/dL, Iron 18 μg/dL, ferritin 14ng/mL, TIBC 370, and saturation 4.9%). LFTs and LDH were within normal limits. Colonoscopy was performed with removal of a solitary 6-mm cecum ulcer and biopsies of ulcerated area of terminal ileum. He received red cell transfusions, anticoagulation agent was adjusted with a conservative INR goal, and he was started on iron-supplements with out-patient follow-up. Three weeks later, the patient returned with a near-syncopal event and Hgb of 8 gm/dL. He reported an episode of melena, bloody bowel movements, and vague abdominal discomfort. Infectious, auto-immune and malignancy work-up was initiated. Repeat colonoscopy was significant for increased ulceration of terminal ileum. Fungal (GMS), mycobacteria (Fite) and AFB-Kinyoun’s special stain again did not identifying an organism. The presence of inflammatory changes and caseating granulomas on pathology raised suspicion for TB. TB quantiferon and AFB cultures from biopsy specimen during second colonoscopy was positive for mycobacterium tuberculosis. He was started on RIPE therapy and continues to improve. Discussion: TB occurs worldwide. In 2012, the largest number of new cases occurred in Asia, accounting for 60% of new cases globally. Up to 3% of cases are extra-pulmonary. The GI tract is the sixth most common extra-pulmonary site of TB and most commonly involved is the ileocecal region due to the preponderance of lymphoid tissue, stasis of gut flow, and increased rate of fluid and electrolyte absorption. A high index of suspicion is required to make the diagnosis.

Surgical treatment of perforative tubercular intestines ulcers at patients with HIV infection

High incidence of HIV infection leads to increase in number of tuberculosis cases. The Abdominal Tuberculosis (AT) makes 1/4 among other extra pulmonary localizations at patients with late stages of HIV infection. The worst complication of AT is perforation of tubercular ulcers of intestines when the lethality reaches 80%. The clinical material is presented by 76 patients with HIV infection in 4B stage and ruptured tubercular intestines ulcers. Depending on localization of ulcers, resection of small intestine or a right-sided hemicolectomy was made. The first group included 40 patients, the second one - 36. Duration of HIV infection was 7-8 years. The periods from the moment of perforation to operation varied from 12 to 36 hours. In group 1 primary anastomosis was not made, leaving the created stumps of bringing and taking-away departments of intestines in an abdominal cavity, carrying out a decompression of bringing department of intestines. Relaparotomy was carried out with an interval of 48 hours. After knocking peritonitis two-row anastomosis was made. In group 2 resection of a gut was finished with one-stage anastomosis, sanitation of an abdominal cavity was made. Active heavy bilateral processes prevailed among the other forms of lungs tuberculosis. The patients’ number of CD4 was noted to have decreased lower than 150, at this time at the number of CD4 of 55 (72,4%) patients was less than 50. Tuberculosis colitis at all patients was presented by infiltrative and ulcer form. In 25% of all the cases acid resisting mycobacterium was revealed in the exudate received from an abdominal cavity by luminescent microscopy method. During luminescent microscopy of ulcers edges, mycobacterium tuberculosis was always revealed. In group 1 the results of the treatment were better: the faster recover from peritonitis was note, and there was no insolvency anastomosis, perforation of new tubercular intestines ulcers was noted at 8 patients. 14 patients delivered in a sad plight with intense immunodeficiency died of accruing polyorgan insufficiency. In group 2 - 28 patients died, at 18 of which new guts perforation and peritonitis progressing occurred what required repeated surgeries.

Peripheral T-cell lymphoma of the colon associated with hemophagocytic lymphohistiocytosis

Peripheral T-cell lymphoma (PTCL) of the colon is classified as a subtype of intestinal T-cell lymphoma, which usually has multiple ulcerations. Herein, we report a case of multiple ulcers in the large intestine of a 55-year-old male, who presented to us with symptoms of abdominal pain and watery diarrhea for a month. In addition, results of his endoscopic biopsy revealed crypt abscess with dense inflammatory cells infiltrated in the lamina propria of the colon. One week later, he presented with pancytopenia and jaundice, and results of a biopsy of the bone marrow showed the appearance of hemophagocytosis. Unfortunately, colon perforation occurred during the 10th day of hospitalization, and a histopathological analysis of the colonic resection revealed PTCL. Finally, the patient died of sepsis on the 29th day of hospitalization. The endoscopic character of ulcerative colon T-cell lymphoma is easily confused with Crohn's disease, tuberculosis colitis, and viral colitis. In addition, it is also difficult to distinguish between lymphoma cells and dense inflammatory cells while performing endoscopic biopsy of the mucosa in colon lymphoma. Once a typical geographic and punched out ulcers of the colon are found accompanying the presentation of hemophagocytic lymphohistiocytosis, the diagnosis of PTCL involving the colon should be highly suspected, even if the initial endoscopic biopsy has failed to confirm it.

Tuberculous Colitis in a Patient with Crohnʼs Disease after Treatment with Infliximab

Purpose: Tuberculous Colitis is a rare manifestation of abdominal tuberculosis (TB). It is located in the ileocecal area in 90% of cases. Since 10/01 a boxed warning is added to infliximab package insert advising physicians to screen for TB before treatment. We report a case of TB colitis in a patient with negative PPD & Crohn's disease after starting infliximab. Methods: Our patient is a 23 year old Peruvian female who presented with abdominal pain, weight loss, diarrhea & hematochezia. Colonoscopy in 3/07 revealed edematous, friable and inflammed rectosigmoid. Biopsies and Prometheus-7 panel were consistent with Crohn's disease. Biopsy specimens were negative for AFB. She denied any h/o TB or HIV. She was started on Mesalamine with no relief & subsequently started on azathioprine. Colonoscopy in 7/07 showed severe Crohn's colitis in left colon. Infliximab was considered & patient had a PPD test which was negative with completely normal CXR. First dose of infliximab was given in 8/07 & second dose 2 weeks later. 4 weeks after starting infliximab she was hospitalised with high grade fever, diarrhea & abdominal pain. CT scan was negative for retroperitoneal adenopathy or abscesses & showed diffuse colonic thickening. Colonoscopy showed severely worsened pancolitis with biopsies from entire colon positive for AFB. Repeat PPD & CXR remained negative. She denied recent travel, ill contact or cough. She was started on quadruple therapy for possible TB & biopsy PCR confirmed the diagnosis of TB colitis. The patient improved dramatically on TB medications & has gained 20 lbs. Conclusion: Infliximab is a chimeric monoclonal antibody to TNF-α. One of its FDA approvals is for treatment of Crohn's disease. From 1998–2001, out of 147,000 patients who received infliximab for RA or Crohn's disease, 70 cases of TB associated with infliximab were reported. The median time to onset from starting infliximab therapy to TB diagnosis is 10 months (1–72 months). TB Colitis can present as ulcerations, stenosis & shortening. It can mimic Crohn's disease making diagnosis difficult. CXR is often normal & 15–20% patients with abdominal TB present with active pulmonary TB. Retracted cecum & asymmetric wall thickening have been reported to be suggestive of TB. Clinicians should be vigilant for TB in patients on infliximab even if pretreatment PPD is negative, especially if risk factors for TB are present. Patients with demographic risk factors, h/o BCG, exposure to TB, GI resection & occupational exposure are at high risk for TB. Currently recommended screening such as risk assessment, tuberculin skin testing and CXR prior to anti-TNF-α treatment can reduce TB rates by up to 90% but newer screening interferon gamma assays may enhance screening efficacy.

Complications, Mortality and Functional Outcome following a Total Colectomy and Ileo-rectal Anastomosis

Purpose: This study reviews the feasibility of a total colectomy with ileo-rectal anastomosis (TCIRA) and the functional outcome following the operation. Methods: The cases of a total of 50 patients (31 men and 19 women) with a median age of 61 who underwent a TCIRA were reviewed retrospectively. The median follow-up time was 28 months (4∼72). The clinical records were reviewed to analyze the postoperative complications and bowel function. The clinical outcomes were examined directly from patients' scoring. Results: The indications of TCIRA were metachronous or synchronous colorectal cancer (34 percent), multiple polypoid lesions (22 percent), malignant colon obstruction (24 percent), ischemic colitis (2 percent), Crohn's disease (6 percent), and tuberculosis colitis (2 percent). The overall mortality and morbidity rates were 0 and 31 percent, respectively. The morbidity included postoperative bleeding, obstruction, intra-abdominal abscess formation, pneumonia, and wound complications. We used the CCIS index to evaluate postoperative functional bowel habit change. The CCIS index evaluation revealed perfect continence in 57 percent of the patients with short-term follow up (＜6 months) and in 83 percent of the patients who had undergone a TCIRA more than 2 years ago. Conclusions: Most patients were satisfied with their bowel function on long-term follow up, and we think the TCIRA is a safe operation, and the clinical outcomes are relatively satisfactory.

EXPRESSION OF CYCLOOXYGENASE‐2 IN COLONIC MUCOSA IN PATIENTS WITH TUBERCULOUS COLITIS

Cyclooxygenase‐2 has shown increased expression on crypt epithelium, inflammatory cells of the lamina propria and myenteric neural cells of active inflammatory bowel disease. In tuberculosis colitis, colonoscopic findings are multiple discrete ulcers on terminal ileum, ic valve and cecum with normal surrounding mucosa which are similar with Crohn's colitis. Pathologically the two disease show similar chronic inflammation and granuloma because typical acid fast bacilli and caseation necrosis are not usually detected by biopsy. We evaluated Cox‐2 expression on mucosal biopsy and surgical specimen of tuberculous colitis comparing with Crohn's colitis and nonspecific infectious colitis using immunohistochemistry. This study included 10 patients with tuberculous colitis which are confirmed by antituberculosis treatment, and 10 patients with active Crohn's colitis and 10 patients with acute infectious colitis. We find high Cox‐2 expression on both crypt epithelium and laminar propria lymphocyte (LPL) in all of tuberculous colitis (10 of 10). There are low and weak expression on epithelium (two of 10) and LPL (nine of 10) of Crohn's colitis and epithelium (one of 10) and LPL (seven of 10) of infectious colitis. Cox‐2 expression on crypt epithelium in patients with tuberculous colitis is significantly higher than Crohn's colits and infectious colitis (P < 0.01). This finding suggests that Cox‐2 expression may help differentiate tuberculous colitis from Crohn's colits before experimental antituberculosis medication.