Massive gastrointestinal bleeding as a clinical manifestation of miliary tuberculosis

Tuberculosis is still a public health problem today and can have acute and chronic manifestations challenging clinics for various medical specialties. Because it's a disease of multisystem potential, it is often overlooked when outside the respiratory clinical context. As a result, a clinical case report was carried out at the Hospital de Clínicas de Porto Alegre, in 2020, of a patient with voluminous gastrointestinal bleeding as severe acute clinical manifestation of Miliary and Intestinal Tuberculosis. Due to the potential severity of undiagnosed and untreated tuberculosis, high suspicion is suggested at all levels of health systems (whether public or private) with a view to early diagnosis, treatment and prevention of complications resulting from the disease.

Tuberculosis peritoneal, un diagnóstico diferencial para ascitis en cirrosis / Peritoneal tuberculosis, a differential diagnosis for ascites in cirrhosis

Resumen Se presenta el caso de un paciente con antecedente de consumo crónico de alcohol, que consultó por dolor abdominal inespecífico, fiebre intermitente no cuantificada y pérdida de peso, con posterior aumento del perímetro abdominal. Se encontró ascitis y hallazgos en imágenes que sugerían cirrosis. El estudio del líquido ascítico fue no hipertensivo con predominio de linfocitos y niveles de adenosina-desaminasa (ADA) elevados. La ecografía y tomografía de abdomen mostraron el engrosamiento del peritoneo y la biopsia peritoneal por laparoscopia fue compatible con enfermedad granulomatosa, con reacción en cadena de la polimerasa (PCR) positiva para Mycobacterium tuberculosis en un paciente sin otras causas de inmunosupresión. Este caso muestra la necesidad de mantener una alta sospecha clínica de TB en patologías abdominales con clínica inespecífica, aun en pacientes sin inmunocompromiso claro.

Abstract This is the case of a patient with a history of chronic alcohol consumption, who consulted for nonspecific abdominal pain, intermittent fever, and weight loss, with subsequent increase in the abdominal perimeter. Ascites and imaging findings suggestive of cirrhosis were found. The study of ascitic fluid was non-hypertensive with a predominance of lymphocytes and elevated adenosine deaminase (ADA) levels. Ultrasound and abdominal tomography showed peritoneal thickening. Laparoscopic peritoneal biopsy was compatible with granulomatous disease, with positive PCR for Mycobacterium tuberculosis in a patient with no other causes of immunosuppression. This report shows the importance of keeping a high index of suspicion for TB in patients with abdominal pathology, even in those without evident inmunocompromise.

Tuberculosis infantil sistémica

Introducción: La tuberculosis infantil, definida como la enfermedad infectocontagiosa producida por el bacilo de Koch en pacientes menores de 15 años, continúa siendo un problema de salud pública debido a la cantidad de casos que anualmente se informan, además de ser un desafío para el pediatra en el diagnóstico y tratamiento de esta enfermedad. Objetivo: Describir el caso de un paciente varón con un cuadro de tuberculosis multisistémica. Presentación de caso: Paciente varón de 13 años con un cuadro progresivo de pérdida de peso de 20 kilos en 3 meses, dolor abdominal de localización difusa, tos seca e hiporexia. En los exámenes realizados, se encontraron lesiones cavitarias pulmonares, múltiples adenopatías enteroperitoneales y baciloscopia positiva en heces y orina; con lo que se llegó al diagnóstico de tuberculosis sistémica infantil y se inició esquema antituberculoso. El paciente evolucionó favorablemente y se encuentra estable. Conclusiones: Ante un paciente pediátrico con síndrome consuntivo, procedente de una zona endémica, la tuberculosis debe ser una de las primeras opciones en el diagnóstico diferencial.

Introduction: Childhood tuberculosis, defined as the infectious-contagious disease caused by the Koch bacillus in patients under 15 years of age, continues to be a public health problem due to the number of cases that are reported annually; in addition to represent a challenge for the pediatrician in the diagnosis and treatment of this disease. Objective: Describe the case of a male patient with a picture of multisystem tuberculosis. Case presentation: A 13-year-old male patient with a progressive weight loss of 20 kg in 3 months, abdominal pain of diffuse location, dry cough and hyporexia. In the examinations carried out, pulmonary cavitary lesions, multiple enteroperitoneal adenopathies and positive smears in feces and urine were found; with which the diagnosis of systemic tuberculosis in children was reached and an antituberculous scheme was initiated. The patient progressed favorably and he is stable. Conclusions: In the case of a pediatric patient with a wasting syndrome, and coming from an endemic area, tuberculosis should be one of the first options in the differential diagnosis.

Surgical management of abdominal tuberculosis in a tertiary care referral center

Background: Abdominal tuberculosis encompasses gastrointestinal, visceral and peritoneal forms of tuberculosis in different proportions. Their clinical presentation and radiological findings are varied and non-specific often warranting surgical intervention either for confirmation of diagnosis or for definitive management.  It is not very clear as of now as to which type of patients would require surgical intervention for diagnosis or treatment of abdominal tuberculosis. This study aims to profile such patients accurately to revalidate the need for surgical intervention in cases of abdominal tuberculosis.Methods: This study is a retrospective descriptive observational study wherein the documents of patients whose final diagnosis was confirmed as ‘Abdominal Tuberculosis’ from January 2011 to December 2013 were analysed. Their demographic and clinical profile, hematological, biochemical and radiological investigations including barium meal follow-through, ultrasonography, CT scan abdomen, colonoscopy and biopsy, HIV status and ascitic fluid analysis were analysed. Patients in whom diagnosis was not confirmed by these investigations, and therefore underwent diagnostic laparoscopy or exploratory laparotomy were studied. Simultaneously, patients in whom, the diagnosis was confirmed, but still underwent surgical intervention for therapeutic purposes were also analysed.Results: It was found that 44 out of 54 patients (81.4%) underwent surgical procedure.  28 (52%) required surgical intervention for confirmation of diagnosis (diagnostic procedures: diagnostic laparoscopy- 21 and exploratory laparotomy- 07) while 16 (29.4%) required therapeutic procedures (emergency- 08; elective- 08).Conclusions: In spite of extensive investigations, many patients of abdominal tuberculosis require surgical management either minimally invasive or otherwise, both for confirmation of diagnosis and for definitive management.

Linfoma de células T/NK extranasal primario en íleon / Natural Killer/T cell primary extranasal ileum lymphoma

RESUMEN El linfoma extranodal de células T/NK extranasal (NKTL) primario del tracto gastrointestinal es poco frecuente y tiene carácter agresivo. Presentamos el caso de un paciente inmunocompetente de 51 años que ingresa por dolor abdominal de dos meses de evolución. En la colonoscopía, se hallaron ulceraciones ileales, por lo que se le realizaron estudios para descartar enfermedad de Crohn y tuberculosis intestinal, posteriormente presentó obstrucción intestinal. En la laparotomía exploratoria, se encontró un conglomerado ganglionar en mesenterio. La anatomía patológica confirmó el diagnóstico de NKTL primario en íleon. Se inició quimioterapia y el paciente pidió alta voluntaria dada su precaria condición. Dos meses después del alta el paciente fallece. Este linfoma ha sido reportado principalmente en Asia y posiblemente sea el primer caso reportado en Perú. Tiene un pronóstico funesto con una supervivencia global de ocho meses. Por ello, es necesario un diagnóstico precoz e iniciar la terapia oportunamente.

ABSTRACT Primary extranodal Natural Killer / T cell lymphoma (NKTL) on gastrointestinal tract is an uncommon and aggressive neoplasm. We present the case of a 51-year-old immunocompetent patient with a 2-month history of abdominal pain. Colonoscopy findings showed ileal ulcerations, so studies were carried out to rule out Crohn's disease and intestinal tuberculosis. Later, he developed intestinal obstruction. Exploratory laparotomy found a nodal conglomerate in the mesentery. Anatomical pathology confirmed the diagnosis of primary NKTL on the ileum. Chemotherapy was initiated but the patient asked for voluntary discharge because of his precarious condition. Two months after discharge the patient died. This lymphoma has been reported mainly in Asia and is possibly the first case in Peru. It has a dismal prognosis with overall survival of 8 months. Therefore, it is necessary to get an early diagnosis and begin therapy in a timely manner.

Tuberculosis gastrointestinal como causa de hemorragia digestiva masiva en un paciente con infección por VIH / Gastrointestinal tuberculosis as a cause of massive gastrointestinal bleeding in a patient with HIV infection

Resumen La tuberculosis (TBC) gastrointestinal es una complicación infrecuente y fatal en pacientes con infección por VIH. Se presenta en 3-16% de las formas extrapulmonares y su principal localización es la válvula ileocecal y colon. La hemorragia digestiva baja con presencia de una o múltiples úlceras en colon es una presentación muy inusual de TBC intestinal. El diagnóstico se confirma por biopsia y cultivo del tejido intestinal. La cirugía en caso de perforación intestinal sigue siendo el tratamiento de elección. Se presenta el caso de un paciente con infección por VIH, sin tratamiento anti-retroviral, quien desarrolló una TBC diseminada con perforación intestinal y hemorragia digestiva masiva de curso fatal.

Gastrointestinal tuberculosis is a rare and fatal complication in patients with HIV infection. It occurs in 3%-16% of extra pulmonary forms. The main location in 90% of cases is the ileocecal valve and colon. The most unusual presentation of gastrointestinal tuberculosis is massive bleeding with the presence of one or multiple ulcers in the colon. The diagnosis can be confirmed by biopsy and by culture of intestinal tissue. Surgical resection is the treatment of choice. We report a case of a HIV-infected patient, who did not receive antiretrovirals, and who developed disseminated tuberculosis with intestinal perforation, presenting a fatal massive intestinal bleeding.

Tuberculosis intestinal, un reto diagnóstico: a propósito de un caso / Intestinal tuberculosis, a diagnostic challenge: report of a case

La tuberculosis gastrointestinal es una patología rara y difícil de diagnosticar, que está asociada con diversos factores sociales y económicos, así como con el estado de salud de la víctima. Este relato de caso se realizó sobre la tuberculosis intestinal en el Departamento de Boyac, en el que se describen los principales aspectos clínicos, paraclínicos, el proceso de diagnóstico y el plan de manejo en el paciente. La afectación gastrointestinal de la tuberculosis tiene una baja incidencia, siendo el sexto lugar de compromiso. Los signos y síntomas manifestados por el paciente no son específicos ya menudo el personal de salud sospecha y primero se centra en otras enfermedades que son más frecuentes. A partir de este caso médico, se ponen de relieve las diversas sospechas diagnósticas que se plantearon en el curso de la enfermedad con el fin de lograr un diagnóstico de la tuberculosis intestinal, lo que proporciona una mayor orientación para que los médicos tengan en cuenta esta enfermedad en su práctica clínica.

Gastrointestinal tuberculosis is a rare and difficult pathology to diagnose, which is associated with various social and economic factors as well as the state of health of the sufferer. This case report was made about intestinal tuberculosis in the Department of Boyac , in which the main clinical, paraclinical, the process of diagnosis and management plan in place in the patient are described. Gastrointestinal involvement of tuberculosis has a low incidence, being the sixth place of commitment. Signs and symptoms manifested by the patient are not specific and often the health staff suspect and first focuses on other diseases that are more prevalent. From this medical case, the various diagnostic suspicions that were raised in the course of the disease are emphasized in order achieve a diagnosis of the intestinal tuberculosis, which provides a higher guidance for doctors to take this disease into account in their clinical practice.

Tuberculosis pulmonar, esofágica y laríngea / Pulmonary, esophageal and laryngeal tuberculosis

Resumen La tuberculosis es una de las enfermedades que más ha impactado en la sociedad a nivel mundial siendo influenciada por la pandemia del VIH, los patrones migratorios y el uso de la medicación antituberculosa. La forma extrapulmonar es rara siendo más característica en los pacientes inmunocomprometidos, cuyas manifestaciones clínicas son inespecíficas, por lo que constituye un reto diagnósticopara los clínicos, en la mayoría de los casos retardando su detección y tratamiento. Se presenta el caso clínico de un paciente aparentemente inmunocompetente que consulta por cuadro de seis años de evolución de disfagia progresiva, pérdida de peso inexplicada, en quien se encontró compromiso por tuberculosis a nivel esofágico y laríngeo que explicaban los síntomas de ingreso, así como compromiso pulmonar sin clara sintomatología. Cuadro llamativo y de relevancia por su forma de presentación de alto riesgo de diseminación de la infección en un paciente sin inmunocompromiso. (Acta Med Colomb 2014; 39: 85-89).

Abstract Tuberculosis is one of the diseases that has more impacted the global society, being influenced by the HIV pandemic, migration patterns and the use of anti-TB drugs. Extrapulmonary tuberculosis is rare, being more characteristic in immunocompromised patients, whose clinical manifestations are nonspecific, thus constituting a diagnostic challenge for clinicians and in most cases delaying its detection and treatment. The case of a patient apparently immunocompetent consulting for a six years history of progressive dysphagia and unexplained weight loss, in whom involvement of esophagus and larynx by tuberculosis was found explaining the symptoms of admission, as well as the pulmonary involvement with no clear symptoms, is presented. It is a striking and relevant clinical picture by its presentation with high risk of dissemination of the infection in a patient without immunocompromise. (Acta Med Colomb 2014; 39: 85-89).

A Case of Intestinal Tuberculosis with Perianal Fistula Diagnosed after 30 Years / 대한소화기학회지

Tuberculosis can occur anywhere in the gastrointestinal tract. However, anorectal tuberculosis has rarely been reported. A 46-years-old male presented with abdominal pain and perianal discharge of 30 years' duration. The patient had received operations for anal fistula and inflammation three times. Although he had been taking mesalazine for the past three years after being diagnosed with Crohn's disease, his symptoms persisted. Colonoscopy performed at our hospital revealed cicatricial change of ileocecal valve and diffuse ulcer scar with mild luminal narrowing of the ascending, transverse, and descending colon without active lesions. Multiple large irregular active ulcers were observed in the distal sigmoid and proximal rectum. An anal fistula opening with much yellowish discharge and background ulcer scar was observed in the anal canal. However, cobble-stone appearance and pseudopolyposis were not present. Therefore, we clinically diagnosed him as having intestinal tuberculosis with anal fistula and prescribed antituberculosis medications. Follow-up colonoscopy performed 3 months later showed much improved multiple large irregular ulcers in the distal sigmoid colon and proximal rectum along with completely resolved anal fistula without evidence of pus discharge.

Gastric Cancer and Concomitant Gastric Tuberculosis: A Case Report

Gastric tuberculosis is rare even in the endemic areas of tuberculosis, and can mimic neoplasm by causing elevation of the mucosa with or without ulceration. Here, we report a case in which a 54-year-old female patient admitted for resection of early gastric cancer was found to have coexisting histopathologically and bacteriologically confirmed gastric cancer and tuberculosis.

Gastric Cancer and Concomitant Gastric Tuberculosis: A Case Report

Gastric tuberculosis is rare even in the endemic areas of tuberculosis, and can mimic neoplasm by causing elevation of the mucosa with or without ulceration. Here, we report a case in which a 54-year-old female patient admitted for resection of early gastric cancer was found to have coexisting histopathologically and bacteriologically confirmed gastric cancer and tuberculosis.

Clinical Features of Intestinal Tuberculosis in Recent Ten Years (2001-2010)

BACKGROUND/AIMS: Intestinal tuberculosis (ITB) evades early diagnosis due to non-specific clinical manifestations and difficulties in confirming the disease process. In the current study, we determined the diagnostic appearance and clinical manifestations of ITB in recent 10 years according to diagnostic guidelines, as proposed by the IBD Study Group of Korean Association for the Study of the Intestinal Diseases (KASID). METHODS: Fifty-six patients with ITB who were diagnosed at Seoul Paik Hospital between January 2001 and August 2010 were retrospectively reviewed. The diagnosis of ITB was defined as definite or probable in accordance with the diagnostic guidelines and the clinical features were analyzed in comparison with previous studies involving ITB in Korea. RESULTS: The mean age at the time of diagnosis was 45+/-15 years (range, 17-71 years). Definite and probable diagnoses were obtained in 29% and 71% of the patients, respectively. Twenty-three percent of the patients had synchronous active pulmonary TB and 14% of the patients had other forms of abdominal TB, such as TB mesenteric lymphadenitis or peritonitis. The most common symptoms were abdominal pain (43%), followed by diarrhea (30%), weight loss (14%). Twenty-seven percent of the patients (15 cases) were asymptomatic and diagnosed on comprehensive health care or post-operative surveillance. Only 2 patients (3.6%) underwent surgery for complications, such as intestinal obstruction and perforation. CONCLUSIONS: ITB is still prevalent in Korea; however, in the recent 10 years the symptoms of ITB have been milder than previously reported. In addition, the complication rates of ITB were remarkably decreased, suggesting that early diagnosis of ITB was increased.

Morphological spectrum of gastrointestinal tuberculosis.

Introduction: Gastrointestinal tuberculosis (GITB) is a great mimicker and it is often difficult to distinguish GITB from other inflammatory lesions of the intestine. Aim: This study was carried out with the objective of analysing the entire morphological spectrum of GITB. Methods: A total of 110 diagnosed cases of GITB were included in the study. The diagnosis was based on the presence of acid-fast bacilli (AFB) on histology, caseating or non-caseating epithelioid cell granulomas (ECGs), evidence of tuberculosis at other extraintestinal sites, and all of these along with a complete response to anti-tuberculous treatment (ATT). Results: The mean age was 30.9 years with M:F ratio of 1:1. On gross examination, apart from typical tuberculous lesions in the form of transverse ulcers, strictures, hyperplastic lesions and serosal tubercles, intestinal perforation (32.6%) was seen with higher frequency and ischemic bowel was also identified (7.3%). Varied morphological patterns of ECGs in the form of caseating, non-caseating, confluent, discrete and even suppurative granulomas were identified on histopathology. An important finding was the co-existence of different types of granulomas within the same case. In a significant number of cases (44.5%) granulomas were seen in a submucosal location. The predominant type of inflammation seen in the lamina propria was lymphoplasmacytic in 85.5% cases. Conclusion: Pathologists should be aware of the entire spectrum of gross and histopathological features of GITB, so as to avoid misdiagnosis.

A Case of Pseudomembranous Colitis Associated with Rifampicin Therapy in a Patient with Rectal Cancer and Gastrointestinal Tuberculosis / 대한소화기학회지

Pseudomembranous colitis (PMC) is known to be associated with the administration of antibiotics which alter normal gastrointestinal flora and allow overgrowth of Clostridium difficile. Most cases of rifampicin-induced PMC are seen in patients with pulmonary tuberculosis, but not with gastrointestinal tuberculosis. We report a case of PMC associated with rifampicin therapy in a patient with gastrointestinal tuberculosis. A 65-year-old female patient with rectal cancer and gastrointestinal tuberculosis was admitted due to abdominal pain and diarrhea. She was treated with anti-tuberculosis agents containing rifampicin. On colonoscopic examination, mucoid exudates and yellowish plaque lesions were observed. Anti-tuberculosis agents were stopped, and the patient was treated with metronidazole. Symptoms were relieved and did not recur when all the anti-tuberculosis agents except rifampicin were started again. When a patient complains of abdominal pain or diarrhea while taking rifampicin, the physician should consider the possibility of rifampicin-associated PMC.

The Usefulness of Angiotensin Converting Enzyme in the Differential Diagnosis of Crohn's Disease and Intestinal Tuberculosis

BACKGROUND: Since the pathologic findings of Crohn's disease (CD) and intestinal tuberculosis (IT) overlap to a large degree, the development of other biomarkers will be of great help for making the differential diagnosis of these 2 diseases. The aim of the present study is to examine the clinical efficacy of using the tissue angiotensin converting enzyme (ACE) assay in making the differential diagnosis between CD and IT. METHODS: Tissue specimens were obtained from 36 patients who were diagnosed with CD or IT by the colonoscopic biopsy, as well as by the clinical findings. The expression of tissue ACE was detected by immunohistochemical staining. The optimal cut-off value of the immunoreactive scoring (IRS) system we used to differentiate CD from IT was determined by analysis of the ROC curve and AUROC. RESULTS: Granuloma was present in 15 of 19 patients with CD (78.9%) and in 15 of 17 patients with IT (88.2%). ACE was present in the cytoplasm of the epithelioid cells in the granulomas from 13 of 15 patients with CD and in 14 of 15 patients with IT. The IRS scores of ACE were greater in the patients with CD than that of the patients with IT (8.07+/-4.38 vs. 4.13+/-2.47, respectively, p=0.006). In differentiating CD from IT, the AUROC curve for the IRS of ACE was 0.767 with a sensitivity of 66.7%, a specificity of 93.3% and the cut-off point was 7.5. CONCLUSIONS: The results of our study suggest that the assessment of the tissue ACE expression can be helpful for making the differential diagnosis between CD and IT.