SCIENTIFIC
Tuberculosis Presenting as Intestinal Granulomas in a Patient from West Virginia
AUTHORS : Kristen Catherman , MD 1
Vishal Deepak , MD 2 Bathmapriya Balakrishnan , MD 2 Hatim Al-Jaroushi , MD 2
1
West Virginia University Department of Internal Medicine
2
West Virginia University Section of Pulmonary Critical Care and Sleep Medicine , Department of Medicine
ABSTRACT
Tuberculosis ( TB ) is relatively uncommon in West Virginia compared to surrounding Appalachia and the rest of the country . Despite the low prevalence , it is essential to diagnose promptly given the high potential for significant disease burden . Miliary TB is a form of disseminated Mycobacterium tuberculosis infection resulting from hematogenous spread of the organism . Known risk factors for developing disseminated TB include immunosuppressant medications , human immunodeficiency virus infection , and extremes of age . We present a case in which a patient without identifiable risk factors for TB developed intestinal TB that had been misdiagnosed as Crohn ’ s disease . Shortly after being started on immunosuppressant therapy for the presumed inflammatory bowel disease , the patient developed significant miliary TB .
CASE
A 73-year-old man presented with one month history of productive cough , lethargy , fever , anorexia , and night sweats . His past medical history was significant for hypertension , prostate mass status post biopsy four months prior , and recent diagnosis of suspected Crohn ’ s disease ( CD ). The patient did not have any prior travel and denied any history of homelessness , incarceration , military service , illicit drug use , or family history of tuberculosis ( TB ). Laboratory results at time of presentation were significant for neutropenia and positive QuantiFERON-TB Gold test . His chest computed tomography ( CT ) scan revealed diffuse tree-in-bud and miliary nodular opacities ( Figures A , B , and C ). Flexible bronchoscopy was performed and bronchoalveolar lavage ( BAL ) studies revealed acid-fast bacilli ( AFB ) organisms , and polymerase chain reaction was positive for Mycobacterium tuberculosis ( TB ). Abdominal CT scan additionally showed a new prostate abscess measuring 3.1 x 2.3 x 1.9 cm . Multiple subsequent urine AFB stains were also positive for AFB .
Notably , two months prior to this presentation , the patient had been diagnosed with CD following endoscopic evaluation for lower abdominal pain , nausea , weight loss , and focal thickening of the ascending colon . Biopsy of the cecum and ascending colon at that time had shown severe inflammation and cryptitis with granulomas .
These findings were presumed to be secondary to CD , for which he had been started on prednisone and sulfasalazine . Within a month of this treatment initiation , he developed the presenting symptoms of cough , fever , and night sweats . After receiving the positive urine and BAL sample results , the biopsied colon specimens from his initial endoscopy were reviewed with AFB stain and did show the presence of AFB .
Given the above findings , the patient ’ s sulfasalazine was discontinued , and he was placed on a prednisone taper . He was simultaneously initiated on anti-tuberculous treatment with isoniazid ( with pyridoxine ), rifampin , ethambutol , and pyrazinamide for disseminated TB . Shortly after this initial hospitalization , he was re-admitted for acute encephalopathy secondary to multiple tuberculomas visualized on intracranial CT
FIGURES A , B and C
A B C
angiography ( Figures D and E ). The patient had no previous brain imaging , and his encephalopathy was attributed to inflammation in the setting of tapering steroids . His symptoms improved with restarting oral prednisone at a dose of 1 mg / kg , which was continued at discharge in addition to his anti-tuberculosis therapy .
The patient ’ s case was discussed with authorities at the West Virginia ( WV ) Department of Health prior to his initial discharge . The patient was agreeable to directly observed therapy by the health department to ensure adequate follow up and medication compliance . Subsequent abdominal and pelvic imaging revealed improvement in bowel inflammation as well as reduced size of his known prostate abscess . He remains on anti-tuberculosis treatment with marked improvement in his symptoms from multi-system involvement .
Computed tomography scan of the chest in the axial section showing diffuse discrete small pulmonary nodules .
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