Gastrointestinal Tuberculosis Presenting as Malnutrition and Distal Colonic Bowel Obstruction: 1418

Gastrointestinal tuberculosis (TB) is rare and can occur in the context of active pulmonary disease or as a primary infection with no pulmonary symptoms. It typically presents with vague abdominal symptoms making it difficult to discern from alternative infectious, autoimmune and neoplastic processes. To demonstrate the importance of maintaining a high clinical suspicion for the disease, we present a case of gastrointestinal TB presenting as with abdominal pain, diarrhea, weight loss found to have severe malnutrition and evidence of segmental colitis of the left colon. A 36 year-old woman, originally from the Dominican Republic, presented to the emergency department with a one year history of intermittent abdominal pain, diarrhea and a 70 pound weight loss. She had no reported medical history, recent travel outside of the US or known sick contacts. She was cachectic with diffuse muscle wasting and a body mass index (BMI) of 14. Computed tomography (CT) of the chest and abdomen showed several right-sided pulmonary nodules, a large left-sided pleural effusion and diffuse small and large bowel wall thickening with enlarged mesenteric lymph nodes. Clinical suspicion remained high for malignancy, inflammatory bowel disease or infection such as TB. EGD revealed friable tissue along the esophagus and atrophic mucosa throughout the stomach and proximal duodenum. Colonoscopy showed circumferential friable ulcerated mucosa in the descending colon. Biopsies only showed necrotic tissue that was AFB negative. Extensive autoimmune and infectious workup was unrevealing. Quantiferon gold and Mycobacterium Tuberculosis (MTB) PCR from an induced sputum sample came back positive. She was started on anti-tuberculin therapy. She subsequently developed a large bowel obstruction at the splenic and hepatic flexures. She underwent a subtotal colectomy with endileostomy. Pathology of the resected colon showed confluent necrotizing granulomatous inflammation with transmural colonic wall involvement as well as necrotizing granulomas of the surrounding lymph nodes, consistent with tuberculosis. The ileocecal region is the most commonly involved site of gastrointestinal TB, accounting for almost 64% of cases. Involvement of the splenic flexure with segmental colitis, as in the above reported case, is unusual. Antimicrobial therapy remains the mainstay of the treatment for gastrointestinal TB however surgical or endoscopic intervention is often required in cases complicated by perforation or obstruction.Figure: Circumferential friable ulcerated mucosa in the descending colon just distal to the splenic flexure.