A case of difficult to diagnose intestinal tuberculosis

Abstract

A 21-year-old male patient was admitted to our hospital with symptoms of pyrexia and diarrhea. Colonoscopy showed circumferential active mucosal inflammation and multiple ulcers in the ascending colon. Histological findings showed non-caseating epithelioid cell granuloma and lymphocytic infiltration. Smear examination of gastric juice, intestinal mucosa and feces were all negative for acid-fast bacilli. PCR assay of intestinal mucosa was also negative for Mycobacterium tuberculosis. However, a QuantiFERON-TB Gold test was positive. Chest CT showed tiny nodular shadows at the apex of the left lung, which were suspected to be remote lesions of Mycobacterium tuberculosis. From these results, we suspected that the patient’s diagnosis was Crohn’s disease. Treatment was initiated with mesalazine and antibiotics, but these therapies were ineffective. Therefore, a combination protocol of isoniazid, refampicin, ethambutol and pyrazinamide was commenced. His symptoms and results of blood tests for inflammatory response were markedly improved. From the clinical data, we diagnosed the patient with intestinal tuberculosis. Culture of gastric juice, intestinal mucosa and feces demonstrated tuberculosis. Intestinal tuberculosis is often difficult to diagnose by histological findings and TB-PCR. A cautious trial with antitubercular agents may help in confirmation of tuberculosis.