We present the case of a 37-year-old female patient hospitalized in the Gastroenterology Department of the Craiova County Emergency Clinical Hospital in September 2020 for high dysphagia, odynophagia and weight loss (approximately 5kg in the last 2 months before presentation).
From the personal medical history, we noted that the patient has been known to have ileo-colonic Crohn's disease since 2007, currently in clinical remission, associating extraintestinal manifestations such as spondylitis and sacroiliitis, for which she underwent biological treatment with Infliximab combined with Azathioprine, discontinued on her own initiative about 5 years ago, subsequently treatment with Mesalazine 3g/day and Azathioprine 100mg/day, and in October 2019 was initiated biological therapy with Adalimumab, discontinued one month before the presentation due to recurrent pharyngitis.
The patient's family medical history was insignificant.
The patient complained of the onset of symptoms approximately two months before the presentation, by odynophagia, symptoms that did not yield to symptomatic medication, which is why she went to the ENT Department, where, following investigations, the diagnosis of acute erythematous angina was established, for which she subsequently received antibiotic treatment (Amoxicillin+Clavulanic Acid), with no clinical response.
Other medical examinations were performed, initially throat cultures were achieved, which highlighted the presence of Enterobacter cloacae, following antibiotic treatment with Ceftriaxone; however, the symptoms did not improve significantly.
Subsequently, tonsillar biopsies were performed, which ruled out malignancy.
In evolution, the patient's symptoms worsened, from progressive difficulty in swallowing to total high dysphagia, both for solid and liquid foods, accompanied by sialorrhea, marked physical asthenia and weight loss (approximately 5kg). The patient also stated night sweats.
At physical examination, the patient was with an affected general condition, temperature 36.9 C, underweight (Weight of 48kg, Height 164cm, body mass index of 17.85), pale and dehydrated skin and mucous membranes, morphologically intact osteo-articular system, with pain when mobilizing the pelvis and lumbar spine, positive Eriksen sign, positive Volkman sign; examination of the superficial lymph nodes system, highlights at the level of the right latero-cervical region, two oval structures, of firm consistency, immobile on deep and superficial planes, without sensitivity to palpation, with a long axis of about 1cm.
No significant pathological changes were observed on chest auscultation.
ENT examination found congested and hypertrophied palatine tonsils bilaterally and the presence of multiple gray-whitish granules, small in size, diffusely disseminated in the pharynx and larynx.
Several differential diagnoses were discussed: viral pharyngotonsillitis, bacterial pharyngotonsillitis, herpetic pharyngotonsillitis, pharyngotonsillitis in acute retro-viral syndrome, oropharyngeal candidiasis, periamygdalian abscess, retropharyngeal abscess, pharyngeal syphilis, acute or chronic laryngitis, tonsillar neoplasm, haematological diseases (agranulocytosis, acute leukemias, lymphomas).
Laboratory tests showed mild hypo-albuminemia, moderate microcytic hypochromic anemia, lymphopenia, ESR=120mm/h (N: 2-12mm/h), C-reactive protein=88.24mg/L (N: 0-5mg/L), prothrombin index=61% (N: 79-146%), INR=1.38 (Normal range between 0.8 and 1.16), the rest of the blood tests being within normal limits.
Additional biological investigations were performed: microbiological examination of pharyngeal exudate (negative for Candida spp, Staphylococcus aureus, Streptococcus pyogenes), anti-HIV antibodies 1/2 (absent), venereal disease research laboratory (VDRL) (negative); however, we found a positive result for the Koch Bacillus in the patient's sputum.
Following the changes encountered in the physical examination and the results of biological tests, it was decided to perform a computed tomography examination of the neck and chest region.
At the level of the neck we distinguished a diffuse thickening of the epiglottis, of ariepiglottic folds bilaterally, of vocal cords bilaterally, without obvious asymmetries andhomogeneous, non-specific jugular latero-cervical lymph nodes at the right postero-superior level with dimensions up to 12/7mm and up to 10/6mm at the level of the left postero-inferior triangle with the same characteristics (Figure 1).
Computed tomography of the thoracic region showed pulmonary condensation with massive cavitation at the level of the apical segment of the right upper lobe and the segments of the middle lobe; multiple nodular focal condensation areas, disseminated in both lung areas except the basal segments of the left lower lobe, with a tendency to confluence; micronodular lesions with the same arrangement; nonspecific right lower para-tracheal mediastinal adenopathy 14/7mm; without pleuro-pericardial fluid; the described appearance may argue for hematogenous disseminated tuberculous lesion (Figure 2).
Based on the information obtained from the anamnesis, physical examination and paraclinical investigations, we established the diagnosis of pulmonary tuberculosis with extrapulmonary, pharyngeal and laryngeal foci, most likely developed in the context of biological therapy with Adalimumab for Crohn's disease.
Therefore, therapy with Adalimumab was discontinued, and the patient was referred to a specialized medical unit to initiate the specific treatment.
The patient's evolution was favorable with the beginning of the tuberculostatic treatment, being discharged from the Leamna Pneumophthisiology Hospital with good general condition and improved symptoms.
Regarding the gastrointestinal pathology, the patient is still in clinical remission (one-two stools of normal consistency per day, without blood in stool), and will return for follow-up control visits, after the completion of tuberculosis-specific treatment.
Also, a clinico-biological and imaging re-evaluation of Crohn's disease will be needed in order to establish the new therapeutic approach.
CT thoracic region:. pulmonary window, encircled area. right upper lobe condensation area with massive cavitation, arrows. focal pulmonary condensation areas bilaterally.