A 50-year-old woman has suffered from repeated abdominal pain for 6 years. She had had a history of lung tuberculosis 10 years ago; consequently, she had received standard anti-tuberculosis chemotherapy for 9 months. The patient presented with acute lower right abdominal pain for 1 day due to intestinal obstruction proved with plain abdominal radiography. She had no fever, no cough, and no weight loss. Physical examination revealed mild tenderness of the right lower quadrant abdomen. Barium enema showed filling defects of the ileum (Fig. 1). Blood analysis showed a white blood cell count of 7.5x109/L and her C-reactive protein level was 8 mg/L. Chest X-ray revealed pulmonary scars. Bowel thickening (approximately 8.5 mm), distal bowel dilation, and comb sign were seen on small bowel CT (Fig. 2). Colonoscopy was performed and returned without ulcers or nodularities. A purified protein derivative test revealed 15 mm of induration, and T-SPOT was positive. Furthermore, her HIV antibody test was negative. Chest contrast-enhanced CT showed pulmonary scar proliferation without active findings. Her intestinal obstruction was worsening with exclusive nutritional support treatment.
We held a multiple-discipline workshop involving a senior surgeon, gastroenterologist, radiologist, and pathologist. Fibrosis of the local small bowel was observed, and all experts reached the consensus that laparoscopic resection was indicated in this patient due to poor outcome of conservative therapy. Informed consent for surgical resection was obtained from the patient. The surgical specimen showed severe fibrosis and stenosis of 6 cm in length, the maximum depth of the lesion was 1.8 cm, additional to multiple cobblestone appearances (Fig. 3). Microscopically, these lesions consisted of granuloma and numerous macrophages. Hematoxylin and eosin staining and immunohistochemistry with periodic acid-Schiff revealed budding forms of histoplasma capsulatum within the macrophages (Fig. 4). Ileum histoplasmosis was diagnosed by the senior pathologist. No postoperative complications were seen.