A 51-year-old female presented with abdominal pain, diarrhea, and weight loss for 4 years. The abdominal pain was localized to epigastric region, non-radiating, and not associated with meals. She had loose bowel movements on-and-off with bowel movements occurring approximately five to six times per day. Initially, the stool was watery and mucoid with no foul odor, and not tinged with blood. The patient had significant weight loss despite good appetite and adequate oral intake. There was no associated fever, sweating, evening rise of temperature, vomiting, jaundice, mouth ulcers, or joint pain.
Patient was diagnosed with generalized anxiety disorder and has been on treatment with selective serotonin receptor inhibitors. She had previously presented to a local hospital, where she was treated with triple therapy for Helicobacter pylori and vitamin D supplementation for a low vitamin D level. She had no significant surgical history.
During physical examination, the patient did not have a fever peripheral lymphadenopathy or skin discoloration. Upon palpation, the abdomen was soft and non-tender, and no palpable mass or organomegaly was present. The rectal examination was non-painful and revealed no palpable rectal mass. The hematological reports showed a hemoglobin level of 13.6 g/dL and a white blood cell count of 7400/mm3 with 57% neutrophils, 39% lymphocytes, and 3% monocytes. The patient had an elevated level of anti-cyclic citrullinated peptide (CCP) at 22.83 U/mL and an anti-nuclear antibody (ANA) level of 81.31 AU/mL. The liver and renal function tests were within normal limits.
The stool test for occult blood was negative, and both the serum and stool tests for H. pylori were negative. The stool and urine cultures showed no growth after 48 h of incubation, and no eggs or intestinal parasites were seen on stool microscopy.
Ultrasonography of abdomen and pelvis showed no abnormality. Chest X-ray did not reveal any fibrosis or cavitations. Tuberculin skin test (TST) was negative. Colonoscopy with biopsy showed multiple aphthous ulcers with normal intervening mucosa in terminal ileum suggesting CD (Figure 1). Biopsy specimens showed focal active neutrophilic inflammation with villitis on terminal ileum. CD was suspected and patient was treated with tapering dose of steroids for 3 weeks. However, patient's symptoms were not improving. Subsequently, a repeat TST was done that was positive with an induration of 27 mm diameter. On GeneXpert test, Mycobacterium tuberculosis was not detected. A repeat colonoscopy with biopsy was performed and specimen was sent for acid-fast bacilli (AFB) stain where M. tuberculosis was detected. The patient started on antitubercular therapy with rifampicin, isoniazid, pyrazinamide, and ethambutol according to the national guideline of Nepal.   Patient responded well to the antitubercular regimen leading to resolution of symptoms and weight gain.