A 23-year-old Hispanic female presented to the gastrointestinal clinic with multiple episodes of right-sided abdominal pain, fever, emesis, night sweats, and a 30-pound weight loss over the previous seven months. The patient denied diarrhea, melena or hematochezia. Hematologic studies revealed a leukocytosis and iron-deficiency anemia. Blood cultures were negative, including those for acid-fast bacilli. The patient reported a history of positive purified protein derivative (PPD) previously. CT scan of the abdomen revealed cholelithiasis as well as thickening and inflammation of the wall of the ascending colon to the mid transverse colon with moderate right-sided mesenteric adenopathy. Superior mesenteric venous thrombosis was also observed and subsequently treated with low-molecular weight heparin.
Esophagogastroduodenoscopy (EGD) and colonoscopy were performed to further evaluate the patient's CT findings. The EGD appeared normal while the colonoscopy revealed a large, circumferential, fungating mass near the hepatic flexure. Biopsy with histology of the mass was interpreted to be most consistent with tubulovillous adenoma with low-grade dysplasia. A second pathologic evaluation was obtained and the biopsy was thought to be most consistent with CD due to the presence of submucosal granulomas and histiocyte aggregates. Acid-fast bacilli stains of the biopsy specimens were negative, as were other immunohistochemistries.
Repeat colonoscopy with random biopsies was performed to clarify the etiology of the mass and evaluate the extent of the patient's colitis. Colonic involvement was observed to be isolated to the hepatic flexure. Biopsy specimens at this time were considered to be consistent with CD. Acid-fast bacilli staining of the biopsied specimens were again negative. Abdominal CT enterography was performed to evaluate for small bowel involvement. Significant wall thickening from the terminal ileum to the transverse colon with adjacent lymphadenopathy was found.
The patient was advised to undergo an elective right hemicolectomy with primary anastomosis. The patient declined the surgery, returning to Mexico to receive herbal therapies. The patient returned with a 20 pound weight loss and symptoms and imaging consistent with compete bowel obstruction. CT of the chest was unremarkable and did not show evidence of active or latent TB. The patient underwent urgent right hemicolectomy with diverting loop ileostomy (which was subsequently closed).
Histological analysis of the resected bowel segment revealed chronic inflammation with abundant caseating granulomas and fibrosis. Acid-fast bacilli staining of the lymph nodes was positive, consistent with isolated tuberculous colitis. The patient was referred to infectious disease for postoperative antitubercular chemotherapy.