Presentation
Constipation for days. Rectal bleeding and loss of 15 kg over 3 years.
Patient Data
Long segment transmural concentric wall thickening of the ileocaecal valve, terminal ileum, ascending colon and caecal appendix (15mm) with mucosal enhancement and pericolonic fat spiculation.
Small layer of free liquid in subhepatic region and nodular peritoneal thickening.
Fibrofatty proliferation of the right mesocolic fat and lymphadenopathy.
Dilatation of the common bile duct of up to 1cm in maximum diameter and normalisation in the distal segment, without any visible obstructive cause.
Bilateral pulmonary fibrosis in the apical and posterior segments consisting of multiple small centrilobular nodules, reticulation and traction bronchiectasis.
Mosaic attenuation suggesting paracicatricial and lower lobe hyperinflation.
Calcified and well-defined nodular lesions located in both upper lobes, compatible with calcified granulomas. No pleural effusion.
All these findings are compatible with ‘postprimary tuberculosis’.
Case Discussion
The patient provided a colonoscopy report describing a stenosing lesion 75 cm from the anal margin with marked subacute colitis and epithelial and giant cell granulomas without caseous necrosis.
The distinction should be made between neoplasm vs Crohn disease vs subacute infectious colitis. The findings support a diagnosis of a tuberculosis (given the thoracic findings), chronic Crohn disease reactivated and severe (given the fibrofatty proliferation and possible associated sinus tracts) or less likely lymphoma (given the absence of clear submucosal oedema and luminal dilation of the terminal ilium).
A biopsy of the large intestine was performed, showing fragments of intestinal mucosa with necrotising granulomatous inflammation, compatible with TB infection.
Two months later, the patient suffered an intestinal obstruction that required a right hemicolectomy. The pathology of the surgical specimen confirmed the diagnosis of ileocaecal tuberculosis.
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