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      Intestinal tuberculosis in a 55-year-old woman with a 30-year history of rheumatoid arthritis

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          Abstract

          Introduction

          Tuberculosis (TB) is one of the endemic diseases with a challenging diagnosis in the absence of pulmonary disease. On the other hand, rheumatoid arthritis (RA) is a systemic autoimmune disease with extra-articular manifestations that occur at any age after onset, such as nodules, Sjögren’s syndrome, anemia of chronic disease, and pulmonary manifestations, which are more frequently seen in patients with severe, active disease. Here we present a case of RA with intestinal TB.

          Case report

          A 55-year-old woman with a 30-year history of RA using prednisolone and hydroxychloroquine presented with a nonpositional hypogastric pain and a weight loss of 20 kg over 7 months. No history of biological therapy was recorded. Colonoscopy revealed an ulcerated mass that was suspicious for malignancy. The pathobiological assessments confirmed ulceration and granulation tissue formation, foci of necrotizing granulomatous inflammation in lamina propria with adjacent mild crypt regenerative changes. Also, Ziehl–Neelsen staining for acid-fast bacilli in the granulomas was positive though the polymerase chain reaction assay did not detect the Mycobacterium tuberculosis. Anti-TB medication for 2 weeks eliminated the symptoms.

          Conclusions

          Intestinal TB in patients with vague abdominal symptoms and relevant physical findings such as pain and palpable mass should be considered to prevent late or misdiagnosis.

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          Most cited references 17

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          Tuberculosis of the gastrointestinal tract and peritoneum.

           B Marshall (1993)
          Gastrointestinal and peritoneal tuberculosis remain common problems in impoverished areas of the world, but is relatively infrequent in the United States. A resurgence of tuberculosis in America since the mid-1980s means that clinicians will continue to see cases. Immigrants and AIDS patients are two population groups at particular risk for abdominal tuberculosis in this country; the urban poor, the elderly, and Indians on reservations are others. The symptoms and signs of GI and peritoneal tuberculosis are nonspecific, and unless a high index of suspicion is maintained, the diagnosis can be missed or delayed resulting in increased morbidity and mortality. Only 15-20% of patients have concomitant active pulmonary tuberculosis. Tuberculous peritonitis needs to be considered in all cases of unexplained exudative ascites. Laparoscopy with directed biopsy currently is the best way to make a rapid specific diagnosis. The measurement of ascites adenosine deaminase levels represents a major diagnostic advance in tuberculous peritonitis, particularly in underdeveloped areas where the affliction is common and laparoscopy may not be available. With greater experience, this testing procedure could also supersede invasive studies in western countries, particularly in high-risk patient groups. The commonest sites of tuberculous involvement of the GI tract are the ileocecal area, the ileum and the colon, although any area of the gut can be involved. If the area of affected gut is within reach of the flexible endoscope, rapid diagnosis may be possible with biopsy (if acid-fast bacilli or caseating granulomas are seen). Not infrequently, the disease is not considered until it is diagnosed at the time of surgery. In countries with a high prevalence of intestinal tuberculosis, a therapeutic trial of antituberculous drugs may be reasonable if the clinical picture is compatible. The diagnosis of tuberculous enteritis can be taken as highly probable if the patient responds to treatment and this is followed by no recurrence. Serologic tests for diagnosing tuberculosis are being improved and evaluated in intestinal tuberculosis. Gastrointestinal and peritoneal tuberculosis are treated with antituberculous drugs. Surgery is reserved for complications or uncertainty in diagnosis. Six-, 9-, and 18- to 24-month regimens are all effective for extrapulmonary tuberculosis. Standard therapy of at least 9 months duration is also effective in most AIDS patients who are started on appropriate treatment in a timely fashion and who are compliant. The potential for multidrug resistance needs to be kept in mind and accounted for.
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            Intestinal tuberculosis: return of an old disease.

            Tuberculosis (TB) can no longer be considered a rare disease in the United States due, in part, to the AIDS epidemic. Because the signs and symptoms of intestinal TB are nonspecific, a high index of suspicion must be maintained to ensure a timely diagnosis. The aim of this article is to review the history, epidemiology, pathophysiology, and treatment of TB. This review is based on an examination of the world literature. In only 20% of TB patients is there associated active pulmonary TB. Areas most commonly affected are the jejunoileum and ileocecum, which comprise >75% of gastrointestinal TB sites. Diagnosis requires colonoscopy with multiple biopsies at the ulcer margins and tissue sent for routine histology, smear, and culture. If intestinal TB is suspected, empiric treatment is warranted despite negative histology, smear, and culture results. Treatment is medical, and all patients should receive a full course of antituberculous chemotherapy. Exploratory laparotomy is necessary if the diagnosis is in doubt, in cases in which there is concern about a neoplasm, or for complications that include perforation, obstruction, hemorrhage, or fistulization. This review draws attention to the resurgence of tuberculosis in the United States. An increased awareness of intestinal tuberculosis, coupled with knowledge of the pathophysiology, diagnostic methods, and treatment should increase the number of cases diagnosed, thus improving the outcome for patients with this disease.
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              Diagnosis of abdominal tuberculosis: experience from 11 cases and review of the literature.

              To analyze the experience within our hospital and to review the literature so as to establish the best means of diagnosis of abdominal tuberculosis. The records of 11 patients (4 males, 7 females, mean age 39 years, range 18-65 years) diagnosed with abdominal tuberculosis in Harran University Hospital between January 1996 and October 2003 were analyzed retrospectively and the literature was reviewed. Ascites was present in all cases. Other common findings were weight loss (81%), weakness (81%), abdominal mass (72%), abdominal pain (72%), abdominal distension (63%), anorexia (45%) and night sweat (36%). The average hemoglobin was 8.2 g/dL and the average ESR was 50 mm/h (range 30-125). Elevated levels of cancer antigen CA-125 were determined in four patients. Abdominal ultrasound showed abnormalities in all cases: ascites in all, tuboovarian mass in five, omental thickening in 3, and enlarged lymph nodes (mesenteric, para-aortic) in 2. CT scans showed ascites in all, pelvic mass in 5, retroperitoneal lymphadenopathy in 4, mesenteric stranding in 4, omental stranding in 3, bowel wall thickening in 2 and mesenteric lymphadenopathy in 2. Only one patient had a chest radiograph suggestive of a new TB lesion. Two had a positive family history of pulmonary TB. None had acid-fast bacilli (AFB) in the sputum and the tuberculin test was positive in only two. Laparotomy was performed in 6 cases, laparoscopy in 4 and ultrasound-guided fine needle aspiration in 2. In those patients subjected to operation, the findings were multiple diffuse involvement of the visceral and parietal peritoneum, white 'miliary nodules' or plaques, enlarged lymph nodes, ascites, 'violin string' fibrinous strands, and omental thickening. Biopsy specimens showed granulomas, while ascitic fluid showed numerous lymphocytes. Both were negative for acid-fast bacilli by staining. PCR of ascitic fluid was positive for Mycobacterium tuberculosis (M. tuberculosis) in all cases. Abdominal TB should be considered in all cases with ascites. Our experience suggests that PCR of ascitic fluid obtained by ultrasound-guided fine needle aspiration is a reliable method for its diagnosis and should at least be attempted before surgical intervention.
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                Author and article information

                Journal
                Int Med Case Rep J
                Int Med Case Rep J
                International Medical Case Reports Journal
                International Medical Case Reports Journal
                Dove Medical Press
                1179-142X
                2018
                10 July 2018
                : 11
                : 151-155
                Affiliations
                [1 ]Gastrointestinal and Liver Diseases Research Center, Guilan University of Medical Sciences, Rasht, Iran
                [2 ]Caspian Digestive Diseases Research Center, Guilan University of Medical Sciences, Rasht, Iran, farajov@ 123456gmail.com
                [3 ]Shiraz University of Medical Sciences, Shiraz, Iran
                Author notes
                Correspondence: Farahnaz Joukar, Caspian Digestive Diseases Research Center (CDDRC), Guilan University of Medical Sciences (GUMS), Razi Hospital, Sardar-Jangle Ave., P.O. Box: 41448-95655, Rasht, Iran, Email farajov@ 123456gmail.com
                Article
                imcrj-11-151
                10.2147/IMCRJ.S162908
                6044367
                © 2018 Mansour-Ghanaei et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

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