Gastrointestinal Tuberculosis. Microbiol Spectr. 2016;4. [PMID: 28084201 DOI: 10.1128/microbiolspec.tnmi7-0014-2016]

Microscopic polyangiitis With Pauci-Immune Glomerulonephritis Associated With Gastrointestinal Tuberculosis

Introduction: Tuberculosis (TB) is a prevalent disease in Guatemala, present in 20-25 cases per 100 thousand inhabitants. Extrapulmonary TB (EPTB) accounts for only 10%-17% of TB cases. The diagnosis of EPTB is challenging, especially in low-resource settings, because TB can present with clinical characteristics of rheumatological, oncological, or other infectious diseases. Occasionally, mycobacterial infection stimulates the immune system, inducing the generation of antibodies that may lead to autoimmune diseases secondary to primary TB infection, such as vasculitis. To the best of our knowledge, no data have been reported on the prevalence of vasculitis, although some studies worldwide have determined that small-vessel vasculitis is the most common. Here, we present a case report of a male patient with EPTB diagnosed with Microscopic polyangiitis (MPA). Methods: A 17-year-old boy with no past medical history visited the emergency room with a three-day history of gastrointestinal bleeding. During hospitalization, acute kidney injury (AKI), disseminated lymphadenopathy, imaging studies, renal biopsy, and immunological tests were performed to confirm the diagnosis. Results: Endoscopy revealed a duodenal lesion containing Mycobacterium TB DNA. Further investigation of AKI led to autoimmune serological tests and kidney biopsy, confirming the diagnosis of antineutrophil cytoplasmic antibodies (ANCA)-positive pauci-immune GN. The patient was treated with antituberculous agents, steroids, and plasmapheresis. However, he developed alveolar hemorrhage and respiratory failure leading to death. Conclusion: TB is a common disease in low-income countries, with the pulmonary form being the most common presentation; however, the bacteria can spread to any organ, known as EPTB. It is important to consider that the inflammatory reaction associated with any form of TB can generate other types of noninfectious inflammatory diseases, such as ANCA-positive pauci-immune GN.

Foregut tuberculosis: Too close but miles apart

The worldwide burden of tuberculosis (TB) has increased and it can involve virtually any organ of the body. Intestinal TB accounts for about 2% of the cases of TB worldwide. The ileocecal region is the most commonly affected site, and the foregut is rarely involved. The reported incidence is approximately 0.5%. Esophageal TB presents with dysphagia, weight loss, and hematemesis in rare cases. Gastroduodenal TB usually manifests with symptoms such as nausea, vomiting, weight loss, and sometimes with gastric outlet obstruction. Gastroscopy may reveal shallow ulcers in stomach and duodenal deformity when underlying TB is suspected, therefore histopathology plays pivotal role. On computed tomography, duodenal TB typically manifests as duodenal strictures predominantly, accompanied by extrinsic compression, and occasionally as intraluminal mass. But their diagnosis can easily be missed if proper biopsies are not taken and samples are not sent for GeneXpert testing, TB polymerase chain reaction investigation and histopathological analysis. Despite being in close proximity to the lungs, the esophagus and stomach are rare sites of TB. The reasons could be low gastric pH and acidity which does not let mycobacterium grow. But there are various case reports of TB involving the foregut. We have summarized the rare cases of foregut TB in different sections and highlighted the importance of esophagogastroduodenoscopy, histopathology and advanced techniques like endoscopic ultrasound in establishing the diagnosis.

Tuberculosis of gastrointestinal tract revealed by acute abdomen due to ileocecal perforation in an HIV-infected patient: A case report

INTRODUCTION

Gastrointestinal tuberculosis (TB) is a rare condition, but it poses significant diagnostic and management challenges, especially in immunocompromised individuals. This case report discusses the diagnostic complexities and therapeutic strategies for managing gastrointestinal TB in an HIV-positive patient, emphasizing the importance of considering TB in differential diagnoses.

CASE PRESENTATION

A 33-year-old male with no significant medical history presented with a five-day history of severe abdominal pain, initially epigastric and later localized to the right lower quadrant (RLQ). Physical examination revealed RLQ tenderness, and elevated inflammatory markers were observed in laboratory tests. Imaging studies suggested splenomegaly and signs consistent with acute appendicitis. Laparotomy uncovered a perforated cecal mass and diffuse white lesions across the small intestine. Histopathological analysis confirmed necrotizing granulomatous colitis, and PCR identified Mycobacterium tuberculosis (MTB). During hospitalization, the patient was diagnosed with HIV.

CLINICAL DISCUSSION

This case underscores the diagnostic challenge of abdominal TB, particularly in HIV-infected patients where clinical presentation can mimic other conditions like Crohn's disease or appendicitis. Effective management requires timely surgical intervention, followed by appropriate anti-tuberculous and antiretroviral therapies. The multidisciplinary approach ensures comprehensive care and better patient outcomes.

CONCLUSION

Effective recognition and diagnosis of gastrointestinal TB in HIV-positive patients are critical for successful treatment. This report highlights the necessity for heightened clinical suspicion and a collaborative approach in managing such complex cases, ultimately improving patient prognosis and care.

Recognizing and addressing the challenges of gastrointestinal tuberculosis

In this editorial, we comment on the article by Ali et al published in the recent issue of the World Journal of Clinical Cases. This case report shed light on a particularly rare manifestation of this disease-primary gastrointestinal tuberculosis (GTB) presenting as gastric outlet obstruction. GTB presents diagnostic challenges due to its nonspecific symptoms and lack of highly accurate diagnostic algorithms. This editorial synthesizes epidemiological data, risk factors, pathogenesis, clinical presentations, diagnostic methods, and therapies to raise awareness about GTB. GTB constitutes 1%-3% of all tuberculosis cases globally, with 6%-38% of patients also having pulmonary tuberculosis. Pathogenesis involves various modes of Mycobacterium tuberculosis complex entry into the gastrointestinal system, with the terminal ileum and ileocecal valve commonly affected. Clinical presentation varies, often resembling other intra-abdominal pathologies, necessitating a high index of suspicion. Diagnostic tools include a combination of biochemical, microbiological, radiological, and endoscopic assessments. Anti-tubercular medication remains the cornerstone of treatment, supplemented by surgical intervention in severe cases. Multidisciplinary management involving gastroenterologists, surgeons, pulmonologists, and infectious disease specialists is crucial for optimal outcomes. Despite advancements, timely diagnosis and management challenges persist, underscoring the need for continued research and collaboration in addressing primary GTB.

Primary Gastric Tuberculosis in an Immunocompetent Patient: The Truth Lying beneath the Surface

Gastrointestinal tuberculosis is an uncommon entity, in which clinical presentation can be widely variable, from mild and nonspecific symptoms to an acute abdomen and gastrointestinal bleeding. Gastric involvement by Mycobacterium tuberculosis is rare, especially when it occurs without other recognized infectious foci - primary gastric tuberculosis - with only a few reported cases. Endoscopic findings can be very heterogeneous, from areas of hyperemia to pseudotumor lesions. We present a case of primary gastric tuberculosis in an immunocompetent patient, in which the absence of an epidemiological context and nonspecific endoscopic findings led to a delay in the diagnosis. Bite-on-bite biopsies proved to be essential, allowing to obtain samples from deeper layers of the submucosa where M. tuberculosis was identified. This case aimed to increase awareness for this entity, especially in endemic countries or regions with a high prevalence of tuberculosis since the diagnosis is based mainly on a high index of suspicion.

Revisiting the Era of Intestinal Tuberculosis: A Case Presenting As Small Bowel Obstruction With Classical Imaging and Histopathological Appearances

The incidence of tuberculosis (TB) worldwide is still significantly high, with India contributing a high global TB burden. This case study features a 49-year-old male who had complaints of pain and abdominal distention for one and a half months. An erect abdominal radiograph showed features suggesting small bowel obstruction. Contrast-enhanced computed tomography (CT) of the abdomen was done. It showed multiple strictures involving the distal jejunum and ileum, causing small bowel obstruction. There was mesenteric and retroperitoneal lymphadenopathy with central necrosis and ascites. The patient was operated on for a small bowel obstruction. The resected intestine showed four strictures, tiny nodules on the serosal surface, and many enlarged lymph nodes. Representative tissue from these areas showed the typical picture of multiple caseating granulomas and fibrosis. Ziehl-Neelsen (ZN) staining highlighted the acid-fast bacilli (AFB). The suspicion index for intestinal tuberculosis (ITB) should be kept high while evaluating patients with intestinal obstruction presenting in endemic areas and high-risk populations, such as HIV-infected, undernourished, immunocompromised, and those with diabetes, smoking, and alcohol addiction.

Clinical Analysis of Intestinal Tuberculosis: A Retrospective Study

PURPOSE

This study aimed to summarize and analyze the clinical data of intestinal tuberculosis (ITB) in order to provide guidance for accurate diagnosis and treatment of ITB.

METHODS

This study consecutively included patients with ITB who were admitted to our hospital from 2008 to 2021 and retrospectively analyzed their clinical features.

RESULTS

Forty-six patients were included. The most common clinical symptom was weight loss (67.4%). Seventy percent of 20 patients were positive for tuberculin skin test; 57.1% of 14 patients were positive for mycobacterium tuberculosis specific cellular immune response test, while 84.6% of 26 patients were positive for tuberculosis infection T cell spot test. By chest computed tomography (CT) examination, 25% and 5.6% of 36 patients were diagnosed with active pulmonary tuberculosis and with inactive pulmonary tuberculosis, respectively. By abdominal CT examination, the most common sign was abdominal lymph node enlargement (43.2%). Forty-two patients underwent colonoscopy, and the most common endoscopic manifestation was ileocecal ulcer (59.5%), followed by colonic ulcer (35.7%) and ileocecal valve deformity (26.2%). ITB most frequently involved the terminal ileum/ileocecal region (76.1%). Granulomatous inflammation with multinucleated giant cells and caseous necrosis was found via endoscopic biopsies, the ultrasound-guided percutaneous biopsy of enlarged mesentery lymph nodes, and surgical interventions. The acid-fast bacilli were discovered in 53.1% of 32 samples. Twenty-one cases highly suspected of ITB were confirmed after responding to empiric anti-tuberculosis therapy.

CONCLUSIONS

It was necessary to comprehensively analyze clinical features to make an accurate diagnosis of ITB and aid in distinguishing ITB from diseases such as Crohn's disease and malignant tumors.

Surgical Management of Patients With GI Tuberculosis

BACKGROUND

The Philippines ranks 10th in tuberculosis prevalence worldwide. Aside from pulmonary tuberculosis, GI tuberculosis remains an important cause of morbidity and mortality, particularly in endemic areas.

OBJECTIVE

This study aimed to describe the clinicopathologic profile and surgical outcomes of patients with GI tuberculosis.

DESIGN

Retrospective descriptive study.

SETTING

Department of Surgery at the Philippine General Hospital, Manila, Philippines.

PATIENTS

This study included all newly diagnosed cases of GI tuberculosis from January 1, 2009, to December 31, 2019.

MAIN OUTCOME MEASURES

Clinical response to surgery.

RESULTS

A total of 241 confirmed new cases were managed during an 11-year period. Of these, 208 patients (86.30%) underwent outright surgery, whereas the remaining patients (13.69%) received antituberculous therapy. Fifteen medically managed patients eventually required surgery, bringing the total surgically managed patients to 223. The patients' age ranged from 19 to 72 years, with a 1.9:1 male to female ratio. The most common complaint was abdominal pain. Intestinal obstruction was the most common indication for surgery. A right hemicolectomy was the most often performed procedure, with the ileocecal area as the most frequently involved segment. The most common histopathologic findings were epithelioid granuloma and caseation necrosis. Postoperative length of stay ranged from 0 to 59 days (mean, 7 days). Morbidity rate was 5.38% and mortality rate was 3.14%. Four deaths were operative and resulted from septic shock because of hollow viscus perforation.

LIMITATIONS

This study was limited to histopathologic basis for diagnosis.

CONCLUSION

The recommended initial therapy for all forms of extrapulmonary tuberculosis is a 6-month regimen of antituberculous therapy unless the organisms are known or suspected to be resistant to first-line drugs. Surgery is reserved for complications of intra-abdominal tuberculosis: obstruction, perforation, or severe bleeding. Timely surgical intervention, coupled with medical management led to the best outcomes for these patients. See Video Abstract at http://links.lww.com/DCR/C56.

MANEJO QUIRRGICO DE PACIENTES CON TUBERCULOSIS GASTROINTESTINAL

ANTECEDENTES:Las Filipinas ocupa el décimo lugar en prevalencia de tuberculosis en todo el mundo. Aparte de la tuberculosis pulmonar, la tuberculosis gastrointestinal sigue siendo una causa importante de morbilidad y mortalidad, especialmente en las zonas endémicas.OBJETIVO:Este estudio tuvo como objetivo describir el perfil clinicopatológico y los resultados quirúrgicos de pacientes con tuberculosis gastrointestinal.DISEÑO:Estudio descriptivo retrospectivo.AJUSTE:Departamento de Cirugía del Hospital General de Filipinas, Manila, Filipinas.PACIENTES:Todos los casos de tuberculosis gastrointestinal recién diagnosticados desde el 1 de Enero del 2009 hasta el 31 de Diciembre del 2019.MEDIDAS DE RESULTADO PRINCIPAL:Respuesta clínica a la cirugía.RESULTADOS:Se manejaron un total de 241 casos nuevos confirmados durante un período de 11 años. De estos, 208 (86,30%) pacientes fueron intervenidos directamente quirúrgicamente mientras que el resto recibió tratamiento antituberculoso (13,69%). Quince pacientes manejados médicamente finalmente requirieron cirugía, lo que elevó el total de pacientes manejados quirúrgicamente a 223. Las edades de los pacientes oscilaron entre 19 y 72 años, con una proporción de 1,9: 1 entre hombres y mujeres. La queja más común fue el dolor abdominal. La obstrucción intestinal fue la indicación más frecuente para cirugía. La hemicolectomía derecha fue el procedimiento más realizado, siendo la zona ileocecal el segmento más afectado. Los hallazgos histopatológicos más comunes fueron granuloma epitelioide y necrosis caseosa. La estancia postoperatoria varió de 0 a 59 días (media, 7 días). Las tasas de morbilidad y mortalidad fueron 5,38% y 3,14%, respectivamente. Cuatro fueron muertes operatorias por choque séptico debido a perforación de víscera.LIMITACIONES:Este estudio se limitó a la base histopatológica para el diagnóstico.CONCLUSIÓN:La terapia inicial recomendada para todas las formas de tuberculosis extrapulmonar es un régimen de 6 meses de terapia antituberculosa a menos que se sepa o se sospeche que los organismos son resistentes a los medicamentos de primera línea. La cirugía se reserva para las complicaciones de la tuberculosis intraabdominal, es decir, obstrucción, perforación o hemorragia grave. La intervención quirúrgica oportuna, junto con el manejo médico, condujo a mejores resultados para estos pacientes. Consulte el Resumen del Video en http://links.lww.com/DCR/C56. (Traducción- Dr. Yesenia Rojas-Khalil).

Spontaneous Resolution of Strangulated Small Bowel Obstruction in a Patient With Intestinal Tuberculosis After Starting Anti-tuberculosis Drugs: A Case Report

Intestinal tuberculosis can cause strangulated small bowel obstruction. Strangulated small bowel obstruction usually requires surgery. We report a case of a patient with intestinal tuberculosis, who developed a spontaneously resolving strangulated small bowel obstruction after the commencement of anti-tuberculosis drugs. A 72-year-old woman presented with abdominal pain and ascites was noticed on abdominal ultrasonography. Contrast-enhanced computed tomography (CT) revealed a 50-mm tumor in the ileocecal region that was darkly contrasted, along with peritoneal thickening and ascites. A malignant tumor and carcinomatous peritonitis were suspected. Colonoscopy showed an ulcerative lesion in the terminal ileum, and the acid-fast bacillus culture was positive; therefore, the patient was diagnosed with intestinal tuberculosis and was treated with isoniazid, rifampicin, ethambutol, and pyrazinamide. After commencing treatment, improvement in peritoneal thickening and ascites was confirmed using abdominal ultrasonography; therefore, we concluded that the ascites was due to tuberculous peritonitis. Six weeks after the initiation of treatment, the patient visited our facility with complaints of abdominal pain. Contrast-enhanced CT revealed unenhanced small intestinal walls, and a diagnosis of strangulated small bowel obstruction was made; however, her symptoms improved naturally. Strangulated small bowel obstruction was presumed to be due to the presence of bands as anti-tuberculosis therapy could promote fibrosis. In this case, abdominal ultrasonography was useful in the evaluation of the effects of treatment.

An Unusual Presentation of Esophageal Tuberculosis: A Case Report

The lungs, kidneys, liver, and pancreas are just some of the organs that can be affected by tuberculosis. Tuberculosis is a disease that can affect many organs of the human body. Rarely can tuberculosis (TB) manifest itself in the digestive tract; in fact, the gastrointestinal tract ranks as the sixth most common site of extrapulmonary TB. However, involvement of the esophagus by tuberculosis is extremely uncommon. We present a case of esophageal tuberculosis in a 27-year-old man with epigastric pain and weight loss as his only symptoms. There were no complaints of odynophagia or dysphagia, nor was there any evidence of immunodeficiency. Upper gastrointestinal endoscopy found an ulcer 26 centimeters from the incisor. Histopathology and a biopsy confirmed the diagnosis of primary esophageal tuberculosis. Six months after beginning anti-TB therapy, he was confirmed to be free of tuberculosis.

Diagnostic performance of adenosine deaminase for abdominal tuberculosis: A systematic review and meta-analysis

Background and aim

Abdominal tuberculosis (TB) is a common type of extrapulmonary TB with an insidious onset and non-specific symptoms. Adenosine deaminase (ADA) levels increase rapidly in the early stages of abdominal TB. However, it remains unclear whether ADA serves as a diagnostic marker for abdominal TB.

Methods

We performed a systematic literature search for relevant articles published in PubMed, Web of Science, Cochrane Library, and Embase up to April 2022. First, we used the Quality Assessment of Diagnostic Accuracy Studies tool-2 (QUADAS-2), to evaluate the quality of the included articles. Bivariate and hierarchical summary receiver operating characteristic (HSROC) models were then utilized to analyze pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR) and area under the receiver operating characteristic curve (AUROC). In addition, we explored a subgroup analysis for potential heterogeneity and publication bias among the included literature.

Results

Twenty-four articles (3,044 participants, 3,044 samples) which met the eligibility criteria were included in this study. The pooled sensitivity and specificity of ADA for abdominal TB detection were 93% [95% confidence interval (CI): 0.89-0.95] and 95% (95% CI: 0.93-0.96), respectively. PLR and NLR were 18.6 (95% CI: 14.0-24.6) and 0.08 (95% CI: 0.05-0.12), respectively. DOR and AUROC were 236 (95% CI: 134-415) and 0.98 (95% CI: 0.96-0.99), respectively. Furthermore, no heterogeneity or publication bias was found.

Conclusions

Our meta-analysis found ADA to be of excellent diagnostic value for abdominal TB and could be used as an auxiliary diagnostic tool.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42022297931.

Intestinal tuberculosis-the challenging mimicker-in a young Sudanese patient: A case report

This article reported a case of intestinal tuberculosis (ITB)in a young patient. ITB could mimic many other diseases such as inflammatory bowel diseases (Crohn's disease), abdominal lymphoma, and others which make it difficult to differentiate; hence, many ITB patients could get mis-diagnosed and suffer wrong treatment consequences.

Intestinal Tuberculosis Presenting with Gastrointestinal Bleeding in Patient on Warfarin Therapy

Background

Intestinal tuberculosis (ITB) constitutes less than 5% of overall cases of extrapulmonary disease and mostly affects the ileocecal region. The presentation and radiologic findings in enteric tuberculosis can mimic Crohn's disease (CD). Case Presentation. We present a case report of an African woman who presented to a Kenyan hospital with lower gastrointestinal bleeding while on anticoagulation for valvular atrial fibrillation, and was diagnosed with intestinal tuberculosis after colonoscopy, biopsy, and positive staining for tuberculous bacilli.

Conclusion

Intestinal tuberculosis causing gastrointestinal bleeding is rare but should be suspected in patients living in TB endemic regions.

Recent advances in the diagnosis of intestinal tuberculosis

BACKGROUND

Intestinal tuberculosis still has a high incidence, especially in developing countries. The biggest challenge of this disease is the establishment of the diagnosis because the clinical features are not typical. Investigations such as culture, acid-fast bacilli (AFB) staining, and histopathology have low sensitivity, so other investigations are needed. Latest molecular-based diagnostic modalities such as GeneXpert, interferon-gamma (IFN-γ) release assays (IGRA), polymerase chain reaction (PCR), multiplex-PCR, and immunological markers are expected to help diagnose intestinal tuberculosis. This article review will examine the latest diagnostic modalities that can be used as a tool in establishing the diagnosis of intestinal tuberculosis.

RESULTS

Through a literature search, we were able to review the diagnostic values of various available diagnostic modalities as the appropriate additional test in intestinal tuberculosis. Culture as a gold standard has a sensitivity and specificity value of 9.3% and 100% with the MGIT BACTEC system as the most recommended medium. The sensitivity values of AFB staining, histopathology examination, GeneXpert, IGRA, PCR, multiplex-PCR and, immunological markers were ranged between 17.3 and 31%; 68%; 81-95.7%; 74-88%; 21.6-65%; 75.7-93.1%; and 52-87%, respectively. Meanwhile the specificity values were 100%; 77.1%; 91-100%; 74-87%; 93-100%; 96.4-100%; and 70-95%, respectively.

CONCLUSION

The combination of clinical examination, conventional examination, and the latest molecular-based examination is the best choice for establishing the diagnosis of intestinal tuberculosis. Most recent modalities such as multiplex PCR and immunological marker examinations are diagnostic tools that deserve to be used in diagnosing intestinal tuberculosis as their sensitivity and specificity values are quite high and more evidences are expected to support the application of these examinations shortly soon.

Gut Microbiome in Probable Intestinal Tuberculosis and Changes following Anti-Tuberculosis Treatment

PURPOSE

Information on the gut microbiome in patients with intestinal tuberculosis (ITB) and changes therein following anti-tuberculosis treatment (ATT) is lacking. We aimed to elucidate differences in stool microbiome between ITB patients and controls and to evaluate stool microbiome changes after ATT.

MATERIALS AND METHODS

Eleven patients with probable ITB underwent ATT for 6 months, with stool samples collected at 0, 2, and 6 months. We performed next-generation sequencing of 16S rRNA genes in stool bacteria and compared the gut microbiome.

RESULTS

Initially, the relative abundance of Verrucomicrobia was higher (5.0% vs. <1%) and that of Proteobacteria was lower (<1% vs. 6.6%) in ITB patients than in controls. Higher numbers of butyrate-producing bacteria (Blautia and Roseburia) were noted in ITB patients. The alpha-diversity of stool microbiome of ITB patients was lower than that in controls (p=0.045). There was a significant difference in beta-diversity between the groups (p=0.001). At 6 months, the proportion of Verrucomicrobia decreased to <1%, while the proportion of Proteobacteria remained at <1%.

CONCLUSION

There were no significant differences in alpha- and beta-diversity in the stool microbiome at 0, 2, and 6 months after ATT. The stool microbiome composition of probable ITB patients was different from that of controls, and 6 months of ATT did not significantly affect it.

Rare manifestation of a large stenosing gastrointestinal tumor caused by Mycobacterium tuberculosis in a previously healthy man from Austria

BACKGROUND

Gastrointestinal tuberculosis (TB) is a rare manifestation in low TB-incidence countries such as Austria. It is usually seen in immunocompromised patients or in migrants being more susceptible for extrapulmonary disease manifestations.

CASE DESCRIPTION

We report a very rare manifestation of severe gastrointestinal TB in a 49-year-old previously healthy man from Upper Austria. Endoscopy showed a large tumor mass obstructing about 2/3 of the lumen of the cecum. Positron emission tomography/computed tomography scan revealed not only a high metabolic activity in the tumor mass, but also active pulmonary lesions in both upper lung lobes. Bronchial secretion showed acid-fast bacilli in the microscopy and polymerase chain reaction was positive for M. tuberculosis complex. Phenotypic resistance testing showed no resistance for first-line anti-TB drugs. Treatment with isoniazid, rifampicin, pyrazinamide and ethambutol was initiated. Based on therapeutic drug monitoring, the standard treatment regime was adapted to rifampicin high dose. TB treatment was well tolerated and the patient achieved relapse-free cure one year after the end of treatment.

CONCLUSION

Gastrointestinal involvement mimicking an intestinal tumor is a very rare TB manifestation in previously healthy Austrians. However, it should be kept in mind due to increasing migration from countries with higher rates of extrapulmonary TB and due to an increasing number of immunocompromised patients. TB telephone consultations can support medical professionals in the diagnosis and the management of complex TB patients. TB management is currently at a transitional stage from a programmatic to personalized management concept including therapeutic drug monitoring or biomarker-guided treatment duration to achieve relapse-free cure.

A rare case of gastric fundus tuberculosis with nonspecific abdominal pain

A 53-year-old patient who experienced recurring upper abdominal pain and discomfort for 4 years was admitted to our hospital. Gastroscopy was performed to identify the location of the pain and evaluate the characteristics of a mass in the abdomen. Endoscopic ultrasonography (EUS) and abdominal computed tomography (CT) revealed a space-occupying lesion in the gastric fundus, suggestive of a submucosal tumor and highly likely of stromal origin. Surgical resection of the lesion was performed for identification; however, postoperative histopathological examination of the lesion revealed gastric fundus tuberculosis (TB). Gastric TB is relatively rare; therefore, clinicians should be highly suspicious of patients with abdominal symptoms from regions with a high incidence of TB to prevent treatment delay caused by misdiagnosis.

Gastrointestinal tuberculosis: A systematic review of epidemiology, presentation, diagnosis and treatment

Tuberculosis (TB) once considered a disease of the developing world is infrequent in the developing world too. Its worldwide prevalence with a huge impact on the healthcare system both in economic and health terms has prompted the World Health Organization to make it a top priority infectious disease. Tuberculous infection of the pulmonary system is the most common form of this disease, however, extrapulmonary TB is being increasingly recognized and more often seen in immunocompromised situations. Gastrointestinal TB is a leading extrapulmonary TB manifestation that can defy diagnosis. Overlap of symptoms with other gastrointestinal diseases and limited accuracy of diagnostic tests demands more awareness of this disease. Untreated gastrointestinal TB can cause significant morbidity leading to prolonged hospitalization and surgery. Prompt diagnosis with early initiation of therapy can avoid this. This timely review discusses the epidemiology, risk factors, pathogenesis, clinical presentation, current diagnostic tools and therapy.

Extrapulmonary Tuberculosis—An Update on the Diagnosis, Treatment and Drug Resistance

Pathogenic Mycobacterium tuberculosis complex organisms (MTBC) primarily cause pulmonary tuberculosis (PTB); however, MTBC are also capable of causing disease in extrapulmonary (EP) organs, which pose a significant threat to human health worldwide. Extrapulmonary tuberculosis (EPTB) accounts for about 20–30% of all active TB cases and affects mainly children and adults with compromised immune systems. EPTB can occur through hematogenous, lymphatic, or localized bacillary dissemination from a primary source, such as PTB, and affects the brain, eye, mouth, tongue, lymph nodes of neck, spine, bones, muscles, skin, pleura, pericardium, gastrointestinal, peritoneum, and the genitourinary system as primary and/or disseminated disease. EPTB diagnosis involves clinical, radiological, microbiological, histopathological, biochemical/immunological, and molecular methods. However, only culture and molecular techniques are considered confirmatory to differentiate MTBC from any non-tuberculous mycobacteria (NTM) species. While EPTB due to MTBC responds to first-line anti-TB drugs (ATD), drug susceptibility profiling is an essential criterion for addressing drug-resistant EPTB cases (DR-EPTB). Besides antibiotics, adjuvant therapy with corticosteroids has also been used to treat specific EPTB cases. Occasionally, surgical intervention is recommended, mainly when organ damage is debilitating to the patient. Recent epidemiological studies show a striking increase in DR-EPTB cases ranging from 10–15% across various reports. As a neglected disease, significant developments in rapid and accurate diagnosis and better therapeutic interventions are urgently needed to control the emerging EPTB situation globally. In this review, we discuss the recent advances in the clinical diagnosis, treatment, and drug resistance of EPTB.

Primary duodenal tuberculosis misdiagnosed as tumor by imaging examination: A case report

BACKGROUND

Primary duodenal tuberculosis is very rare. Due to a lack of specificity for its presenting symptoms, it is easily misdiagnosed clinically. Review of the few case reports and literature on the topic will help to improve the overall understanding of this disease and aid in differential diagnosis to improve patient outcome.

CASE SUMMARY

A 71-year-old man with a 30-plus year history of bronchiectasis and bronchitis presented to the Gastroenterology Department of our hospital complaining of intermittent upper abdominal pain. Initial imaging examination revealed a duodenal space-occupying lesion; subsequent upper abdominal contrast-enhanced computed tomography indicated duodenal malignant tumor. Physical and laboratory examinations showed no obvious abnormalities. In order to confirm further the diagnosis, electronic endoscopy was performed and tissue biopsies were taken. Duodenal histopathology showed granuloma and necrosis. In-depth tuberculosis-related examination did not rule out tuberculosis, so we initiated treatment with anti-tuberculosis drugs. At 6 mo after the anti-tuberculosis drug course, there were no signs of new development of primary lesions by upper abdominal computed tomography, and no complications had manifested.

CONCLUSION

This case emphasizes the importance of differential diagnosis for gastrointestinal diseases. Duodenal tuberculosis requires a systematic examination and physician awareness.

Intestinal tuberculosis: Case series of three patients

Background

Intestinal tuberculosis (ITB) is a fraction of extrapulmonary TB, and its diagnosis often pose a significant challenge due to nonspecific presentation. Several methods have been utilized to diagnosed ITB, including findings of specific inflammatory process on histopathological examination. We hereby report three cases of ITB that manifested as caecal and adnexal mass.

Case report

First case, a 22-year-old male, presenting with abdominal pain, underwent exploratory laparotomy, biopsy, right hemicolectomy, and anastomosis end-to-side to the transverse ileocolical region due to partial ileus obstruction from caecal tumor. The second and third cases, a 27-year-old and 39-year-old females, both presenting with abdominal pain and distension, underwent exploratory laparotomy, adhesiolysis and biopsy. Histopathological examination in all three cases showed chronic granulomatous inflammation caused by TB. All three patients were diagnosed as ITB and received 6 months of anti-tuberculosis drug (ATD).

Discussion

Intestinal TB most commonly affected region is the ileocaecal, accounts for 64% of the incidence of gastrointestinal TB. The main reasons for the predilection of ileocaecal region are due to relatively longer faecal static, the abundant of lymphoid tissue, a neutral pH environment and absorptive transport mechanisms that allow swallowed mycobacterium to be absorbed. Intestinal TB may pose similar symptoms as those found in pulmonary TB, yet patients most commonly presenting with abdominal pain. Bacteriological signs and histopathological findings are gold standard for ITB diagnosis. Therapy for ITB includes pharmacological ATD and surgical therapy.

The Polymorphism rs17525495 of LTA4H Is Associated with Susceptibility of Crohn's Disease instead of Intestinal Tuberculosis in a Chinese Han Population

Background

Because of the similarity of intestinal tuberculosis and Crohn's disease in disease phenotype, differential diagnosis has always been a clinical problem. Arachidonic acid metabolites play an important role in the inflammatory response of intestinal tuberculosis and Crohn's disease. Recent studies have shown that the polymorphism locus in the promoter region of LTA4H gene affects LTB4 expression level and the susceptibility to extrapulmonary tuberculosis. Thus, we identified a total of 148 patients with intestinal tuberculosis, 145 with Crohn's disease, and 700 normal controls in this study.

Methods

All the study participants were local Han people from Jiangxi Province in the past eleven years. DNA was extracted from the paraffin-embedded specimens or the whole blood. The LTA4H promoter SNP (rs17525495) was genotyped with TaqMan assay.

Results

The T-alleles frequency was not significantly increased in patients with intestinal tuberculosis compared with healthy control group (p=0.630; OR=1.07; 95%CI=0.81-1.41), while patients with Crohn's disease have significantly increased T allele frequency compared with healthy population (p=0.032; OR=1.34; 95%CI=1.03-1.75). During treatment, the presence of the T allele significantly increased the proportion of Crohn's patients requiring glucocorticoids (p<0.05).

Conclusions

The T allele of LTA4H gene SNP (rs17525495) is a risk factor for Crohn's disease instead of intestinal tuberculosis. More importantly, there may be a potential association of the different genotypes of rs17525495 with the treatment efficacy of 5-ASA and glucocorticoids in patients with Crohn's disease. The association between LTA4H polymorphism and drugs therapeutic effects might contribute to the practice of precision medicine and the prediction of clinical outcomes.