Rare Case of Lower Gastrointestinal Bleeding Secondary to Miliary Tuberculosis in the United States

Tuberculosis (TB) remains a significant global health challenge. Miliary TB is a rare manifestation of TB that involves systemic lymphohematogenous dissemination of infection and presents diagnostic challenges due to its often asymptomatic or non-specific nature. This case report documents a rare occurrence of gastrointestinal (GI) bleeding secondary to miliary TB without pulmonary symptoms in an 81-year-old Filipino-American male living in the United States. Extensive imaging studies revealed a mass in the right colon with multiple bleeding vessels draped around it; it was not amendable to treatment with embolization and required right hemicolectomy with end ileostomy. The pathology report of the excised mass demonstrated miliary TB with necrotizing granulomas and granulomatous lymphadenopathy involving 23 lymph nodes. The patient was started on anti-tuberculosis medical management; however, the patient remained clinically unstable and expired on postoperative day 39. This case highlights the importance of the heightened clinical awareness required during times of globalization and in regions with dense immigrant populations. We aim to delineate the clinical understanding of gastrointestinal TB (GITB) and review possible indications for surgical management. We aim to help reduce diagnostic delay, therefore improving patient outcomes and limiting the spread of disease.

Intestinal Tuberculosis: A Diagnostic Challenge

Diagnosing intestinal tuberculosis (TB) with uncommon clinical manifestations is often challenging. Here, we report a case of an alcoholic patient who presented with vague symptoms and was later diagnosed with intestinal TB. This patient experienced multiorgan failure causing hemodynamic instability requiring ionotropic support; acute hypoxic respiratory failure managed with non-invasive positive pressure ventilation, hepatic failure, transudative peritoneal effusion, and transudative pleural effusion. These conditions clouded our judgment to pursue colonoscopy for a definite diagnosis and delayed the anti-tuberculosis treatment. When intestinal tuberculosis TB is suspected, the differential diagnosis must be established with other gastrointestinal involving diseases, including mycobacterium avium complex (MAC) and Crohn's disease (CD). MAC can show overlapping features with intestinal TB or coexist with it; Acid-fast stain and tissue culture are the key tests to differentiate these two. In the presence of diagnostic uncertainty between intestinal TB and CD, a therapeutic trial with anti-tuberculous therapy may be warranted.