A 17-year-old previously well girl presented to the emergency department with right iliac fossa (RIF) pain of 6 days’ duration. The pain was severe, colicky in nature and associated with diarrhoea and vomiting. There was no fever or other gastrointestinal symptoms and a review of the patient’s systems was unremarkable.
She was ill looking, thin and afebrile with a regular pulse of 131 bpm of normal volume. Blood pressure was 103/66 mm Hg. The chest and cardiovascular examination were normal. Examination of the abdomen revealed moderate rebound tenderness with an ill-defined small mass in the RIF.
Complete blood count (CBC) showed haemoglobin (Hb) 10.9 g/dl (normal 12–15), white blood count (WBC) 9.6×103/μl (normal 4.5–11×103/μl), neutrophils 70%, lymphocytes 20% and platelets 648 k/μl (normal 150–450 k/μl). Electrolytes, renal function and blood sugar were normal. Corrected calcium was normal. Albumin was 27 g/l (normal 35–50). Total protein and the liver enzymes were normal apart from alkaline phosphatase which was 174 (normal 50–136), but this level was expected for the patient’s age. Serum amylase was also normal. HIV 1 and 2 were negative. Erythrocyte sedimentation rate (ESR) was 20, which is normal. Chest x-ray was normal. Abdomen and pelvic CT scan showed thickening of the ileal and cecal walls with secondary chronic obstructed dilated distal ileal loops. Multiple enlarged mesenteric lymph nodes were seen. Fat stranding of the mesentery was also noted. Intestinal tuberculosis was considered possible but Crohn’s disease was another option (). A small bowel enema showed an irregular thread-like narrowing in the distal ileal segment (the contrast did not pass beyond the stricture) and dilated ileal loops proximal to the stricture, suggesting tuberculosis rather than Crohn’s disease or lymphoma. Colonoscopy showed inflammation, friability and exudate formation with large ulcerated areas of the cecum and a stenosed ileocecal valve; the terminal ileum could not be accessed (). Colonic biopsy showed evidence of cryptitis and crypt abscess formation, and basal plasma cytosis and one non-caseating granuloma was noted; Ziehl-Neelsen stain was negative for Mycobacterium tuberculosis. The pathological impression was more consistent with inflammatory bowel disease (Crohn’s disease) than tuberculosis.
Figure 1 (A,B) The first patient’s CT scan of the abdomen and pelvis showed thickening of the ileal and cecal walls with secondary chronic obstructed dilated distal ileal loops. Multiple enlarged mesenteric lymph nodes were seen. Fat stranding of the mesentery (more ...)
The first patient’s colonoscopic examination showed inflammation, loss of normal vascular pattern, friability and exudate formation with large ulcerated areas of the cecum and a narrowing at the ileocecal valve region.
The patient was started on prednisolone 20 mg per day and azathioprine 50 mg per day. She continued on this treatment for a few weeks until she was lost to follow-up. However, 5 months later she presented to another hospital with RIF pain and mass. She underwent surgery for appendicular mass. The biopsy results were consistent with tuberculosis and showed foreign body giant cell epithelioid caseating granuloma. She was started on anti-tuberculosis treatment, but once again she stopped treatment and was lost to follow-up. Two months after the surgery she returned with an 8-week history of poor appetite, weight loss, and RIF abscess that opened to the anterior abdominal wall as a fistula discharging a large amount of fecal material. She was resumed on anti-tuberculosis medications: isoniazid (INH) 200 mg per day, rifampicin 300 mg per day, ethambutol 400 mg on alternate days, pyrazinamide 1 g per day, with vitamin B6 40 mg per day. As the patient weighed only 26.4 kg and her height was 150 cm, the doses were weight adjusted. The patient was discharged on anti-tuberculosis medication, but 2 weeks later she was readmitted with acute abdominal pain and Gram-negative sepsis. A CT scan of the abdomen showed a thickened narrowed terminal ileum, thickened cecum and other areas of the colon with luminal narrowing; a right lower abdominal fistula was seen between the terminal ileum and the skin and there was a moderate amount of ascites (). Repeated colonoscopy revealed severe narrowing of the sigmoid colon with a large inflammatory mass seen at 45 cm from the anal verge (). Biopsy of the narrowed segment and of the mass showed chronic focal active colitis without granuloma or evidence of malignancy; the final report was consistent with inflammatory bowel disease. PCR for M tuberculosis was negative. The patient was started on broad spectrum antibiotics and fluid resuscitation but her condition deteriorated and she died in the ICU 10 months after initial presentation.
Figure 3 The first patient’s follow-up CT scan of the abdomen showing a thickened narrowed terminal ileum, thickened cecum and other the parts of the colon with luminal narrowing. A right lower abdominal fistula (arrow) was seen between the terminal ileum (more ...)
Follow-up colonoscopy of the first patient after deterioration showed severe narrowing of the sigmoid colon with a large polypoid inflammatory mass seen at 45 cm from the anal verge.
A 39-year-old woman was seen in the surgical outpatient department because of a 2-year history of progressive RIF pain which improved following fasting or vomiting. She also noticed a fullness in her RIF. On examination she was afebrile with BP 100/60 mm Hg with a normal pulse of 85 bpm. She had a tender RIF mass measuring about 6×5 cm and a perianal fistula. The rest of the examination was unremarkable. CBC showed Hb 10.7 g/l, WBC 4.9 k/μl, 64% neutrophils and platelets 385 k/μl. Electrolytes, renal function and liver function were normal apart from albumin of 26 g/l (normal 35–50). The patient was HIV 1 and 2 negative. ESR was 96 mm/h (normal 1–20). Chest x-ray was normal. A purified protein derivative (PPD) skin test was strongly positive with induration measuring 20×15 mm. CT scan of the abdomen showed a huge mass with heterogeneous density in the RIF measuring 7.4×8.7×12 cm extending to the terminal ileum, the ileocecal junction and the cecum associated with thickening of the bowel and fat stranding causing narrowing of the lumen ().
Figure 5 The second patient’s CT scan of the abdomen showed a huge heterogeneous density mass in the right iliac fossa measuring 7.4×8.7×12 cm extending to the terminal ileum, the ileocecal junction and the cecum. Thickening of the bowel (more ...)
The patient underwent a colonoscopy which showed inflammation, friability and ulceration with loss of the mucosal vascular pattern involving the cecum and narrowing at the ileocecal valve region (). Endoscopic colonic biopsy showed well defined epithelioid granuloma, inflammatory cell infiltrate and the inflammatory process extending to the submucosa, suggesting inflammatory bowel disease consistent with Crohn’s disease.
The second patient’s colonoscopic pictures showing inflammation, friability, ulceration, exudation and inflammatory polyps formation. Loss of the mucosal vascular pattern in the cecum and narrowing at the ileocecal valve are also seen.
The patient was started on Pentasa (mesalamine) 1 g three times per day, oral prednisolone 30 mg per day and azathioprine 50 mg per day, and was discharged home and followed closely in the outpatient clinic. Over the following 18 months the abdominal pain persisted and the RIF mass gradually increased in size to form a large abscess. A follow-up CT scan of the abdomen 1 year later showed a huge mass measuring 6×9.5×13 cm with heterogeneous soft tissue density in the RIF extending to the terminal ileum, the ileocecal junction and the cecum reaching to the hepatic flexure. There was thickening and narrowing of the bowel, but no fistula was seen. Azathioprine was increased to 100 mg per day and prednisolone was gradually reduced, but the patient’s condition worsened. A CT scan 2 months later showed that the RIF mass was enlarging and forming an abscess, associated with right abdominal wall collection, a fistula arising between the ascending colon and the abdominal wall muscle collection, and psoas abscess. The patient was admitted three times with high grade fever for CT guided drainage of the abscess. On two occasions culture of the drained content was positive for Gram-negative bacilli but AFB stain was negative. She received multiple courses of intravenous and oral antibiotics. Fever subsided and the abdominal wall collection resolved. Later on the fistula opened to the anterior abdominal wall; it was draining a large amount of pus without signs of inflammation (cold abscess). At that point the patient had lost 6 kg in weight, her Hb had dropped to 7.9 g/l and she had finished 20 months of treatment for Crohn’s disease. Infliximab (TNF1α Ab) as treatment for refractory Crohn’s disease was not considered because of recurrent uncontrolled infection. Azathioprine and prednisolone were stopped. AFB PCR and AFB culture were obtained on three occasions from the RIF drain and she was started on tuberculosis treatment with four drugs: isoniazid (INH) 300 mg per day, rifampicin 600 mg per day, ethambutol 1.2 g per day and pyrazinamide 1.5 g per day, with vitamin B6 40 mg per day. The results of AFB PCR and tuberculosis culture were negative. Two months after she was started on anti-tuberculosis treatment, the RIF mass had significantly decreased in size and the opening of the fistula at the anterior abdominal wall had become much smaller (). Ethambutol and pyrazinamide were stopped and rifampicin and INH were continued. Over the following 6 months the fistula completely closed. On her most recent follow-up the patient was asymptomatic; anti-tuberculosis medication was stopped after 12 months of treatment.
The second patient’s colonoscopic findings 2 months after anti-TB treatment was started showed marked improvement of the inflammation and ulceration in the ileocecal region.
A 15-year-old female was admitted to the hospital with a 2-week history of RIF pain and mass. She had been unwell for a year with dull aching abdominal pain, infrequent vomiting, low grade fever and progressive weight loss. Her past history was unremarkable and there was pyrazinamide
On examination she was febrile with a temperature of 39°C, BP 90/60 mm Hg and a pulse of 120 bpm. Her weight was 27 kg and her height was 146 cm. Examination of the abdomen revealed a 7×7 cm RIF mass; the non-tender the skin was intact over the mass. The rest of her physical examination was normal.
CBC showed WBC 11.2 k/μl, Hb 8.5 g/l and platelets 534 k/μl. ESR was 34 (normal 1–20), C reactive protein was 35 mg/l (normal 0–3). Electrolytes, renal function, blood sugar and liver enzymes were all normal. Albumin was 13 g/l. Chest x-ray was normal. A CT scan of the abdomen showed a multiloculated pelvic abscess extending to the anterior abdominal wall, possibly secondary to complicated appendicular abscess (). Colonoscopy showed severe inflammation and severe narrowing of the cecum and the ileocecal region; the scope was not advanced to the terminal ileum (). The colonic biopsy was consistent with inflammatory bowel disease (Crohn’s disease). Due to active infection the patient was not started on prednisolone or azathioprine. She was started on Pentasa (mesalamine) 1 g three times per day, broad spectrum intravenous antibiotics and she had CT scan guided drainage of the abscess with insertion of drains. Culture of the drained pus was positive for Enterobacter cloacae; AFB stain and culture were negative. The pelvic collection did not resolve completely after the CT guided drainage. Three weeks after her initial presentation the patient had distal ileal resection with limited right hemicolectomy and primary anastomosis. Pathological examination of the excised tissue showed chronic inflammatory fistula and the ileocecal margin revealed foreign body giant cell reaction, Paneth cell hyperplasia, and transmural mononuclear cell infiltration; no granuloma was seen. The picture was consistent with Crohn’s disease (). Molecular biology for M tuberculosis (PCR detection) on the tissue and the AFB culture from the surgical specimen were negative. Post operatively the patient was stable and gradually resumed oral feeding. On discharge she was maintained on Pentasa 1 g three times a day. Over the following 4 months she gained 10 kg in weight. Currently she is receiving the same dose of Pentasa and is asymptomatic.
The third patient’s CT scan of the abdomen showed a multiloculated pelvic abscess extending to the anterior abdominal wall. The film also showed a needle which was introduced to the abscess for drainage.
The third patient’s colonoscopy showed inflammation with loss of vascular pattern and severe narrowing of the ileocecal valve.
Histology of part of the excised bowel mucosa of the third patient showed foreign body giant cell reaction, Paneth cell hyperplasia, and transmural mononuclear cell infiltration. No granuloma was seen.
A 33-year-old woman had progressive abdominal distension and low grade fever for 3 weeks. There was no other significant past history or recent complaints and she had had no contact with tuberculosis. She is a hospital ward clerk. On examination she was afebrile with a temperature of 37°C, a regular pulse of 107 bpm, and BP 110/77 mm Hg. Examination of the abdomen revealed massive ascites. The rest of the examination was normal. CBC showed WBC 6.6 k/μl, neutrophils 59.7%, lymphocytes 32.7%, Hb 11.3 g/l and platelets 383 k/μl. ESR was 69 (normal 1–20). Electrolytes, renal function and liver function were normal. The patient was HIV 1 and 2 negative. Carcinoembryonic antigen (CEA) was normal, CA125 was 937 (normal 0–35) and alphafetoprotein was normal. Analysis of the ascitic fluid showed exudate with protein 68 g/l and lactate dehydrogenase 266 U/l. The fluid cell count showed WBC 1355/CU MM, polymorphs 14%, lymphocytes 4% and monocytes 70%. PCR for M tuberculosis from the fluid was not carried out. Cytology of the fluid was negative for malignancy. A CT scan of the abdomen showed circumferential abnormal wall thickening of the ascending colon and the hepatic flexure with paracolic fat stranding, multiple mesenteric and precaval large lymph nodes, a large amount of free ascites and left side pleural effusion; the ovaries were normal. Based on the CT results, carcinoma of the colon was the most likely diagnosis (). However, colonoscopy revealed severe inflammation with multiple large deep ulcers, necrosis and inflammatory polyp formation involving the ascending colon and the cecum, indicating either tuberculous colitis or Crohn’s disease; the terminal ileum was normal (). Endoscopic colonic biopsy showed marked infiltration of acute and chronic inflammatory cells, cryptitis and crypt abscesses, and multiple caseating granulomas with Langerhan’s giant cells, consistent with tuberculosis. The patient was started on four anti-tuberculosis drugs: isoniazid (INH) 300 mg per day, rifampicin 600 mg per day, ethambutol 1.2 g per day and pyrazinamide 1.5 g per day, with vitamin B6 40 mg per day. Ethambutol and pyrazinamide were stopped after 2 months. Six months after diagnosis the patient was free of symptoms, and an ultrasound of the abdomen showed no ascites. Treatment with anti-tuberculosis treatment was continued for 1 year and then stopped.
Figure 11 The fourth patient’s CT scan of the abdomen showed circumferential abnormal wall thickening of the colon lumen (blue arrow) with paracolic fat stranding; multiple mesenteric and precaval large lymph nodes were seen. There was a large amount of (more ...)
The fourth patient’s colonoscopy showed inflammation with multiple large deep ulcers, necrosis and inflammatory polyp formation indicating either tuberculous colitis or Crohn’s disease.