Case report of a Nigerian with ileocecal tuberculosis which mimicked Crohn's disease at colonoscopy

Adegboyega Akere; Samuel O Ola; Oludolapo O Afuwape; Abideen O Oluwasola; Temitope O Oke

doi:10.4103/2276-7096.176050

CASE REPORT

Year : 2016 | Volume : 18 | Issue : 1 | Page : 47-50

Case report of a Nigerian with ileocecal tuberculosis which mimicked Crohn's disease at colonoscopy

Adegboyega Akere¹, Samuel O Ola¹, Oludolapo O Afuwape², Abideen O Oluwasola³, Temitope O Oke¹
¹ Department of Medicine, College of Medicine, University of Ibadan, University College Hospital, Ibadan, Nigeria
² Department of Surgery, College of Medicine, University of Ibadan, University College Hospital, Ibadan, Nigeria
³ Department of Pathology, College of Medicine, University of Ibadan, University College Hospital, Ibadan, Nigeria

Date of Web Publication

1-Mar-2016

Correspondence Address:
Adegboyega Akere
Department of Medicine, College of Medicine, University of Ibadan, University College Hospital, P.O. Box 28829, Agodi, Ibadan
Nigeria

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/2276-7096.176050

Abstract

Both tuberculosis (TB) and Crohn's disease can affect any part of the gastrointestinal tract, but the terminal ileum and ileocecal region are mostly affected. Colonoscopic features of erythema, mucosal nodules, ulcers, strictures, and a deformed ileocecal valve occur in TB are nonspecific and can also occur in Crohn's disease. This is a case of a Nigerian with ileocecal TB, which mimicked Crohn's disease at colonoscopy. The patient is a 23-year-old man who presented to the clinic on account of recurrent abdominal pain and weight loss of 7 months duration. There was history of nonmucoid, nonbloody, and nonfoul smelling bowel motions. He had progressive weight loss was progressive with history of nausea, bloating, and anorexia but no vomiting. Colonoscopy revealed polypoid lesions in the cecum, deformed and polypoid ileocecal valve, and cobblestone appearance in the ileum. The histology of the ileal and colonic biopsies showed diffuse transmural infiltration by lymphocytic cells. Because of the extent of cecal and ileal involvement together with severe abdominal pain the patient was experiencing, he was taken for surgery where a right hemicolectomy with ileotransverse anastomosis was performed. The histology of the resected bowel then revealed features consistent with TB.

Keywords: Airway, cardiovascular system, chronic fluorosis, endocrine system, skeleton, spinal anaesthesia, teeth

How to cite this article:
Akere A, Ola SO, Afuwape OO, Oluwasola AO, Oke TO. Case report of a Nigerian with ileocecal tuberculosis which mimicked Crohn's disease at colonoscopy. J Med Trop 2016;18:47-50

How to cite this URL:
Akere A, Ola SO, Afuwape OO, Oluwasola AO, Oke TO. Case report of a Nigerian with ileocecal tuberculosis which mimicked Crohn's disease at colonoscopy. J Med Trop [serial online] 2016 [cited 2021 Jan 20];18:47-50. Available from: https://www.jmedtropics.org/text.asp?2016/18/1/47/176050

Introduction

Any part of the gastrointestinal tract can be affected by both tuberculosis (TB) and Crohn's disease, but terminal ileum and ileocecal region are mostly affected. About one-half of the patients with Crohn's disease have affectation of both the ileum and colon.^[1]

Colonoscopy is one of the useful ways of diagnosing both colonic TB and Crohn's disease. Although colonoscopic features of erythema, mucosal nodules, ulcers, strictures, and a deformed ileocecal valve occur in TB, these are nonspecific and can also occur in Crohn's disease. However, one of the typical findings of advanced Crohn's disease is cobblestoning,^[2] which is uncommon in TB.^[3]

We present a Nigerian with ileocecal TB, which mimicked Crohn's disease at colonoscopy.

Case Report

Mr B.S was a 23-year-old man who presented to the clinic on account of recurrent abdominal pain and weight loss of 7 months duration. Abdominal pain was of insidious onset, located at epigastric area and radiated to the right iliac fossa, dull in nature, and disturbed his daily activities and sometimes woke him up at night. There was history of nonmucoid, nonbloody, and nonfoul smelling bowel motions. There was no history of alternating diarrhea with constipation and no passage of bulky pale stool. He had no history of fever. He had appendectomy about 6 months before presentation at another facility on account of worsening lower abdominal pain without any resolution of the pain. Weight loss was progressive, and there was history of nausea, bloating, and anorexia but no vomiting. He had history of nonproductive cough, but no drenching night sweat, orthopnea, or paroxysmal nocturnal dyspnea. He was not a known hypertensive, diabetic, or asthmatic. He neither drank alcohol nor smoked cigarette. On examination, he was chronically ill-looking, febrile, pale, anicteric, acyanosed, and not dehydrated and there was no peripheral lymph node enlargement or pedal edema. The abdomen was scaphoid, moved with respiration and there was suprapubic fullness as well as tenderness in the right iliac fossa. He had no palpable organomegaly, and digital rectal examination was essentially normal.

The respiratory rate was 26 cpm, trachea was central, percursion note was resonant, and the breath sound was vesicular, there were no added sounds. The pulse was 120 bpm, normal volume, blood pressure was 80/60 mmHg, and the heart sounds were one and two. He was conscious, well-oriented in time, place, and person. There were no focal neurological deficits and asterixis.

The full blood count showed a packed cell volume of 25% and white blood cell and platelets count were normal. The chest X-ray was also normal.

Colonoscopy revealed polypoid lesions in the cecum [Figure 1], deformed and polypoid ileocecal valve [Figure 2], and cobblestone appearance in the terminal ileum after it was intubated via the ileocecal valve [Figure 3].

Figure 1: Cecum showing polypoid lesions

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Figure 2: Ileocecal valve which is deformed, patulous, and polypoid

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Figure 3: Ileum showing cobblestone appearance

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The clinical diagnosis was ileocecal lymphoma, and the differentials were TB and Crohn's disease. The histology of the ileal and colonic biopsies showed diffuse transmural infiltration by lymphocytic cells [Figure 4] based on which a tentative diagnosis of lymphoma was made but was not confirmed by immunohistochemistry. This prompted a consideration of a diagnosis of Crohn's disease based on the findings of a transmural chronic inflammatory infiltration in the absence of clear histological features of TB.

Figure 4: Photomicrograph of cecal biopsy showing diffuse infiltration by lymphocytic cells (H and E, ×400)

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Hence, because of the extent of cecal and ileal involvement together with severe abdominal pain the patient was experiencing, he was taken for surgery where a right hemicolectomy with ileotransverse anastomosis was performed. The histology of the resected bowel then revealed features consistent with TB [Figure 5].

Figure 5: Photomicrograph of cecal biopsy of resected colonic segment showing caseating granuloma with Langhan's type giant cells (thick long arrow) and surface ulceration (H and E, ×100)

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Discussion

TB and Crohn's disease commonly affect the ileocecal region. Therefore, there is a need to differentiate these two entities because treatment is different in both cases. While antituberculous drugs are required for the former, the latter requires immunosuppressive therapy.

However, differentiating these two conditions on the basis of clinical, radiologic, and endoscopic features may be a challenge as in the index patient.

Increasing incidence of abdominal TB has been reported worldwide, and about 2–3% of these patients have isolated colonic involvement.^[4],[5]

In a study by Misra et al.,^[6] abdominal pain, fever, anorexia, weight loss, and diarrhea were the presenting symptoms seen in patients with colonic TB. This is also true for our illustrated patient who presented with all these symptoms. However, it is known that Crohn's disease also present with all of these symptoms.

In patients with tuberculous colitis, typical features on colonoscopy are transverse or linear ulcers, deformed ileocecal valve and cecum, presence of nodules, multiple fibrous bands, and inflammatory polyps.^[7],[8] In contrast, features of Crohn's disease are longitudinal ulcers with a cobblestone appearance, stricture, perianal lesions, and pseudopolyps.^[9] In addition, Pettengell et al.^[10] reported multiple nodules, superficial ulcers, deformed ileocecal valve, solitary nodules, and erythema as typical features of colonic TB.

In our patient, transverse ulcers which could have suggested TB were not seen during colonoscopy, probably, because these ulcers were located proximal to the level in the ileum where the scope reached during ileal intubation. The colonoscopic picture that was very prominent in this patient was the cobblestone appearance of the ileum, which is typical of Crohn's disease. Also, the initial histology was not in keeping with TB.

In a study by Lee et al.,^[3] anorectal lesions, longitudinal ulcers, aphthous ulcers, and cobblestone appearance were found to be significantly more common in patients with Crohn's disease than TB. In contrast, a patulous ileocecal valve, transverse ulcers, and scars or pseudopolyps were seen more frequently in TB.

In our patient, the features that would have suggested TB were not seen at colonoscopy. However, these features were only seen in the resected portions of the ileum, and the histology subsequently confirmed the diagnosis.

Histologically, in very chronic lesions of intestinal TB, the granulomas become hyalinized and eventually disappear, leaving behind only small aggregates of lymphocytes, an excess of fibrous tissue and sometimes “tombstones” of effete coalescent granulomas. Then, the appearances can closely mimic chronic or burnt-out Crohn's disease. The principal microscopic features that differentiate TB from Crohn's disease are a relative lack of fissuring, coalescence of granulomas with caseation, lack of submucosal edema, and the presence of small serosal tubercules. Examination of regional lymph nodes is particularly important as they can show better evidence of former tuberculous infection. The regional lymph nodes nearly always contain granulomas in intestinal TB whereas these are relatively infrequent in Crohn's disease.^[11] However, our patient did not have enlarged lymph nodes at surgery and so these could not be examined in addition for features of TB. This case not only demonstrates the usefulness of immunohistochemistry in identifying reactive lymphoid infiltrates in cases of suspected lymphoid neoplasms but also emphasizes the need to always intubate the ileum in patients with abnormalities of the cecum and ileocecal valve, as well as moving the scope as far as possible to cover every abnormal portions and take adequate biopsy. In our patient, if the proximal parts of the ileum had been viewed, probably the transverse ulcers would have been seen and the diagnosis of TB would have been suspected at colonoscopy. In addition, if capsule endoscopic facility had been available in our center, it would have been possible to visualize the proximal ileal transverse ulcers prior surgery.^[12] Also, the pitfalls of endoscopic biopsies and the usefullness of surgery with good histologic backing were revealed in this case.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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