[Lymphoid form of intestinal tuberculosis with miliary dissemination: case report]

Tuberculosis with the incidence 28-29/100000 residents still presents a major public health problem in Croatia. Miliary tuberculosis is uncommon cause of fever of unknown origin. Intestinal tuberculosis pose as diagnostic problem that can be identified by colonoscopy and/or explorative laparatomy involving histopathology and microbiology. A case is reported of a 40-year-old HIV negative patient admitted to the Department of Infectious Diseases after two weeks of fever, diarrhea, abdominal pain and weight loss. Biochemistry testing showed mild elevation of the erythrocyte sedimentation rate and increased serum aminotransferases. On admission, chest x-ray was normal and tuberculin skin test was negative. Crohn's disease was suspected. Computed tomography of the abdomen revealed solid infiltrative mass located retroperitoneally, along with enlarged lymph nodes. Explorative laparoscopy was necessary to confirm the diagnosis. Intraoperative specimens were referred for histopathologic and microbiologic examination, which proved the existence of granulomatous inflammation of the areas with caseous necrosis. Direct microscopy of the periappendicular abscess and Ziehl-Neelsen staining of a lymph node specimen confirmed the presence of an acidoresistant bacillus. The specimen culture on solid egg based agar (Löwenstein Jensen) and liquid broth (MGIT) showed the growth of Mycobacterium tuberculosis. Then the causative agent was cultured from all specimens: sputum, stool and urine. Repeat cheast x-ray, performed on day 30 of hospitalization, showed miliary dissemination to the lungs. The patient was treated with four antituberculotics (streptomycin, isoniazide, rifampin, ethambutol) and methylprednisolone for one month, then with isoniazide, rifampin and for 11 months ethambutol. Therapy led to a decrease of abdominal lymph nodes and absence of miliary lesions on chest radiography after two months of treatment. Intestinal tuberculosis has been almost forgotten in Croatia. The latest published cases referred to HIV infected patients. In less than 50% of patients with intestinal tuberculosis the lungs are also affected, which poses a diagnostic problem. Crohn's disease is the most common diagnostic problem. Histopathology of a specimen obtained on colonoscopy and/or explorative laparoscopy can often solve the dilemma, as also confirmed in our patient. Of diagnostic studies, computed tomography has the advantage of evaluating intestinal wall involvement, which is important for the early diagnosis of intestinal tuberculosis. Enteroclysis and irrigography provide diagnostic information in the advanced stage of intestinal tuberculosis. In a patient with fever, abdominal disorders and parameters which implicate granulomatosis hepatitis or Crohn's disease, the existence of abdominal tuberculosis is also possible. Computed tomography and biopsy obtained on colonoscopy for microbiology can help in making the diagnosis and initiating appropriate treatment.