Hiding in Plain Sight: A Case of Intestinal Tuberculosis Masquerading as Benign Lower GI Bleeding

Intestinal tuberculosis (TB) represents the most common form of abdominal TB, often affecting the ileocaecal region. Lower gastrointestinal bleeding is an uncommon presentation and may create significant diagnostic uncertainty, particularly in immunocompromised patients and in settings where inflammatory bowel disease is also encountered.

A woman in her sixties from Africa presented with recurrent diarrhoea and intermittent haematochezia over a 6-month period. Initial endoscopic evaluation was nondiagnostic. Cross-sectional imaging later demonstrated multifocal bowel involvement affecting both the small and large bowel, including ileocaecal and rectoanal disease, with associated abdominopelvic lymphadenopathy. Histopathology from repeat colonoscopy biopsy showed caseating granulomas and Ziehl-Neelsen-positive acid-fast bacilli, confirming intestinal TB. Subsequent HIV serology was positive, with a CD4 count of 55 cells/mm³ at diagnosis. The patient improved markedly following antituberculous therapy and subsequent antiretroviral treatment.

This case highlights a diffuse presentation of intestinal TB without pulmonary involvement in a patient with newly diagnosed advanced HIV infection. It underscores the diagnostic challenge posed by overlap with more common causes of lower gastrointestinal bleeding and inflammatory bowel disease and the importance of integrating clinical, radiological, endoscopic and histopathological findings to achieve timely diagnosis and successful medical management.