CASE 1
A 31-year-old female accountant was followed up for an outpatient for
abdominal pain and deterioration in general condition. The patient had
been vaccinated against tuberculosis in childhood according to the
expanded immunization program . She had no history of tuberculosis or
any notion of tuberculosis contagion in her entourage. Since May 2017,
the patient presented with febrile diarrhea, abdominal pain and weight
loss. Physical examination showed a defense in the right lumbar and
iliac region. The proctological examination was normal. We had not
objectified extra-digestive signs (cutaneous, articular, ocular and
biliary). The abdominal and pelvic ultrasound on 06/08/17 was normal.
The ileo-colonoscopy of 06/12/17 showed the presence of deepening,
circumferential ulcerations of the right colon and of the low caecal
fundus with modification of the ileocaecal valves. The terminal ileum
was normal. The histology of the colonic biopsies of 06/23/17 revealed
focal ulcerations with a discreet architectural modification, a small
focus of basal plasmacytosis, without inflammatory granuloma, without
caseous necrosis and without Ziehl stain microstates. Despite the
absence of granuloma, the morphological signs of the biopsies could be
in favor of Crohn’s disease. The first chest x-ray on 07/05/17 was
normal. The first test for acid-fast bacilli (AFB) in sputum was
negative on 07/10/17. All the symptoms suggested severe ileocecal
Crohn’s disease. Corticosteroid therapy (Solupred) at a dose of 1
mg/kg/day was started on 07/17/17. The patient was hospitalized on
08/11/17 (1 month from Solupred) for respiratory distress and increased
digestive symptoms. The corticosteroid therapy was immediately stopped.
The general examination reported hemodynamic instability with a
hypotension (70/40 mm Hg), tachycardia (130/mm), tachypnea (31/mm),
oxygen desaturation at 88% in ambient air and fever at 39.8°C
signifying severe sepsis. Clinical examination reported bilateral
pulmonary crackling rales and diffuse abdominal defense. The management
of severe sepsis was immediately initiated with filling with
physiological serum combined with a double antibiotic therapy such as
3rd generation cephalosporin (Ceftriaxone) and aminoglycoside
(Gentamicin). The second chest x-ray of 08/11/17 revealed diffuse
bilateral alveolar opacities (Figure 1). The chest CT scan of 08/11/17
showed diffuse heterogeneous infiltrates (Figure 2-a) with a 50 mm
cavitary lesion of the apex of the right lung (Figure 2-b) suggesting
tuberculosis. The abdominal and pelvic CT scan of 08/11/17 was normal.
Laboratory investigations of 08/11/17 showed a clear inflammatory
syndrome with a C-reactive Protein (CRP) at 186 mg/L (Table 1). The
second search for acid-alcohol-resistant bacilli in the sputum on
08/14/17 came back positive on direct examination. Severe sepsis in the
context of disseminated tuberculosis with digestive involvement has been
suggested. Anti-tuberculous therapy according to the national protocol
was initiated on 08/14/17. The digestive and respiratory outcomes were
satisfactory, with appetite resuming after one week of treatment.
Apyrexia was only demonstrated from the 17th day (08/31/17) of the
anti-tuberculous therapy. The diagnosis of disseminated tuberculosis
with digestive involvement was made based on clinical, biological,
radiological et endoscopic arguments associated with a satisfactory
response to anti-tuberculosis treatment. The reassessment of 10/15/2017
reported an absence of clinico-radiological tuberculosis signs and a
return to normal weight. The patient had been declared cured at the end
of treatment.