CASE 2
A 51-year-old woman had since December 2020 intermittent episodes of rectal bleeding alternating with febrile diarrhea with a weight loss of 15 kg in two months requiring her first hospitalization (01/15/20). The patient did not report a history of tuberculosis or any notion of tuberculosis contagion in her entourage. Initial clinical examination reported mucocutaneous paleness and diffuse abdominal pain. The patient did not present extra-digestive symptoms. Laboratory investigations on 01/15/20 showed a significant inflammatory syndrome with a CRP at 186 mg/L associated with hyperleukocytosis at 22,800/mm3 and anemia at 10.7 g/dL (Table 1). The upper gastrointestinal endoscopy on 01/16/20 was normal. The abdominal and pelvic CT scan of 01/16/20 revealed a thickening of the left colon. The ileo-colonoscopy of 01/23/20 revealed circumferential ulcerations and sometimes deep of the rectum (Figure 3-a). Progression stopped at 20 cm from the anal margin because of an inflammatory stenosis (Figure 3-b). The histology of the rectal biopsies on 02/01/20 showed samples consisting of edematous fibrous tissue, densely infiltrated by lymphocytes and polynuclear neutrophils and surrounded by fibrino-leukocyte coatings, without epithelioid granuloma, without lymphocytic follicular hyperplasia, without plasma cell infiltrate, without caseous necrosis and absence of microstates in Ziehl’s stain. Deep ulceration points to Crohn’s disease, but remains insufficient to make a diagnosis. The absence of plasma cell infiltrate does not allow referral to ulcerative colitis. A collegial decision opted to immediately start corticosteroid therapy (Prednisolone) and bi-antibiotic therapy (3rd generation cephalosporin + Imidazole) in the context of severe acute colitis on 02/06/20. The patient had opted for discharge against medical advice on 02/10/20. The evolution was marked by an increase in digestive, septic and respiratory manifestations with persistence of a gastrointestinal bleeding type melena with severe anemia poorly tolerated after three weeks of treatment, motivating a readmission with immediate stopping of corticosteroids on 03/04/20. General examination showed sepsis with hypotension (90/50 mm Hg), tachycardia (110/min), tachypnea (29/min), oxygen desaturation at 91% and fever at 38.5°C. Physical examination reported bilateral alveolar condensation syndrome and diffuse abdominal defense. Laboratory investigations on 03/05/20 reported severe anemia at 6.6 g/dL hemoglobin and an increased in inflammatory syndrome with CRP at 265 mg/L and hyperleukocytosis at 24400/mm3 (Table 1). The chest x-ray showed bilateral and diffuse interstitial miliary images with some left upper lobe infiltrates suggestive of tuberculosis (Figure 4). The test for acid-fast bacilli was negative on direct examination. A second research was positive on GeneXpert®. The diagnosis of disseminated tuberculosis with digestive involvement has been suggested. Anti-tuberculous therapy according to the national protocol was initiated immediately on 03/09/20. The recto-sigmoidoscopy of 04/06/20 showed a clear improvement of the initial lesions with persistence of small ulcerations. The reassessment on 05/14/20 was satisfactory with disappearance of digestive, respiratory and infectious manifestations with a return to his normal weight. The patient had been declared cured at the end of treatment. 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.