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.