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.