Endoscopic detection of colonic tuberculosis in an asymptomatic patient

There has been a resurgence of intestinal tuberculosis during the last decade following the increase of immigrants to Western countries [1] [2]. The abdominal symptoms of intestinal tuberculosis are nonspecific, consisting mainly of abdominal pain, weight loss, anorexia, and fever [2] [3]. The characteristic endoscopic features of colonic tuberculosis include transversely oriented ulcer, nodules, deformed ileocecal valve, stricture, erosions, and aphthous ulcers [1] [2] [3]. However, in patients without abdominal symptoms or pulmonary infection, endoscopists face the challenge of distinguishing between intestinal tuberculosis and malignancy or Crohn’s disease. We report here a case of colonic tuberculosis found incidentally during a health check-up, and which was diagnosed by typical endoscopic features and histological and microbiological evidence.

A 38-year-old, previously healthy man visited our institution for a scheduled health check-up. His medical history and physical examination were unremarkable. He had a history of travel to China 3 months before coming to our hospital. Chest radiograph showed no active pulmonary lesions. Laboratory data were within reference range except for a triglyceride level of 381 mg/dL (normal range 50 - 130 mg/dL). Tumor markers including CEA, CA 125 and CA 19 - 9 were normal. Ziehl-Neelsen stain and culture of sputum were negative for Mycobacterium tuberculosis.

Colonoscopy revealed a transversely oriented ulcer in the cecum, with steep edges and surrounding flared nodules (Figure [1]). The terminal ileum appeared normal. Histological examination of the biopsy specimens demonstrated well-formed granulomas with caseous necrosis and Langhan’s giant cells (Figure [2]). Culture of biopsy specimens revealed positivity for M. tuberculosis, as did the result of polymerase chain reaction for DNA of M. tuberculosis. A diagnosis of colonic tuberculosis was made. The patient received antitubercular therapy for 9 months with an uneventful clinical course. He remained asymptomatic over the ensuing 2 years of follow-up.

Endoscopy_UCTN_Code_CCL_1AD_2AC

Figure 1 Colonoscopic view showing a transversely oriented ulcer in the cecum with steep edges and flared surrounding nodules. Note its location opposite the ileocecal orifice (arrow).

Figure 2 Histological view showing well-formed granulomas with Langhan’s giant cells (arrows) and caseous necrosis (n), surrounded by a prominent rim of lymphocytes (hematoxylin and eosin; original magnification × 100).

References

• 1 Sato S, Yao K, Yao T. et al . Colonoscopy in the diagnosis of intestinal tuberculosis in asymptomatic patients.  Gastrointest Endosc. 2004;  59 362-368
• 2 Alvares J F, Devarbhavi H, Makhija P. et al . Clinical, colonoscopic, and histological profile of colonic tuberculosis in a tertiary hospital.  Endoscopy. 2005;  37 351-356
• 3 Misra S P, Misra V, Dwivedi M, Gupta S C. Colonic tuberculosis: clinical features, endoscopic appearance and management.  J Gastroenterol Hepatol. 1999;  14 723-729