22 Sep 2021

6/7/21: Intestinal Tuberculosis

PGY2 Robert Tungate presented a case of a 51 y/o female with no past medical history who presents with 3-4 months of worsening 3-4 months of postprandial nausea to the extent that she has eaten only small bits for the last 2 weesks.  Associated with a 3 month history of generalized pruritis, bilateral swelling of the neck and weight loss of unknown quantity.

ROS: +dull R sided flank pain and R sided throat pain each of 3 month duration.

PMH: None

Meds: “Uterine Surgery” in mainland China many years ago

Allergies: NKDA

FH: none

SH: Born in China.  Lives in LA.  Denies tobacco, alcohol, or drug use.

Vitals: T 36.4, HR 104, RR 16, BP 107/73, O2 sat 100% on RA

Physical Exam: Mandarin speaking female lying quietly in gurney, + temporal wasting, b/l nodular cervical LAD present, tachycardic, normal pulm and abdominal exam, skin with scattered erythematous tin scaly plaques with some induration on chest, back, upper and lower extremities (most pronounced on lower extremities)

CBC: WBC 25.8>Hb 9.5/Hct 30.1 <Plt 441 (MCV 76.6, RDW 22.5%)

CMP:

Na 131/K 4.4/Cl 93/HCO3 26/BUN 56/Cr 3<Glucose 81

ALP 120>T.protein 7.9/Albumin 3.7/AST 17/ALT 15/Tbili 0.2/Dbili <0.2

Ca 15.0, Mg 2.8, Phos 4.2

PT 12.7, INR 0.96

Infectious workup done with the following:

  • BCx, UA, UCx and CXR all negative
  • HIV, RPR negative
  • Fungal BCx and Fungal serologies including Aspergillus, Cocci, Crypto, Blasto and Histo all negative
  • Communicable Pulmonary TB negative with AFB smears x3 and MTB PCR neg x2
  • Quantiferon Gold indeterminant

Endocrine workup for the hypercalcemia:

  • PTH low
  • Vit D 1,25 OH elevated
  • ACE negative

L neck LN biopsy: granulomatous inflammation, necrosis and mixed inflammation.

CT C/A/P: Circumferential mass-like wall thickening of the cecum with pericolonic fat stranidning. Multi-station intra-abdominal lymphadenopathy.

Colonoscopy done: Upon reaching the cecum, there was appearance of extenive carpeted polypoid mucosa localized to the cecum.

Cecal biopsy: Marked expansion of the lamina propria by active chronic inflammation whch extends into the submucosa. There is crypt loss, but significant crypt disortation. Numerous ill-defining non-necrotizing epithelioid granulomata are present.

Acid fast culture of the cecal biopsy became positive 6 weeks later.

Treatment: Patient was started on IVF with improvement in serum calcium. Endocrine consulted and calcitonin challenge was given for 2 days. ID was consulted and patient was started on empiric TB RIPE therapy. After 1 week fo RIPE therapy, patient started on prednisone 40mg qday with hydroxychloroquine to treat the hypercalcemia.

Teaching points:

  1. Tuberculous colitis is associated with RLQ mass, ileocecal tropism and stricture and fistula fomration often resulting in bowel obstruction.
  2. Hypercalcemia of granulomatous disease is associated with increased 1-alpha hydroxylase activity in the renal tubule and extra-renally.
  3. Hypercalcemia is common complication of diffuse TB, with an incidence up to 28%
  4. Acute treatment of hypercalcemia of granulomatous disease includes dietary calcium restriction, glucocorticoid administration and IVF administration.
  5. Second line therapies include ketoconazole, anti-TNF mAbs, bisphosphonates or hydroxychloroquine.

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