Miliary tuberculosis causing multiple intestinal perforations in an immigrant worker.

Editor,

The incidence of tuberculosis (TB) in Northern Ireland is increasing1. We present an uncommon case of perforated intestinal TB in an immigrant patient. The clinical presentation and endoscopic findings suggested inflammatory bowel disease (IBD). Subsequent multiple perforations necessitated emergency intestinal resection. With an increasing immigrant population, intestinal TB should be considered in such patients presenting with intestinal symptoms and signs.

Case Report

A 46-year old Polish immigrant presented with weight loss, abdominal pain and bloody diarrhoea. He appeared cachectic and had right iliac fossa tenderness. Colonoscopy revealed segmental ulceration with caecal involvement (Fig. 1). Given the distribution, Crohn's disease was suspected. However colonoscopic biopsies demonstrated caseating granulomatous inflammation and acid-fast bacilli.

Fig 1

Caecal tuberculous ulcer.

Further examination revealed cervical lymphadenopathy and bilateral chest crepitations. Chest radiography showed bilateral infiltrates (Fig. 2). Identification of acid-fast bacilli in sputum and isolation of mycobacterium tuberculosis confirmed pulmonary TB.

Fig 2

Bilateral upper and mid-zone infiltrates consistent with active pulmonary tuberculosis.

After commencing anti-tuberculous treatment, the patient developed an acute abdomen. CT scanning demonstrated a pelvic collection, with free intra-peritoneal fluid.

Emergency laparotomy revealed generalised peritonitis due to multiple ileal perforations. Apart from a short segment of proximal jejunum the entire small bowel and caecum were grossly diseased. An extensive enterectomy and caecal resection was performed, with a high jejunostomy and mucous fistula fashioned.

Histopathology revealed marked small bowel and caecal ulceration. Extensive caseating granulomatous inflammation (Fig. 3) and acid-fast bacilli confirmed intestinal TB.

Fig 3

Photomicrograph of appendix demonstrating multiple trans-mural caseating (arrow) and non-caseating granulomata. (Haematoxylin and eosin, low power x1).

Discussion

In recent years the incidence of intestinal TB in developed countries has increased. In the UK higher rates have been identified in non-UK born individuals. This reflects increasing levels of disease in areas from which migrants are coming to the UK and increasing numbers arriving from high incidence areas 1.

In Northern Ireland the incidence of TB is rising, with a notification rate of 4.7/100,000 in 2004 (compared with 24.6/100,000 in Poland). Furthermore, the proportion of non-UK born cases of TB in Northern Ireland rose to 37% of those reported in 20062.

Intestinal TB presents a diagnostic challenge. Patients can present with abdominal pain, diarrhoea and weight loss, mimicking IBD3. The ileo-caecal region is the most frequent site of intestinal TB (similar to classical Crohn's). Colonic mucosal ulceration is often segmental and may be indistinguishable from Crohn's disease endoscopically. Colonoscopy is valuable in aiding the histopathological diagnosis of ileo-caecal disease4. The presence of caseating granulomata differentiates intestinal TB5. Identification of acid-fast bacilli together with isolation of mycobacteria confirms the diagnosis.

Intestinal TB is primarily managed with anti-tuberculous agents. Surgical intervention is reserved for complications including perforation which is an uncommon but serious complication with high mortality rates. Perforations may be solitary or multiple and surgical resection is required.

With an increasing incidence of TB and a rising immigrant population this case demonstrates the importance of considering intestinal TB in patients, particularly non-UK born, who present with symptoms suggestive of IBD. The role of endoscopic biopsy in differentiating intestinal TB from Crohn's disease is highlighted. This case also underlines the importance of recognition of perforated intestinal TB and the role of timely surgery.