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Gastrointestinal tuberculosis presenting as a diagnostic dilemma with unusual sequalae of Posterior Reversible Encephalopathy Syndrome

An otherwise well 28-year-old-Indian lady presented with bowel obstruction on a background of newly diagnosed Crohn’s disease (18 months prior) for which she was on Azathioprine and Prednisone. She described 1 month of worsening right-sided abdominal pain, constipation and 4 kg weight loss with constitutional symptoms and high-grade fevers. She last visited India 1 month prior to symptom onset. Computed tomography demonstrated terminal ileitis and ascending colitis with significant mesenteric lymphadenopathy (Fig. 1), presumed to be consistent with Crohn’s. Mild splenomegaly was also noted. Inpatient colonoscopy for per-rectal bleeding with associated haemoglobin drop found deep ulcers in the distal ileum (known location of her Crohn’s) and a non-traversable stenosis 15 cm proximal to the ileocaecal valve. Terminal ileum biopsies showed ‘active inflammation/ulceration and necrotising granulomas’ for which differentials included: tuberculosis, sarcoidosis and Crohn’s disease. Laparoscopic right hemicolectomy was performed, extracting 50 cm of small bowel to include both strictures. An end-ileostomy was fashioned, as the patient was deemed high-risk for anastomotic-leak in the setting of active inflammation, significant weight loss and concurrent steroid use. Intra-operative specimens were collected including mesenteric nodes for haematological malignancy, terminal-ileum sections (fresh) for mycobacterial culture and peritoneal fluid for culture. The terminal-ileum specimen PCR detected Mycobacterium tuberculosis Complex DNA (Fig. 2). Standard anti-tuberculosis therapy comprising Rifampicin, Isoniazid, Pyrazinamide and Ethambutol was commenced. Her post-operative course was complicated by generalized tonic– clonic seizures from day 5 post-operation, raising concern for cerebral tuberculosis. However lumbar puncture CSF was bland and an MRI brain showed diffuse pathology more typical of PosteriorReversible-Encephalopathy-Syndrome (PRES) (Fig. 3). PRES arises from failure in autoregulation of cerebral flow and is often due to hypertension causing increased cerebral blood flow and edema. It is common in patients on immunosuppressants though the mechanism for this is unclear. She was discharged on day 40 post-operation and completed 6 months of antibiotics as an outpatient. The current prevalence of tuberculosis in Australia is 6 cases per 100 000 with most being pulmonary (63%). Abdominal tuberculosis is the sixth commonest extra-pulmonary site, mainly affecting the gastrointestinal tract, peritoneum and mesenteric lymph nodes. The ileocaecal region is the commonest site of disease in the gastrointestinal tract (75% of cases) due to physiological stasis and an abundance of lymphoid tissue (Peyer’s patches). Macroscopic appearance of intestinal tuberculosis often resembles Crohn’s disease with transverse ulcerations, skip-lesions, fibrosis, thickening and stricturing of bowel wall and enlarged mesenteric lymph nodes. Ulcerative lesions must be differentiated from lesions in coeliac disease, immunoproliferative disease and tropical sprue. Hypertrophic lesions of malignancy, amoebiasis, actinomycosis and appendiceal masses may also mimic tuberculosis. Intra-abdominal tuberculosis can be confirmed with a positive acid fast bacilli (AFB) test from peritoneal fluid, histological features of caseous granulomas, and response to anti-tuberculosis medications. AFB is easily obtained from peritoneal fluid, but has poor sensitivity. Blood or ascitic fluid PCR cannot distinguish between live and dead bacteria and can remain positive for long periods even after completing antituberculosis treatment. Ultrasound and CT imaging can detect ascites, thickened bowel wall and lymphadenopathy but these are common to many diseases. Colonoscopic biopsy is useful, however specimens may only demonstrate active chronic ileocolitis with ulceration and granuloma formation whilst AFB stains are only positive in 25–30% of cases. Laparoscopy with fresh biopsy specimens for PCR is emerging as the gold standard with a diagnostic yield of over 80%. Most patients with abdominal tuberculosis respond to the same medical treatment used for pulmonary tuberculosis. This comprises rifampicin and isoniazid for 6 months and pyrazinamide and ethambutol for 2 months. Surgery is reserved for acute complications of abdominal tuberculosis including: bowel obstruction, perforation, and abscess or fistula formation. The most common operation, typically for localized disease, is a segmental resection such as ileocolic resection, though this can be associated with malabsorptive complications. Stricturoplasties can be considered in cases of multiple strictures in an attempt to preserve small bowel length. Finally