1 - Unidade de Pediatria Médica, Área de Pediatria Médica, Hospital Dona Estefânia, Unidade Local de Saúde São José, Centro Clínico Académico de Lisboa, Portugal
2 - Unidade de Gastroenterologia Pediátrica, Área de Pediatria Médica, Hospital Dona Estefânia, Unidade Local de Saúde São José, Centro Clínico Académico de Lisboa, Portugal
3 - Unidade de Infeciologia Pediátrica, Área de Pediatria Médica, Hospital Dona Estefânia, Unidade Local de Saúde São José, Centro Clínico Académico de Lisboa, Portugal
- Póster, 42nd Annual Meeting of the European Society for Paediatric Infectious Diseases (ESPID).
Resumo:
Background: Intestinal tuberculosis (ITB) is a rare manifestation of extrapulmonary tuberculosis. Diagnosis is difficult due to non-specific clinical presentation, which can be similar to other gastrointestinal diseases, such as Crohn's disease (CD).
Case presentation summary: A 17-year-old, previously healthy, Portuguese male, presented with persistent spontaneously draining peri-anal abscess. Abdominal ultrasound showed thickening of the terminal ileum, colonoscopy revealed ulcerated lesions and histology evidenced nonspecific ileitis, suggesting CD. Infection screening prior to immunosuppression, showed a positive IGRA and a normal chest CT. Isoniazid was started for latent TB and immunosuppression was started (methotrexate and adalimumab). Five months later, he was hospitalized due to daily fever, fatigue, weight loss, nasal obstruction and soft and non-adherent bilateral cervical adenopathies. The CT showed diffuse hypertrophy of the Waldeyer´s ring. Laboratory results showed normal peripheral blood smear, LDH and uric acid, and excluded HIV, CMV, EBV, toxoplasmosis and bartonella infection. Biopsies of cervical lymph node and Waldeyer´s ring were performed, showing caseous granulomas in the nasopharynx and nasal cavity and positive cultural test for mycobacterium tuberculosis in cervical lymph node and gastric aspirate, resistant to isoniazid. Intestinal biopsies were negative. Immunosuppression was stopped and treatment for TB was started with rifampicin, pyrazinamide, ethambutol and levofloxacin. Four months later, a good clinical and imaging progress (reduction in ileal thickening on ultrasound) and no new episodes of peri-anal abscess drainage, suggesting the diagnosis of ITB, that disseminated due to immunosuppression.
Conclusion: A combined approach using clinical, imaging, histological, molecular and cultural tests is essential for accurate diagnosis and appropriate treatment. When in doubt, mostly in endemic countries, an antituberculosis treatment trial should be started prior to immunosuppression, with posterior follow-up.
Palavras Chave: Crohn; Extrapulmonar; Tuberculose