Scientific letter
Intestinal Tuberculosis
Tuberculosis intestinal
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"apellidos" => "Sancho-Insenser" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Cirugía General y Aparato Digestivo, Hospital del Mar, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital del Mar, Barcelona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tuberculosis intestinal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1461 "Ancho" => 950 "Tamanyo" => 223466 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Mass and perforation of the cecum.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In our setting, tuberculosis is on the rise because of factors such as inadequate patient treatment, HIV-related immunosuppression, resistance to treatment and declining socioeconomic conditions due to immigration.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,2</span></a> Therefore, it should be included in differential diagnoses.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> We present a case of pulmonary and intestinal tuberculosis that caused massive lower gastrointestinal bleeding.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Gastrointestinal tuberculosis is uncommon and usually secondary to pulmonary involvement or due to the consumption of unpasteurized milk.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> The first reported case of peritoneal tuberculosis was recorded in 1843.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> The most frequent intestinal location of this condition is the ileocecal area, where the bacillus is phagocytized by lymph tissue, absorbed by the intestinal mucosa and transferred to Peyer's patches.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6,7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The main complications are intestinal obstruction (15%–100%), enteroenteric fistulas (2%–30%), intestinal perforation (1%–15%) and hemorrhage (2%–24%).<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">We present the case of a 30-year-old Pakistani woman who came to our Emergency Department at 34 weeks of gestation due to premature rupture of membranes. She had had untreated anemia for the previous 2 years (Hb 9<span class="elsevierStyleHsp" style=""></span>g/dL), gastroesophageal reflux and limited weight gain (2<span class="elsevierStyleHsp" style=""></span>kg) during pregnancy, with no apparent cause. Patient evaluation indicated impaired fetal well-being, and she was transferred from her regional hospital for an emergency C-section due to maintained fetal bradycardia. The initial workup showed thrombocytopenia (99<span class="elsevierStyleHsp" style=""></span>000/mm<span class="elsevierStyleSup">3</span>), lactic acid 2.9 and albumin 1.6<span class="elsevierStyleHsp" style=""></span>g/dL. On venous blood gasometry, pH was 7.28, pCO<span class="elsevierStyleInf">2</span> 35<span class="elsevierStyleHsp" style=""></span>mm Hg, pO<span class="elsevierStyleInf">2</span> 62<span class="elsevierStyleHsp" style=""></span>mm Hg, HCO<span class="elsevierStyleInf">3</span> 16.4<span class="elsevierStyleHsp" style=""></span>mmol/L, and BE −10.3<span class="elsevierStyleHsp" style=""></span>mmol/L.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Chest radiograph demonstrated a bilateral reticulonodular pattern that was suspicious for tuberculosis (TB). Tuberculosis treatment was initiated with 4 drugs 24<span class="elsevierStyleHsp" style=""></span>h after her arrival to the ER, and the diagnosis was confirmed by computed tomography (calcified granulomas, peribronchovascular consolidation, numerous bilateral pulmonary nodules and hypodense nodular images in the spleen).</p><p id="par0030" class="elsevierStylePara elsevierViewall">On the 4th day of hospitalization, the patient had profuse vaginal and rectal bleeding that led to cardiac arrest. Cardiopulmonary resuscitation was effective, followed by massive blood transfusion (hemoglobinemia 5<span class="elsevierStyleHsp" style=""></span>g/dL). Abdominal ultrasound showed free fluid compatible with hemoperitoneum. Revision surgery through the Pfannenstiel incision showed no hemorrhage and, given the patient's hemodynamic instability, the surgery was extended to a midline laparotomy. We observed hemoperitoneum secondary to cecal perforation with abundant slightly bloody material that was not fresh, a mass in the hepatic flexure and several omental implants (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). The histopathology analysis confirmed peritoneal tuberculosis. A right hemicolectomy was performed with mechanical ileocolic anastomosis and supra-aponeurotic mesh reinforcement.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The histopathology study reported no tuberculosis in the placenta; in the colon, chronic colitis was observed with abundant necrotizing granulomas and patchy areas of the ileal wall. Histochemistry techniques detected few acid-fast bacilli (positive Ziehl–Neelsen stain). DNA quality testing, with PCR amplification, was definitive for confirming the presence of <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> in the intestinal resection specimen (GenoQuickMTUB; Nehren, Germany). The culture from the bronchoalveolar lavage done on the 5th day confirmed the presence of <span class="elsevierStyleItalic">M. tuberculosis</span> in the lungs.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The postoperative recovery in the intensive care unit (ICU) was favorable until the 5th day post-op, at which time the patient presented dehiscence of the ileocolic suture that required reoperation, ileostomy and mucous fistula. One week after the reoperation, the patient developed ischemia of the ileostomy, which required another ileal resection of 4<span class="elsevierStyleHsp" style=""></span>cm. Meanwhile, she had a syndrome with inadequate hormone secretion secondary to rifampicin and tracheobronchitis secondary to a respiratory infection due to <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> and <span class="elsevierStyleItalic">Stenotrophomonas maltophilia.</span> One month after hospitalization, the patient also required vacuum-assisted closure (VAC Therapy<span class="elsevierStyleSup">®</span>; KCI, Austin, TX, USA) for 15 days in the lower third of the laparotomy due to exposure of the underlying mesh and superficial infection at the surgical site caused by ampicillin-resistant <span class="elsevierStyleItalic">Enterococcus faecium</span>, until the skin was able to be closed. The patient was hospitalized in the ICU for one month and was discharged after 60 days. Bowel transit reconstruction is still pending.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Intestinal tuberculosis is not a frequent etiology of abdominal pain and/or acute abdomen, but it can be the cause of a perforation as well as hemorrhage. If the situation is extreme, as in this case, it is likely that the need for resection will be inevitable.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Intestinal tuberculosis causes the same morphological and clinical changes observed in chronic intestinal diseases, although hypoalbuminemia is detected in 70% of cases and hematocrit is lower than 35%. The tuberculin test is only positive in 50% of cases, but an active lesion is seen on the chest radiograph in 80% of patients.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,9</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In the case we report, these very serious complications could probably have been avoided if tuberculosis had been suspected in a pregnant woman with extreme anorexia, cough with reddish sputum and night sweats.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> Likewise, in a hemodynamically unstable patient with the need for vasoactive agents, massive transfusion and an episode of cardiac arrest, the gastrointestinal anastomosis was probably very risky, and damage control with double ostomy from the start could have prevented the 2 reoperations.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Hernández Martínez L, Membrilla Fernández E, Dot Jordana I, Grande Posa L, Sancho-Insenser JJ. Tuberculosis intestinal. Cir Esp. 2015;93:417–419.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1229 "Ancho" => 950 "Tamanyo" => 210507 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Abundant clotting in the lumen of a swollen ascending colon.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1461 "Ancho" => 950 "Tamanyo" => 223466 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Mass and perforation of the cecum.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Situación de la tuberculosis en el Perú: current status" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "C. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 8 | 3 | 11 |
| 2024 September | 20 | 6 | 26 |
| 2024 August | 19 | 7 | 26 |
| 2024 July | 8 | 8 | 16 |
| 2024 June | 14 | 15 | 29 |
| 2024 May | 14 | 11 | 25 |
| 2024 April | 29 | 29 | 58 |
| 2024 March | 21 | 7 | 28 |
| 2024 February | 17 | 6 | 23 |
| 2024 January | 35 | 1 | 36 |
| 2023 December | 19 | 3 | 22 |
| 2023 November | 16 | 5 | 21 |
| 2023 October | 23 | 6 | 29 |
| 2023 September | 15 | 1 | 16 |
| 2023 August | 20 | 0 | 20 |
| 2023 July | 29 | 6 | 35 |
| 2023 June | 16 | 0 | 16 |
| 2023 May | 18 | 4 | 22 |
| 2023 April | 13 | 2 | 15 |
| 2023 March | 13 | 5 | 18 |
| 2023 February | 13 | 1 | 14 |
| 2023 January | 10 | 7 | 17 |
| 2022 December | 31 | 5 | 36 |
| 2022 November | 27 | 14 | 41 |
| 2022 October | 23 | 10 | 33 |
| 2022 September | 19 | 5 | 24 |
| 2022 August | 17 | 3 | 20 |
| 2022 July | 13 | 8 | 21 |
| 2022 June | 14 | 9 | 23 |
| 2022 May | 23 | 13 | 36 |
| 2022 April | 14 | 10 | 24 |
| 2022 March | 28 | 8 | 36 |
| 2022 February | 22 | 9 | 31 |
| 2022 January | 43 | 9 | 52 |
| 2021 December | 17 | 10 | 27 |
| 2021 November | 30 | 9 | 39 |
| 2021 October | 40 | 18 | 58 |
| 2021 September | 23 | 12 | 35 |
| 2021 August | 32 | 5 | 37 |
| 2021 July | 23 | 11 | 34 |
| 2021 June | 11 | 13 | 24 |
| 2021 May | 23 | 11 | 34 |
| 2021 April | 18 | 11 | 29 |
| 2021 March | 19 | 21 | 40 |
| 2021 February | 20 | 6 | 26 |
| 2021 January | 10 | 10 | 20 |
| 2020 December | 18 | 7 | 25 |
| 2020 November | 10 | 8 | 18 |
| 2020 October | 10 | 5 | 15 |
| 2020 September | 23 | 12 | 35 |
| 2020 August | 13 | 9 | 22 |
| 2020 July | 11 | 10 | 21 |
| 2020 June | 14 | 16 | 30 |
| 2020 May | 17 | 9 | 26 |
| 2020 April | 8 | 3 | 11 |
| 2020 March | 10 | 3 | 13 |
| 2020 February | 13 | 3 | 16 |
| 2020 January | 13 | 6 | 19 |
| 2019 December | 18 | 10 | 28 |
| 2019 November | 16 | 9 | 25 |
| 2019 October | 7 | 8 | 15 |
| 2019 September | 17 | 9 | 26 |
| 2019 August | 7 | 9 | 16 |
| 2019 July | 13 | 10 | 23 |
| 2019 June | 15 | 14 | 29 |
| 2019 May | 40 | 19 | 59 |
| 2019 April | 34 | 27 | 61 |
| 2019 March | 9 | 3 | 12 |
| 2019 February | 13 | 11 | 24 |
| 2019 January | 7 | 3 | 10 |
| 2018 December | 6 | 10 | 16 |
| 2018 November | 17 | 12 | 29 |
| 2018 October | 14 | 2 | 16 |
| 2018 September | 6 | 3 | 9 |
| 2018 August | 1 | 0 | 1 |
| 2018 July | 7 | 2 | 9 |
| 2018 June | 5 | 1 | 6 |
| 2018 May | 12 | 1 | 13 |
| 2018 April | 5 | 1 | 6 |
| 2018 March | 10 | 0 | 10 |
| 2018 February | 4 | 0 | 4 |
| 2018 January | 9 | 0 | 9 |
| 2017 December | 12 | 0 | 12 |
| 2017 November | 8 | 0 | 8 |
| 2017 October | 15 | 2 | 17 |
| 2017 September | 13 | 2 | 15 |
| 2017 August | 12 | 0 | 12 |
| 2017 July | 22 | 2 | 24 |
| 2017 June | 14 | 1 | 15 |
| 2017 May | 7 | 3 | 10 |
| 2017 April | 18 | 1 | 19 |
| 2017 March | 27 | 37 | 64 |
| 2017 February | 26 | 3 | 29 |
| 2017 January | 25 | 2 | 27 |
| 2016 December | 17 | 8 | 25 |
| 2016 November | 20 | 4 | 24 |
| 2016 October | 28 | 9 | 37 |
| 2016 September | 31 | 6 | 37 |
| 2016 August | 15 | 1 | 16 |
| 2016 July | 13 | 1 | 14 |
| 2016 June | 17 | 7 | 24 |
| 2016 May | 15 | 6 | 21 |
| 2016 April | 26 | 4 | 30 |
| 2016 March | 20 | 9 | 29 |
| 2016 February | 11 | 4 | 15 |
| 2016 January | 12 | 4 | 16 |
| 2015 December | 15 | 10 | 25 |
| 2015 November | 17 | 8 | 25 |
| 2015 October | 23 | 9 | 32 |
| 2015 September | 5 | 3 | 8 |
| 2015 July | 1 | 2 | 3 |
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