Scientific Letters
Lower gastrointestinal bleeding as a presentation of miliary tuberculosis
Hemorragia digestiva baja como presentación de una tuberculosis miliar
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"Abelenda Alonso" "email" => array:1 [ 0 => "gabi.abelenda.alonso@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "Eva Marina" "apellidos" => "Fernández-Marcote" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "David" "apellidos" => "Martín-Crespo Posada" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Marta" "apellidos" => "Pérez González" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "Jose Luis" "apellidos" => "Martínez Albares" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Internal Medicine Service, Severo Ochoa University Hospital, Leganés, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Gastroenterology Service, Severo Ochoa University Hospital, Leganés, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "General & Gastrointestinal Surgery Service, Severo Ochoa University Hospital, Leganés, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hemorragia digestiva baja como presentación de una tuberculosis miliar" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1079 "Ancho" => 1583 "Tamanyo" => 207324 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">CT showing (1) blood content in jejunum, (2) multiple peritoneal implants, (3) omental cake, (4) thickening of the omentum, (5) lymphadenopathy.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 44-year-old male, native of Bolivia but living in Spain for the last 10 years without recent travels to his country, and with no history of interest, attended the emergency room complaining of rectal bleeding with hemodynamic instability. The patient also addressed a three-month period of diffuse abdominal pain (predominantly in left flank), dysmotility, dysthermia, night sweats and weight loss. Physical examination, including neurological examination, was unremarkable except for malnutrition and pain in the left flank's deep palpation without detecting masses, organomegaly or ascites.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Tests revealed 7.6<span class="elsevierStyleHsp" style=""></span>g/dL hemoglobin levels with ferropenia profile, 135<span class="elsevierStyleHsp" style=""></span>mg/dL CRP, 60% Quick I. and severe malnutrition. The rest of the parameters, including WBC count, electrocardiogram and chest radiograph resulted without alterations. Colonoscopy was performed without finding mucosal lesions, though with hematic content in terminal ileum. Gastroscopy was normal. CT scan showed jejunal thickening with plenty intraluminal hematic content without actually observing bleeding points. In addition, a thickening of the omentum, multiple peritoneal implants, ascites, and lymphadenopathy were demonstrated. Double contrast CT and gastrointestinal transit were performed without new discoveries (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">On admission the blood culture, HIV and Mantoux tests were negative. Early laparoscopy was performed, obtaining images that suggested miliary TB vs. peritoneal carcinomatosis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Histology showed abundant caseating granulomas. The Ziehl Neelsen stain and PCR for M. Tuberculosis in peritoneal fluid were negative. Due to these findings the patient was isolated until the negative result of sputum smear microscopy arrived. Pleural effusion was found in a second radiography with negative RCP for Mycobacteria.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Treatment was initiated with rifampicin, isoniazid, pyrazinamide and ethambutol in weight-adjusted doses, with resolution of symptoms. As an adverse effect the patient presented transient elevation of transaminases. After 8 weeks, sputum results arrived: both solid and liquid medium cultures were positive for Mycobacterium Tuberculosis sensitive to all TB drugs. Peritoneal fluid and urine cultures in both solid and liquid medium were negative. We had no peritoneum sample for culture. Currently our patient is progressing well with a 5<span class="elsevierStyleHsp" style=""></span>kg weight gain and continues with rifampicin and isoniazid, intending to maintain the treatment for at least 12 months.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In this case gastrointestinal bleeding related to jejunal affectation and probably secondary to peritoneal extension, allowed the diagnosis of miliary tuberculosis.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Despite being a relatively old disease, tuberculosis remains nowadays the World's third leading cause of death by an infectious agent. According to the latest report of the World Health Organization,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> in 2013 nine million people developed TB and 1.5 million died from it. In recent years we are also witnessing another problem, the increasing incidence of multidrug-resistant TB (3.5% in new patients and 20.5% in previously treated). Although the initial target organ is the lung, tuberculosis is a systemic disease that can affect any organ.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> The fact that this can occur after the first contact with the organism, in a second time or never, has to do with various adaptive mechanisms of M. tuberculosis, but also and largely with host factors.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> In the case of intestinal tuberculosis, the organism reaches the abdominal organs through hematogenous dissemination, direct spread from adjacent tissues or, less commonly, through direct ingestion when near a TB focus (positive sputum-smear patients). It is worth noting that up to 25% of abdominal affectation presents itself with pulmonary tuberculosis, and that M. tuberculosis can implant anywhere in the abdominal cavity. This leads to varied and nonspecific clinical manifestations, making the diagnosis difficult.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> There are four main forms of abdominal TB<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a>; lymphadenopathy, peritoneal, gastrointestinal and visceral, being the most common manifestations the first two or a combination of them. It is important to realize that only 30% of cases have fever and that the most common clinical sign is ascitis.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> For early diagnosis and treatment the biopsy is essential since it allows us to obtain histologic results, and most importantly, cultures and mycobacteria RCP (60–70% diagnosis sensitivity).<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> However, as we have seen in our case, the profitability of ascites fluid culture and even its RCP is low (15% and 7% respectively). In gastrointestinal manifestation cases all this gains special importance when making the differential diagnosis with other processes such as Crohn<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> disease or intestinal lymphomas. If, as in our case, endoscopy misses suspicious lesions’ biopsies, laparoscopy becomes an essential tool in the diagnosis of abdominal TB with high yield and minimal risks compared with the high morbidity and mortality rate in non-treated patients pending completion of the study.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflict of interest" ] 1 => array:2 [ "identificador" => "xack244607" "titulo" => "Acknowledgment" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1079 "Ancho" => 1583 "Tamanyo" => 207324 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">CT showing (1) blood content in jejunum, (2) multiple peritoneal implants, (3) omental cake, (4) thickening of the omentum, (5) lymphadenopathy.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1013 "Ancho" => 1400 "Tamanyo" => 358774 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">On the top, two captures showing laparoscopy with multiple nodules both parietal and visceral peritoneum. On the bottom, pathology sample of the omentum showing abundant epithelioid granulomas with caseous necrosis (1) and giant cells on the periphery (2).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Global tuberculosis report 2014" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "WHO" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2014" "editorial" => "World Health Organization" "editorialLocalizacion" => "Geneva" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0055" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tuberculosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 19 | 2 | 21 |
| 2024 September | 51 | 10 | 61 |
| 2024 August | 22 | 2 | 24 |
| 2024 July | 42 | 5 | 47 |
| 2024 June | 61 | 7 | 68 |
| 2024 May | 58 | 5 | 63 |
| 2024 April | 32 | 8 | 40 |
| 2024 March | 76 | 5 | 81 |
| 2024 February | 55 | 8 | 63 |
| 2024 January | 66 | 1 | 67 |
| 2023 December | 60 | 3 | 63 |
| 2023 November | 57 | 2 | 59 |
| 2023 October | 79 | 6 | 85 |
| 2023 September | 41 | 6 | 47 |
| 2023 August | 31 | 4 | 35 |
| 2023 July | 58 | 4 | 62 |
| 2023 June | 55 | 2 | 57 |
| 2023 May | 84 | 7 | 91 |
| 2023 April | 68 | 3 | 71 |
| 2023 March | 58 | 2 | 60 |
| 2023 February | 63 | 4 | 67 |
| 2023 January | 66 | 9 | 75 |
| 2022 December | 53 | 9 | 62 |
| 2022 November | 74 | 14 | 88 |
| 2022 October | 65 | 14 | 79 |
| 2022 September | 94 | 15 | 109 |
| 2022 August | 76 | 10 | 86 |
| 2022 July | 65 | 16 | 81 |
| 2022 June | 44 | 24 | 68 |
| 2022 May | 28 | 8 | 36 |
| 2022 April | 56 | 10 | 66 |
| 2022 March | 97 | 7 | 104 |
| 2022 February | 74 | 7 | 81 |
| 2022 January | 93 | 10 | 103 |
| 2021 December | 62 | 13 | 75 |
| 2021 November | 87 | 11 | 98 |
| 2021 October | 58 | 11 | 69 |
| 2021 September | 34 | 7 | 41 |
| 2021 August | 33 | 4 | 37 |
| 2021 July | 31 | 8 | 39 |
| 2021 June | 31 | 10 | 41 |
| 2021 May | 34 | 9 | 43 |
| 2021 April | 63 | 20 | 83 |
| 2021 March | 42 | 5 | 47 |
| 2021 February | 46 | 10 | 56 |
| 2021 January | 61 | 9 | 70 |
| 2020 December | 47 | 6 | 53 |
| 2020 November | 48 | 2 | 50 |
| 2020 October | 24 | 4 | 28 |
| 2020 September | 24 | 7 | 31 |
| 2020 August | 31 | 11 | 42 |
| 2020 July | 31 | 16 | 47 |
| 2020 June | 22 | 13 | 35 |
| 2020 May | 32 | 17 | 49 |
| 2020 April | 33 | 25 | 58 |
| 2020 March | 43 | 15 | 58 |
| 2020 February | 22 | 12 | 34 |
| 2020 January | 42 | 4 | 46 |
| 2019 December | 42 | 11 | 53 |
| 2019 November | 39 | 6 | 45 |
| 2019 October | 39 | 5 | 44 |
| 2019 September | 41 | 6 | 47 |
| 2019 August | 34 | 8 | 42 |
| 2019 July | 36 | 11 | 47 |
| 2019 June | 42 | 15 | 57 |
| 2019 May | 117 | 5 | 122 |
| 2019 April | 52 | 8 | 60 |
| 2019 March | 7 | 4 | 11 |
| 2019 February | 9 | 4 | 13 |
| 2019 January | 14 | 1 | 15 |
| 2018 December | 16 | 5 | 21 |
| 2018 November | 14 | 2 | 16 |
| 2018 October | 17 | 7 | 24 |
| 2017 September | 1 | 1 | 2 |
| 2017 February | 1 | 0 | 1 |
| 2016 November | 1 | 0 | 1 |
| 2016 October | 4 | 0 | 4 |
| 2016 September | 3 | 2 | 5 |
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