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CASE SNIPPET
Year : 2023  |  Volume : 69  |  Issue : 2  |  Page : 114-115

Tuberculous enteritis-induced small intestinal bleeding in a kidney transplant recipient


Center for Digestive Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan

Date of Submission03-Feb-2022
Date of Decision05-May-2022
Date of Acceptance17-May-2022
Date of Web Publication28-Nov-2022

Correspondence Address:
Dr. K C Chang
Center for Digestive Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpgm.jpgm_122_22

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How to cite this article:
Chou J W, Chang K C, Wu Y H, Huang P J. Tuberculous enteritis-induced small intestinal bleeding in a kidney transplant recipient. J Postgrad Med 2023;69:114-5

How to cite this URL:
Chou J W, Chang K C, Wu Y H, Huang P J. Tuberculous enteritis-induced small intestinal bleeding in a kidney transplant recipient. J Postgrad Med [serial online] 2023 [cited 2023 Jun 4];69:114-5. Available from: https://www.jpgmonline.com/text.asp?2023/69/2/114/362169




A 51-year-old man with a history of end-stage renal disease secondary to hypertension received a living donor renal transplant in 1996. He received several immunosuppressive agents postoperatively for rejection and maintenance treatment, including mycophenolate sodium, sirolimus, tacrolimus, and methylprednisolone. Initially, he had good function of graft with a normal level of serum creatinine. In recent 2–3 years, his renal function showed progressive deterioration because of recurrent infection. This time, he had intermittent fever since 2 months before this admission. He denied having productive cough, chest tightness, or abdominal pain. After hospitalization, several antibiotics were prescribed for suspected pneumonia. Furthermore, he received hemodialysis again in 2020 because of graft failure. Physical examination was unremarkable except he was febrile. Laboratory results revealed a white blood cell count of 13.0 × 109/L with a 67.7% of neutrophil (normal range, 3.5–11 × 109/L), a hemoglobin level of 6.7 g/dL (normal range, 13.7–17 g/dL), a C-reactive protein level of 3.75 mg/L (normal range, <1.0 mg/dL), and a serum creatinine level of 9.52 mg/dL (normal range, 0.6–1.3 mg/dL). Chest radiography showed no specific finding except left mild pleural effusion. However, severe watery diarrhea (more than six times per day) and massive bloody stool with a dropped hemoglobin level of 3.1 g/dL occurred several days later after hospitalization. Esophagogastroduodenoscopy and colonoscopy failed to detect the bleeding lesion. Thus, small intestinal bleeding was suspected. Antegrade double-balloon enteroscopy demonstrated multiple ulcers, 0.2–0.7 cm in size, from the jejunum to the middle ileum [Figure 1]a. Retrograde enteroscopy also revealed multiple ulcers, 0.5–1 cm in size, in the ileum, and mostly located in the terminal ileum [Figure 1]b. Thus, multiple biopsies were taken from these small intestinal ulcers.
Figure 1: Double-balloon enteroscopy showing multiple ulcers in the jejunum (a) and in the ileum (b)

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Histopathologically, it demonstrated surface ulceration, focal villous destruction, and patchy non-caseating epithelioid granulomas with chronic inflammatory cell infiltration in the lamina propria and submucosa [[Figure 2]a, arrows; hematoxylin and eosin staining, original magnification, ×40]. Acid-fast staining showed some slender acid fast-positive bacilli [[Figure 2]b, arrows; original magnification, ×400]. Thus, a diagnosis of tuberculous (TB) enteritis was made. Acid-fast staining and culture of patient's sputum and pleural effusion all yielded negative results for TB infection. The ADA level of aspirated pleural effusion was 3 (normal, <40). The patient also underwent a bronchoscopy and tissue biopsy was taken. Histopathology of biopsy specimen showed some granuloma with central neutrophils infiltration and adjacent multinucleated giant cells and inflammatory cell infiltration. Although biopsy of specimen was negative for acid-fast staining, the possibility of mycobacterium infection was still suspected. The patient then received anti-TB drugs therapy, including ethambutol 1000 mg qod and Rina (Rifampicin/Isoniazid 600 mg/300 mg) qd. Thereafter, his bloody stool improved gradually within 2 weeks. Subsequently, he was transferred to another hospital after the bleeding had stopped.
Figure 2: Histopathology of small intestinal ulcers showing surface ulceration, focal villous destruction, and patchy non-caseating epithelioid granulomas with chronic inflammatory cell infiltration in the lamina propria and submucosa (a, arrows; hematoxylin and eosin staining, original magnification, ×40). Acid-fast staining showing some slender acid fast-positive bacilli (b, arrows; original magnification, ×400)

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TB enteritis is the sixth most frequent form of extra-pulmonary TB. It accounts for about 1–3% of all TB patients and almost 50% of immunocompromised patients. Owing to use of potent immunosuppressive agents and long-term steroids, post-renal transplant TB can occur in any part(s) of the body and poses high mortality.[1] The symptoms of TB enteritis include fever, abdominal pain, night sweats, fatigue, weight loss, constipation, diarrhea, intestinal obstruction, perforation, or bleeding. TB enteritis-induced small intestinal bleeding in a renal transplant recipient is extremely rare in the literature. Definite diagnosis needs histopathology demonstrating caseating granulomas, positive acid-fast stains, or tissue culture. However, non-caseating granulomas can also be found.[2] Standard treatment of TB enteritis is the same as that for pulmonary TB. Clinical improvement can be expected within 2 weeks following initiation of therapy, whereas endoscopic improvement can be seen after 3 months.[3]

Declaration of patient consent

The authors certify that appropriate patient consent was obtained.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 :: References Top

1.
Subramanian AK, Nuermberger EL. Tuberculosis in transplant recipients: Diagnostic and therapeutic dilemmas. Transpl Infect Dis 2008;10:229-30.  Back to cited text no. 1
    
2.
Malikowski T, Mahmood M, Smyrk T, Raffals L, Nehra V. Tuberculosis of the gastrointestinal tract and associated viscera. J Clin Tuberc Other Mycobact Dis 2018;12:1-8.  Back to cited text no. 2
    
3.
Park YS, Jun DW, Kim SH, Lee HH, Jo Y-J, Song MH, et al. Colonoscopy evaluation after short-term anti-tuberculosis treatment in nonspecific ulcers on the ileocecal area. World J Gastroenterol 2008;14:5051-8.  Back to cited text no. 3
    


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Online since 12th February '04
2004 - Journal of Postgraduate Medicine
Official Publication of the Staff Society of the Seth GS Medical College and KEM Hospital, Mumbai, India
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