Grand Rounds—Hammersmith Hospital: Tuberculous enteritis

A serious possibility in some patients

Abdominal tuberculosis should always be considered in immigrants from regions where this disease is endemic who present with abdominal signs and symptoms. We describe the case of a young man from such a region with extensive tuberculous involvement of his gastrointestinal tract and peritoneum. This case highlights the difficulties in diagnosing tuberculous enteritis and the need to consider seriously the possibility of this disease in such patients.

Tuberculous enteritis remains a challenge to the diagnostic acumen and therapeutic skills of both the physician and the surgeon.

Case history

A 25 year old Eritrean student, resident in Britain since 1989, first sought medical advice at this hospital in April 1994, when he was being investigated in relation to emigration to Canada. Plain chest radiography at this time was initially reported as showing a pulmonary nodule. On review, however, it was considered to be normal.

He presented a year later to the gastroenterology department with large amount of weight loss (20 kg over a year), acid reflux, epigastric pain, intermittent vomiting, occasional bloody stools, and depression. He had no history of illicit substance misuse and no risk factors for HIV infection. He admitted having a very erratic eating pattern with poor nutritional intake. He was a non-smoker and did not drink alcohol.

On examination he was extremely cachectic, weighing only 49 kg. He had a left sided proptosis and leukonychia, and he was clinically anaemic. Ascites was also present, but there was no lymphadenopathy, peripheral oedema, or chronic liver disease.

Investigations showed a hypochromic, normocytic anaemia (haemoglobin concentration 99 g/l, mean corpuscular volume 84 fl), a low serum iron concentration (1.6 μmol/l), low transferrin concentration (0.85 g/l), low transferrin saturation index (7%), and raised ferritin concentration (367 μg/l). He had raised inflammatory markers (C reactive protein concentration 77 U/l, erythrocyte sedimentation rate 65 mm …