P105. Unusual presentation of tuberculosis as splenic nodules in a patient with Crohn's disease
Y.T. Jeen, J.M. Lee, H.S. Choi, E.S. Kim, B. Keum, H.J. Chun, Korea University College of Medicine, Department of Internal Medicine, Seoul, South Korea
Increased risk of tuberculosis (Tb) during tumor necrosis factor alpha (TNFa) antagonist therapy is one of severe problems in patients with Crohn's disease. It is usually presented as pulmonary manifestation, sometimes miliary Tb. But, extra-pulmonary Tb has been rarely reported in case of Crohn's disease. Here in, we present a case of unusual presentation of Tb in a patient with Crohn's disease after anti-TNFa therapy.
Case report: A 21-year-old male was diagnosed as Crohn's disease, two years ago. Oral corticosteroid therapy was initial treatment. He complained a nausea after azathioprine administration and oral mesalazine could not improve the Crohn's disease. Because of disease progression, anti-TNFa therapy was started one year ago. Tb Screening test was negative at that time. Crohn's disease was improved after infliximab induction. After 6 month, he admitted to hospital due to right lower abdominal pain. Any other symptom except abdominal pain was not shown and chest X-ray was unremarkable. There was no evidence of appendicitis or Crohn's disease aggravation in abdominal CT. But, multiple nodules were shown in spleen (Figure 1), which were suspected Tb, fungal infection, or lymphoma.
Although abdominal pain was subsided by conservative treatment, Tb screening test was performed for differential diagnosis of Tb. Unexpectedly, rechecked PPD test and Tb specific Ag showed positive. Consolidation of left upper lung was newly found in follow up chest X-ray and high resolution CT (Figure 2).
Percutaneous needle lung biopsy was done and Tb was confirmed by histopathologic feature of necrotizing granulomatous inflammation. Therefore, anti-TNFa therapy was immediately stopped, Tb therapy with 4 regimens (INH, RFP, EMB, and PZA) was continued until now. The size and number of splenic lesions were decreased after Tb therapy and Crohn's disease did not aggravate during the follow up period.
Conclusions: Although Tb screening is negative, the risk of Tb cannot be completely excluded. During anti-TNFa therapy, we must have in mind the possibility of atypical Tb infection. Tb may occur without definite lung lesion. In patients with non-specific symptoms, image modality like as ultrasonography should be considered for early detection of extra-pulmonary TB. Also, more accurate test might be routinely performed, especially in Tb endemic area.
Ultrasound shear wave elastography detects bowel wall fibrosis in ex vivo human Crohn's disease specimensJ.R. Dillman2, R.W. Stidham1, L.A. Johnson1, J.M. Rubin2, 1University of Michigan, Internal Medicine - Gastroenterology, Ann Arbor, United States, 2University of Michigan, Radiology, Ann Arbor, United States
Narrowed, thickened small bowel in Crohn's disease can be due to inflammation or fibrosis. Ultrasound-generated shear waves travel through tissue at differential rates, with increased speed in stiffer, more fibrotic tissue. While this technology has been applied to breast masses and liver fibrosis, it has not been applied to the bowel in Crohn's disease. It is possible that shear wave speed can accurately differentiate inflamed from fibrotic bowel. SWS can be measured transcutaneously, but prior to FDA approval, we performed ex vivo studies of resected bowel segments.
We aimed to determine whether bowel wall fibrosis can be detected in freshly-resected human intestinal specimens based on ultrasound-derived shear wave speed (SWS), and whether SWS can differentiate inflamed from fibrotic bowel.
17 intact (>3 cm) bowel segments (15 small and 2 large intestine) from 12 patients with known Crohn's disease or ulcerative colitis were procured immediately following surgical resection and kept moist in normal saline. Ultrasound shear wave elastography of the bowel wall was performed using two methods (Virtual Touch Quantification [VTQ] and Virtual Touch-IQ [VT-IQ]; Siemens Medical Solutions USA, Inc.). 18 short-axis SWS measurements were acquired from each specimen; 3 from the 9, 12, and 3 o'clock locations for each method. Imaging was performed in two areas for specimens >10 cm in length (separated by ≥5 cm). A gastrointestinal pathologist scored location-matched histologic slides separately on Likert scales for both inflammation and fibrosis. Differences in mean SWS between bowel segments demonstrating low and high inflammation/fibrosis scores were assessed using the student t-test. Receiver operating characteristic (ROC) curve analysis was performed. Both VTQ and VT-IQ methods of measurement were performed with a Siemens Acuson S3000.
High fibrosis score (N = 11) bowel segments demonstrated significantly greater mean SWS than low fibrosis score (N = 6) bowel segments (VTQ: 1.59±0.37 vs. 1.18±0.08 m/s, p = 0.004; VT-IQ: 1.87±0.44 vs. 1.50±0.26 m/s; p = 0.049). There was no significant difference in mean SWS between high inflammation score and low inflammation score bowel segments (p > 0.05 for both VTQ and VT-IQ). ROC curves demonstrated areas under the curve of 0.91 [95%, 0.67–0.99] (VTQ) and 0.77 [95%, 0.51–0.94] (VT-IQ) for distinguishing low from high fibrosis score bowel segments.
Ex vivo bowel wall SWS measurements increase when intestinal fibrosis is extensive and transmural. This is not affected by coincident inflammation. In the ex vivo samples from severe disease, VTQ SWS appears to be able to differentiate fibrotic from inflamed bowel.