Colonic Tuberculosis: A Diagnostic Challenge Colonic Tuberculosis: A Diagnostic Challenge David Epstein Division of Gastroenterology Groote Schuur Hospital and University of Cape Town South Africa David Epstein Division of Gastroenterology Groote Schuur Hospital and University of Cape Town South Africa Falk Foundation, Istanbul, 2007 Ileo- Ileo-
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• Phenotypic Similarities– Protean clinical manifestations – Differentiating CD from ITB
• Treatment of IBD– Immunosuppression and biological therapy in
IBD patients from communities with high rates for TB
Tuberculosis Notification Rates 2005
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8%61%0%61%5%45%Ulcers lined by bands of epithelioid histiocytes
12%44%6%39%5%45%Submucosal granulomas
8%67%0%51%5%90%
Area >0.05mm2Diameter > 400μm Diameter >200μm Large granulomas
0%33%----≥10 granulomas/biopsy site
24%44%0%45%0%40%≥5 granulomas/biopsy site
0%50%3%42%0%60%Confluent granulomas
0%22%0%36%0%40%Caseous necrosis
CD(n=25)
ITB(n=18)
CD(n=31)
ITB(n=33)
CD(n=20)
ITB (n=20)
Kirsch et al (2006)Cape Town, South Africa
Pulimood et al. (2005) Southern India
Pulimood et al. (1999)Southern India
Epstein D et al Aliment Pharmacol Thera 2007 in press
TB
TB TB
CD
Epstein D, Watermeyer G, Kirsch R Aliment Pharmacol Thera 2007 in press
Histological features, other than acid-fast bacilli and caseating granulomas, are useful in differentiating intestinal tuberculosis from Crohn’s disease
• Formalin-fixed paraffin embedded samples
• Confirmed intestinal TB
• PCR ⊕ 22% - 75%
TB PCR on Endoscopic Mucosal Biopsy
Amarapurkar et al J Assoc Physicians India 2004Kim et al Am J Gastroenterol 1998Gan et al Am J Gastroenterol 2002 Anand et al Am J Gastroenterol 1994
New Tools for TB Diagnosis• Interferon-gamma release assays
“ It is impossible to diagnose abdominal tuberculosis with any degree of certainty, since the disease mimics many other abdominal conditions and histological confirmation may be equivocal”
Walsh J 1909 Trans Natl Assoc Prev Tuberc 5:217-222
Intestinal TB remains a diagnostic challenge
Intestinal TB remains a diagnostic challenge
Chronic Ileo-colonic Inflammation
Caseating granulomas or acid-fast bacilli absentNo TB at an extra-intestinal site
• Previous TB / TB contact• Abnormal chest x-ray• HIV positive• Positive test for latent TB• TB lesions on endoscopy• TB lesions on histology• Abdominal imaging with features of TB
• No past TB / No TB contact• Normal chest x-ray• HIV negative • Negative test for latent TB• Crohns lesions on endoscopy • Crohns lesions on histology• Abdominal imaging with features of CD
TB culture ⊕and / or
Clinical improvementInflammatory markers ↓
TB culture Өand
Clinical improvementInflammatory markers ↓
Complete therapy Continue therapy
Treat for TB x 8 wks Treat for CD x 8 wks
Chronic Ileo-colonic Inflammation
Caseating granulomas or acid-fast bacilli absentNo TB at an extra-intestinal site