Goić-Barisić Ivana, Ledina Dragan, Tonkić Marija, Luksić Boris, Barisić Igor
Odjel za klinicku mikrobiologiju, Klinicka bolnica Split, Split, Hrvatska.
Acta Med Croatica. 2006 Dec;60(5):505-8.
Tuberculosis with the incidence 28-29/100000 residents still presents a major public health problem in Croatia. Miliary tuberculosis is uncommon cause of fever of unknown origin. Intestinal tuberculosis pose as diagnostic problem that can be identified by colonoscopy and/or explorative laparatomy involving histopathology and microbiology. A case is reported of a 40-year-old HIV negative patient admitted to the Department of Infectious Diseases after two weeks of fever, diarrhea, abdominal pain and weight loss. Biochemistry testing showed mild elevation of the erythrocyte sedimentation rate and increased serum aminotransferases. On admission, chest x-ray was normal and tuberculin skin test was negative. Crohn's disease was suspected. Computed tomography of the abdomen revealed solid infiltrative mass located retroperitoneally, along with enlarged lymph nodes. Explorative laparoscopy was necessary to confirm the diagnosis. Intraoperative specimens were referred for histopathologic and microbiologic examination, which proved the existence of granulomatous inflammation of the areas with caseous necrosis. Direct microscopy of the periappendicular abscess and Ziehl-Neelsen staining of a lymph node specimen confirmed the presence of an acidoresistant bacillus. The specimen culture on solid egg based agar (Löwenstein Jensen) and liquid broth (MGIT) showed the growth of Mycobacterium tuberculosis. Then the causative agent was cultured from all specimens: sputum, stool and urine. Repeat cheast x-ray, performed on day 30 of hospitalization, showed miliary dissemination to the lungs. The patient was treated with four antituberculotics (streptomycin, isoniazide, rifampin, ethambutol) and methylprednisolone for one month, then with isoniazide, rifampin and for 11 months ethambutol. Therapy led to a decrease of abdominal lymph nodes and absence of miliary lesions on chest radiography after two months of treatment. Intestinal tuberculosis has been almost forgotten in Croatia. The latest published cases referred to HIV infected patients. In less than 50% of patients with intestinal tuberculosis the lungs are also affected, which poses a diagnostic problem. Crohn's disease is the most common diagnostic problem. Histopathology of a specimen obtained on colonoscopy and/or explorative laparoscopy can often solve the dilemma, as also confirmed in our patient. Of diagnostic studies, computed tomography has the advantage of evaluating intestinal wall involvement, which is important for the early diagnosis of intestinal tuberculosis. Enteroclysis and irrigography provide diagnostic information in the advanced stage of intestinal tuberculosis. In a patient with fever, abdominal disorders and parameters which implicate granulomatosis hepatitis or Crohn's disease, the existence of abdominal tuberculosis is also possible. Computed tomography and biopsy obtained on colonoscopy for microbiology can help in making the diagnosis and initiating appropriate treatment.
在克罗地亚，结核病发病率为每10万居民28 - 29例，仍然是一个重大的公共卫生问题。粟粒性肺结核是不明原因发热的罕见病因。肠结核是一个诊断难题，可通过结肠镜检查和/或剖腹探查术并结合组织病理学和微生物学来确诊。本文报告一例40岁HIV阴性患者，因发热、腹泻、腹痛和体重减轻两周后入住传染病科。生化检查显示红细胞沉降率轻度升高，血清转氨酶升高。入院时，胸部X光检查正常，结核菌素皮肤试验阴性。怀疑为克罗恩病。腹部计算机断层扫描显示腹膜后有实性浸润性肿块，伴有淋巴结肿大。需要进行剖腹探查术以确诊。术中标本送去做组织病理学和微生物学检查，结果证实存在伴有干酪样坏死区域的肉芽肿性炎症。阑尾周围脓肿的直接显微镜检查和淋巴结标本的萋 - 尼氏染色证实存在抗酸杆菌。在基于鸡蛋的固体琼脂（罗 - 琴培养基）和液体肉汤（分枝杆菌生长指示管）上进行标本培养，显示有结核分枝杆菌生长。随后从所有标本（痰液、粪便和尿液）中培养出病原体。住院第30天复查胸部X光，显示肺部有粟粒性播散。患者接受了四种抗结核药物（链霉素、异烟肼、利福平、乙胺丁醇）和甲基泼尼松龙治疗一个月，然后用异烟肼、利福平及乙胺丁醇治疗11个月。治疗两个月后，腹部淋巴结缩小，胸部X光片上粟粒性病变消失。在克罗地亚，肠结核几乎已被遗忘。最新发表的病例涉及HIV感染患者。在不到50%的肠结核患者中，肺部也会受到影响，这就造成了诊断难题。克罗恩病是最常见的诊断难题。通过结肠镜检查和/或剖腹探查术获取的标本进行组织病理学检查通常可以解决这一困境，我们的患者也证实了这一点。在诊断检查中，计算机断层扫描具有评估肠壁受累情况的优势，这对肠结核的早期诊断很重要。小肠灌肠造影和灌肠造影在肠结核晚期提供诊断信息。对于发热、腹部疾病以及提示肉芽肿性肝炎或克罗恩病的参数的患者，也有可能存在腹部结核。计算机断层扫描和通过结肠镜检查获取标本进行微生物学检查有助于做出诊断并开始适当治疗。
