BSPGHAN 2021 Virtual Annual Meeting

27- 29 April 2021

A DIAGNOSTIC DILEMMA: CASE REPORT OF A YOUNG BOY WITH ABDOMINAL TUBERCULOSIS WHO WAS INITIALLY THOUGHT TO HAVE CROHN’S DISEASE

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Stephen Allen
Stephen Allen
19 days ago

Hello Dr. Findlay. A very interesting case and an important lesson for us all! A couple of questions:

  1. Could this have been diagnoses based on the initial histology – e.g. presence of caseating granuloma?
  2. Should we routinely screen for TB in higher risk children at initial diagnosis? If so, could you suggest what the main risk factors would be?
Alice Findlay
Alice Findlay
19 days ago
Reply to  Stephen Allen

Thanks for your comment.
The initial histology did not show any obvious caveating granulomas, which is why the diagnosis of TB was not initially considered. The findings were more in keeping with generalised ileocaecal inflammation.

Our learning point was that screening for TB is important early on in complex or non responding cases, and we will be considering earlier screening in cases where initial biochemical or clinical response is not shown with initial treatment. Risk factors of course would include a family history/contact with any individuals with TB and so very direct questioning about TB contact will also be very important to ascertain.

Protima Deb
Protima Deb
19 days ago
Reply to  Stephen Allen

Thanks Stephen for your comments.
Looking back, although the diagnostic biopsies on histology did not pick up TB, 2 large granulomas were noted in caecal biopsy but were not caseating granuloma. However, in hindsight the clinical pointers were there at index presentation for TB infection: weight loss, abd pain, normal crp but raised ESR which remained raised even after EEN.
Taking a thorough history 4 yrs later, TB contact in family was discovered also.
So yup, TB screening should have been done for him as he was higher risk.
His case I think also supports other patients diagnosed with Crohn’s getting screen early for possible TB, especially in those who are not responding to Crohn’s treatments early and as Alice says has risk factors for TB (which living in East End of London is a risk just as if you were living in Asia/Africa these days).
A lesson learnt!

sue protheroe
sue protheroe
17 days ago

really important key messages. I wonder if you might ask the IBD WG who may consider a national audit?

Protima Deb
Protima Deb
17 days ago
Reply to  sue protheroe

Thanks Sue. This will be very worthwhile as I suspect there may be more such cases. Depending on the numbers perhaps this sort of audit will help provide guidelines which Stephen alluded to about TB screening at index presentation for high risk groups.
Looking back, we have certainly had other cases which were more obvious (from CXR etc) who were initially diagnosed as Crohn’s.
Will touch base with colleagues in IBD WG in this regard.

Attah Ocholi
Attah Ocholi
16 days ago

Really interesting. We had a similar case at St George’s in 2014 – EEN and didn’t respond. The reason it was picked up early was that our histopathologist was concerned by the size of the granulomas and felt it was more than IBD – he did the ZN stain, couldn’t find anything thing but sought other eyes (one of our very experienced histopathologists who has now retired) who managed to spot TB. in our case we were saved by histopathologists who trusted their gut. With hindsight it ‘becomes obvious’ but i have to say it remains very difficult! Would certainly be interesting to do a national Audit as Sue and Protima suggest.