Immunohistochemistry and real-time Polymerase Chain Reaction: importance in the diagnosis of intestinal tuberculosis in a Peruvian population.

INTRODUCTION: The diagnosis of intestinal tuberculosis is challenging even nowadays. This study aims to report the positivity rates of new diagnostic methods such as immunohistochemistry and Real-Time Polymerase Chain Reaction in patients with intestinal tuberculosis, as well as describe the pathological and endoscopic features of intestinal tuberculosis in our population. METHODS: This was a retrospective observational study conducted in patients diagnosed with intestinal tuberculosis, between 2010 to 2023 from the Hospital Nacional Daniel Alcides Carrion and a Private Pathology Center, both located in Peru. Clinical data was obtained, histologic features were independently re-evaluated by three pathologists; and immunohistochemistry and real-time Polymerase Chain Reaction evaluation were performed. The 33 patients with intestinal tuberculosis who fulfilled the inclusion criteria were recruited. RESULTS: Immunohistochemistry was positive in 90.9% of cases, while real-time Polymerase Chain Reaction was positive in 38.7%. The ileocecal region was the most affected area (33.3%), and the most frequent endoscopic appearance was an ulcer (63.6%). Most of the granulomas were composed solely of epithelioid histiocytes (75.8%). Crypt architectural disarray was the second most frequent histologic finding (78.8%) after granulomas, but most of them were mild. CONCLUSION: Since immunohistochemistry does not require an intact cell wall, it demonstrates higher sensitivity compared to Ziehl-Neelsen staining. Therefore, it could be helpful for the diagnosis of paucibacillary tuberculosis.

Challenges in Diagnosis of Esophageal Tuberculosis.

Esophageal tuberculosis (TB) is a rare manifestation of extrapulmonary TB, accounting for <0.2% of all TB cases. Esophageal TB most commonly presents with dysphagia, odynophagia, retrosternal pain, and systemic symptoms like decreased appetite, loss of weight, and low-grade fever as associated or other presentations. We report a similar case recently encountered as an elderly male patient presented with chronic dysphagia to solids, loss of appetite, and significant loss of weight. Radiological and endoscopy pictures looked like esophageal cancer with histopathological examination (twice) negative for the same. Diagnosis of esophageal TB was confirmed by GeneXpert Ultra of biopsy sample and histopathological examination was suggestive of granulomatous esophagitis. The patient improved on 6 months antitubercular therapy. The unique aspect of this case was how the lesion mimicked an esophageal carcinoma on imaging which posed a diagnostic challenge.

Differential diagnosis of Crohn's disease and intestinal tuberculosis based on ATR-FTIR spectroscopy combined with machine learning.

BACKGROUND: Crohn's disease (CD) is often misdiagnosed as intestinal tuberculosis (ITB). However, the treatment and prognosis of these two diseases are dramatically different. Therefore, it is important to develop a method to identify CD and ITB with high accuracy, specificity, and speed. AIM: To develop a method to identify CD and ITB with high accuracy, specificity, and speed. METHODS: A total of 72 paraffin wax-embedded tissue sections were pathologically and clinically diagnosed as CD or ITB. Paraffin wax-embedded tissue sections were attached to a metal coating and measured using attenuated total reflectance fourier transform infrared spectroscopy at mid-infrared wavelengths combined with XGBoost for differential diagnosis. RESULTS: The results showed that the paraffin wax-embedded specimens of CD and ITB were significantly different in their spectral signals at 1074 cm-1 and 1234 cm-1 bands, and the differential diagnosis model based on spectral characteristics combined with machine learning showed accuracy, specificity, and sensitivity of 91.84%, 92.59%, and 90.90%, respectively, for the differential diagnosis of CD and ITB. CONCLUSION: Information on the mid-infrared region can reveal the different histological components of CD and ITB at the molecular level, and spectral analysis combined with machine learning to establish a diagnostic model is expected to become a new method for the differential diagnosis of CD and ITB.

Extrapulmonary tuberculosis as a cause of complex perianal fistula disease.

Extrapulmonary tuberculosis (TB) in the gastrointestinal tract is a rare, but yet an essential differential diagnosis to patients with complex fistula disease, since the initiation of immunosuppressive therapy for presumed Crohn's disease can lead to a fulminant course of TB. This case report presents a young Danish woman with a progressive complex fistula disease, where cause and treatment were uncovered by interprofessional collaboration between pulmonologists, gastroenterologists and surgeons including a screening test for TB as well as multiple biopsies from the anal fistula tissue.

Right Colectomy for an Inflammatory Mass in the Cecum Later Found to Be Tuberculosis.

Gastrointestinal tuberculosis (TB) is a rare manifestation of extra-pulmonary TB that is known to mimic many different gastrointestinal diseases. We present a case of an 85-year-old male patient with delayed diagnosis of gastrointestinal TB who underwent colonic resection for a cecal mass that was initially suspected to be malignant. Acid-fast staining of the surgical specimen later revealed acid-fast bacilli and multiple lymph nodes with necrotizing granulomas. The purpose of this study is to stress the importance of including gastrointestinal TB as a differential diagnosis for patients with suspected colorectal malignancy, especially when initial biopsy results do not reveal malignant features.

Artificial intelligence for discrimination of Crohn's disease and gastrointestinal tuberculosis: A systematic review.

BACKGROUND AND AIM: Discrimination of gastrointestinal tuberculosis (GITB) and Crohn's disease (CD) is difficult. Use of artificial intelligence (AI)-based technologies may help in discriminating these two entities. METHODS: We conducted a systematic review on the use of AI for discrimination of GITB and CD. Electronic databases (PubMed and Embase) were searched on June 6, 2022, to identify relevant studies. We included any study reporting the use of clinical, endoscopic, and radiological information (textual or images) to discriminate GITB and CD using any AI technique. Quality of studies was assessed with MI-CLAIM checklist. RESULTS: Out of 27 identified results, a total of 9 studies were included. All studies used retrospective databases. There were five studies of only endoscopy-based AI, one of radiology-based AI, and three of multiparameter-based AI. The AI models performed fairly well with high accuracy ranging from 69.6-100%. Text-based convolutional neural network was used in three studies and Classification and regression tree analysis used in two studies. Interestingly, irrespective of the AI method used, the performance of discriminating GITB and CD did not match in discriminating from other diseases (in studies where a third disease was also considered). CONCLUSION: The use of AI in differentiating GITB and CD seem to have acceptable accuracy but there were no direct comparisons with traditional multiparameter models. The use of multiple parameter-based AI models have the potential for further exploration in search of an ideal tool and improve on the accuracy of traditional models.

Differentiation of Crohn's disease, ulcerative colitis, and intestinal tuberculosis by dual-layer spectral detector CT enterography.

AIM: To investigate the value of radiological features and energy spectrum quantitative parameters in the differential diagnosis of Crohn's disease (CD), ulcerative colitis (UC), and intestinal tuberculosis (ITB) by dual-layer spectral detector computed tomography (CT) enterography (CTE). MATERIALS AND METHODS: Clinical and CTE data were collected from 182 patients with CD, 29 with UC, and 51 with ITB. CT images were obtained at the enteric phases and portal phases. The quantitative energy spectrum parameters were iodine density (ID), normalised ID (NID), virtual non-contrast (VNC) value, and effective atomic number (Z-eff). The area under curve (AUC) of the receiver operating characteristic curve (ROC) was calculated. RESULTS: The vascular comb sign (p=0.009) and enlarged lymph nodes (p=0.001) were more common in patients with CD than UC or ITB. In the differentiation of moderate-severe active CD from UC, enteric phase NID (AUC, 0.938; p<0.001) and portal phase Z-eff (AUC, 0.925; p<0.001) had the highest accuracy, which were compared separately. In the differentiation of moderate-severe active CD from ITB, enteric phase NID (AUC, 0.906; p<0.001) and portal phase Z-eff (AUC, 0.947; p<0.001) had the highest accuracy; however, the AUC value was highest when the four parameters are combined (AUC, 0.989; p<0.001; AUC, 0.986; p<0.001; AUC, 0.936; p<0.001; and AUC, 0.986; p<0.001). CONCLUSION: The present study shows that the combined strategies of four parameters have higher sensitivity and specificity in differentiating CD, UC, and ITB, and may play a key role in guiding treatment.

Crohn's disease and intestinal tuberculosis: challenging from every angle.

A woman in her 20s with a recent diagnosis of Crohn's disease (CD) affecting the ileocaecal valve was started on adalimumab, after routine tuberculosis (TB) tests were negative. Her abdominal symptoms got worse and she started presenting respiratory distress and fever. Tomography revealed a left pleural effusion, pneumonia and peritonitis with pelvic abscess. The diagnosis of disseminated TB with digestive involvement was suggested and sputum cultures were positive for Mycobacterium tuberculosis Treatment for TB was started and immunosuppressants discontinued, leading to respiratory improvement. Abdominal imaging was repeated, showing worsening signs of multisegmental ileal wall thickening, ileocaecal valve obstruction and a persistent pelvic abscess. She was then submitted to a laparoscopic ileocaecal resection for suspicion of worsening CD. Histopathology showed chronic ileocolitis compatible with CD and ganglionic tuberculosis, revealing the diagnosis of intestinal tuberculosis superimposed in CD. Recovery was uneventful.

Intestinal tuberculosis presented as spindle cell pseudotumor in a HIV-positive case / Tuberculosis intestinal presentada como pseudotumor de células fusiformes en un caso VIH positivo

MSP is a rare and atypical form of benign granulomatous inflammation characterised by tumour-like local proliferation of spindle-shaped histiocytes containing acid-fast positive mycobacteria, which should be differentiated from neoplastic lesions. A 26-year-old Chinese man complained an intermittent and mild right lower abdominal pain for 5 months in May 2022.Histopathology of biopsy samples showed Mycobacterial spindle cell pseudotumor (MSP). The test of Mycobacterium tuberculosis detected by polymerase chain reaction using intestinal tissue slice was negative. The metagenomic next-generation sequencing (BGI-Shenzhen) using formalin-fixation and paraffin-embedded intestine samples confirmed Mycobacterium tuberculosis complex (MTBC).(AU)

Spectrum of abdominal tuberculosis presenting as acute surgical emergency: Relevance in 21st century, a case series.

BACKGROUND: Abdominal tuberculosis presenting as acute surgical emergency continues to be a major issue in developing countries including India. Being an indolent disease with varied presentation, there is a need to describe the epidemiology, clinicopathological nature of the disease. Hence, this series was conducted with the aim of describing our institutional experience in the management of abdominal tuberculosis presenting as acute surgical emergency, outlining the epidemiology, management aspects and the analysis of risk factors for poor outcome in our population. METHODS: This was a descriptive series of patients operated for abdominal tuberculosis presenting as acute surgical emergency at a tertiary care hospital in Eastern India from January 2021 to January 2022. All consecutive patients presenting with intestinal obstruction or peritonitis who underwent laparotomy with intra operative and histopathological finding suggestive of tuberculosis were taken for the study. RESULTS: A total of 30 patients with acute abdominal tuberculosis were included in the study. 56.7% of patients were males; the mean age of presentation was 43 years with majority of patients in the younger to middle age groups. Most (80%) patients were from rural areas with limited access to healthcare. One patient had co-infection with HIV. Five patients had diabetes and six patients had hypertension as co-morbidities. 73.3% of patients had primary intestinal tuberculosis. Majority (76.7%) presented with acute intestinal obstruction. All patients had colicky abdominal pain as a consistent feature. 40% of patients were anaemic and 70% had low serum albumin levels. The most common site of affection was Ileo-cecal region (73.3%) with stricture as the pathology. Segmental resection with end to end anastomosis was the most common procedure performed (46.7%). 26.7% of patients had an adverse post operative complication, and 23.3% had surgical site infection (SSI). The mortality rate in our series was 6.7%. Although coexisting SSI, co-morbidities were associated with increased mortality, it was not found to be statistically significant (p = 0.08). 16 patients were lost to follow up. CONCLUSION: Abdominal tuberculosis presenting as acute abdomen continues to challenge surgeons even in the 21st century. Majority in the developing countries present late with varied complications. A high index of clinical suspicion is required for timely diagnosis to reduce the mortality and morbidity of the disease.

A case report of systemic lupus erythematosus and intestinal tuberculosis with lower gastrointestinal bleeding: A treatment approach utilizing parenteral nutrition.

RATIONALE: Limited literatures are available on lower gastrointestinal bleeding in systemic lupus erythematosus (SLE) combined with intestinal tuberculosis. Sharing the treatment experiences of a 26-year-old female patient diagnosed with this complex condition in this report may contribute valuable insights. PATIENT CONCERNS: The patient initially presented with abdominal pain and active gastrointestinal bleeding, leading to admission to the hospital. Over a 2-week period, she experienced persistent bleeding, with daily volumes ranging from 300 mL to 800 mL. DIAGNOSES: Lower gastrointestinal bleeding was diagnosed in this patient with concurrent systemic lupus erythematosus and intestinal tuberculosis. INTERVENTIONS: As her symptoms rapidly progressed, food and water intake had to be completely restricted. The parenteral nutrition was implemented. OUTCOMES: The medical team effectively controlled the bleeding, leading to a notable improvement in the patient's condition. Consequently, she was able to resume oral intake and was discharged from the hospital. LESSONS: This case highlights the significance of using parenteral nutrition in the management of lower gastrointestinal bleeding in patients with concurrent systemic lupus erythematosus and intestinal tuberculosis. Close monitoring and collaborative efforts among healthcare professionals are crucial to achieve successful outcomes in similar cases.

Building a trustworthy AI differential diagnosis application for Crohn's disease and intestinal tuberculosis.

BACKGROUND: Differentiating between Crohn's disease (CD) and intestinal tuberculosis (ITB) with endoscopy is challenging. We aim to perform more accurate endoscopic diagnosis between CD and ITB by building a trustworthy AI differential diagnosis application. METHODS: A total of 1271 electronic health record (EHR) patients who had undergone colonoscopies at Peking Union Medical College Hospital (PUMCH) and were clinically diagnosed with CD (n = 875) or ITB (n = 396) were used in this study. We build a workflow to make diagnoses with EHRs and mine differential diagnosis features; this involves finetuning the pretrained language models, distilling them into a light and efficient TextCNN model, interpreting the neural network and selecting differential attribution features, and then adopting manual feature checking and carrying out debias training. RESULTS: The accuracy of debiased TextCNN on differential diagnosis between CD and ITB is 0.83 (CR F1: 0.87, ITB F1: 0.77), which is the best among the baselines. On the noisy validation set, its accuracy was 0.70 (CR F1: 0.87, ITB: 0.69), which was significantly higher than that of models without debias. We also find that the debiased model more easily mines the diagnostically significant features. The debiased TextCNN unearthed 39 diagnostic features in the form of phrases, 17 of which were key diagnostic features recognized by the guidelines. CONCLUSION: We build a trustworthy AI differential diagnosis application for differentiating between CD and ITB focusing on accuracy, interpretability and robustness. The classifiers perform well, and the features which had statistical significance were in agreement with clinical guidelines.

Case report: a case report and literature analysis on intestinal tuberculosis intestinal perforation complicated by umbilical intestinal fistula and bladder ileal fistula.

BACKGROUND: Intestinal tuberculosis is a chronic and specific infection caused by Mycobacterium tuberculosis invading the intestine. Due to the nonspecific clinical presentation, it is stressed that intestinal perforation complicates umbilical intestinal fistula and bladder ileal fistula is very rare and extremely difficult to be diagnosed. It is significant to identify the disease and take urgent intervene in the early stage. CASE PRESENTATION: An 18-month-old boy patient presented with abdominal pain. Abdominal CT suggested abscess formation in the right lower abdomen and pelvis. The patient underwent resection of necrotic and stenotic intestinal segments with the creation of an ileostomy, cystostomy and vesicoureteral fistula repair for the presence of intestinal perforation complicated by vesicoureteral fistula and umbilical enterocutaneous fistula. Histopathology confirmed the intestinal tuberculosis. The patient was discharged successfully after 11 days post anti-tuberculosis treatment. CONCLUSION: Our case report here is a rare case of umbilical intestinal fistula with bladder ileal fistula secondary to intestinal perforation from intestinal tuberculosis. The purpose of this report is to make the surgical community aware of atypical presentations of intestinal tuberculosis. If our peers encounter the similar situation, they can be prepared for corresponding diagnosis and treatment.

Risk Prediction Model for Crohn's Disease Based on Hematological Indicators.

BACKGROUND: The similarity between Crohn's disease (CD) and non-CD, especially with ulcerative colitis (UC) or intestinal tuberculosis (ITB), makes the diagnostic error rate not low. Therefore, there is an urgent need for an efficient, fast, and simple predictive model that can be applied in clinical practice. The purpose of this study is to establish the risk prediction model for CD based on five routine laboratory tests by logistic-regression algorithm, to construct the early warning model for CD and the corresponding visual nomograph, and to provide an accurate and convenient reference for the risk determination and differential diagnosis of CD, in order to assist clinicians to better manage CD and reduce patient suffering. METHODS: Using a retrospective analysis, a total of 310 cases were collected from 2020 to 2022 at The Sixth Affiliated Hospital, Sun Yat-sen University, who were diagnosed by comprehensive clinical diagnosis, including 100 patients with CD, 50 patients with ulcerative colitis (UC), 110 patients with non-inflammatory bowel disease (non-IBD) diseases (65 cases of intestinal tuberculosis, radioactive enterocolitis 39, and colonic diverticulitis 6), and 50 healthy individuals (NC) in the non-CD group. Risk prediction models were established by measuring ESR, Hb, WBC, ALb, and CH levels in hematology. The models were evaluated and visualized using logistic-regression algorithm. RESULTS: 1) ESR, WBC, and WBC/CH ratios in the CD group were higher than those in the non-CD group, while ALb, Hb, CH, WBC/ESR ratio, and Hb/WBC ratio were lower than those in the non-CD group, and the differences were statistically significant (all p < 0.05). 2) CD occurrence had a strong correlation with the WBC/CH ratio, with the correlation coefficient exceeding 0.4; CD occurrence was correlated with other indicators. 3) A risk prediction model containing age, gender, ESR, ALb, Hb, CH, WBC, WBC/CH, WBC/ESR, and Hb/WBC characteristics was constructed using a logistic-regression algorithm. The sensitivity, specificity, positive predictive value, negative predictive value, and area under the curve of the model were 83.0%, 76.2%, 59.0%, 90.5%, and 0.86, respectively. The model based on the corresponding index also had high diagnostic accuracy (AUC = 0.88) for differentiating CD from ITB. Visual nomograph based on the logistic-regression algorithm was also constructed for clinical application reference. CONCLUSIONS: In this study, a CD risk prediction model was established and visualized by five conventional hema-tological indices: ESR, Hb, WBC, ALb, and CH, in addition to a high diagnostic accuracy for the differential diagnosis of CD and ITB.

Differentiating gastrointestinal tuberculosis and Crohn's disease- a comprehensive review.

Gastrointestinal Tuberculosis (GITB) and Crohn's disease (CD) are both chronic granulomatous diseases with a predilection to involve primarily the terminal ileum. GITB is often considered a disease of the developing world, while CD and inflammatory bowel disease are considered a disease of the developed world. But in recent times, the epidemiology of both diseases has changed. Differentiating GITB from CD is of immense clinical importance as the management of both diseases differs. While GITB needs anti-tubercular therapy (ATT), CD needs immunosuppressive therapy. Misdiagnosis or a delay in diagnosis can lead to catastrophic consequences. Most of the clinical features, endoscopic findings, and imaging features are not pathognomonic for either of these two conditions. The definitive diagnosis of GITB can be clinched only in a fraction of cases with microbiological positivity (acid-fast bacilli, mycobacterial culture, or PCR-based tests). In most cases, the diagnosis is often based on consistent clinical, endoscopic, imaging, and histological findings. Similarly, no single finding can conclusively diagnose CD. Multiparametric-based predictive models incorporating clinical, endoscopy findings, histology, radiology, and serology have been used to differentiate GITB from CD with varied results. However, it is limited by the lack of validation studies for most such models. Many patients, especially in TB endemic regions, are initiated on a trial of ATT to see for an objective response to therapy. Early mucosal response assessed at two months is an objective marker of response to ATT. Prolonged ATT in CD is recognized to have a fibrotic effect. Therefore, early discrimination may be vital in preventing the delay in the diagnosis of CD and avoiding a complicated course.

Visceral Fat Indices: Do They Help Differentiate Crohn's Disease and Intestinal Tuberculosis in Children?

BACKGROUND AND AIMS: Crohn's disease [CD] and intestinal tuberculosis [ITB] are often difficult to differentiate. Mesenteric fat hypertrophy is a feature of CD. We evaluated the utility of fat indices (visceral fat [VF] and subcutaneous fat [SF]) in differentiating CD and ITB in children. METHODS: Symptomatic children diagnosed to have CD or ITB based on recommended criteria were enrolled. Clinical, anthropometric, and laboratory details were noted. Abdominal fat was measured on computed tomography in supine position at the level of L4 vertebrae. VF and SF area was measured separately by a radiologist, blinded to the diagnosis. The sum of VF and SF was taken as total fat [TF]. VF/SF and VF/TF ratios were calculated. RESULTS: Thirty-four (age 14 years [10.8-17.0], 14 boys) children were recruited: 12 had CD [seven boys, age 13.0 years] and 22 had ITB [seven boys, age 14.5 years]. VF area was higher in CD compared to ITB (18.34 cm2 [15.62-40.01] vs 6.48 cm2 [2.65-21.96]; p = 0.012). The SF and TF area was similar in ITB and CD. The ratios of VF/SF (0.82 [0.57-1.5] vs 0.33 [0.16-0.48]; p = 0.004) and VF/TF (0.45 [0.36-0.60] vs 0.25 [0.13-0.32]; p = 0.004) were significantly higher in CD. On comparing CD and ITB in boys and girls separately, the difference was significant for boys but not for girls. A VF/SF ratio of 0.609 predicted CD with a good sensitivity [75%] and specificity [86.4%] [area under the curve 0.795, 95% confidence interval 0.636-0.955; p = 0.005]. CONCLUSION: The VF/SF ratio is a simple, non-invasive, objective parameter to differentiate CD and ITB in children, particularly boys. Larger studies are needed to validate this in girls.

Cecal Perforation Following Intraperitoneal Abscess after Anti-tubercular Therapy: A Case Report.

Abdominal tuberculosis is defined as infection of gastrointestinal tract, peritoneum, abdominal solid organs, and/or abdominal lymphatics constituting approximately 12% of extra-pulmonary tuberculosis cases. Intestinal perforation is an acute presentation of abdominal tuberculosis. Intestinal perforation can occur before or at the beginning of anti-tubercular therapy. It is considered to be a paradoxical reaction if it occurs during or after treatment. Intestinal perforation is uncommon but serious and life-threatening as complication-mortality rate secondary to perforation are estimated to be >30%. We present a case of an 18-year-old female who developed cecal perforation following an intraperitoneal abscess after completion of anti-tubercular therapy for intestinal tuberculosis. She was a known case of intestinal tuberculosis. She had undergone pigtail catheterisation for an intraperitoneal abscess and completed 18 months of anti-tubercular therapy after which she developed cecal perforation. A paradoxical response was observed following the completion of anti-tubercular therapy. Early diagnosis and treatment reduce the complications and mortality rates of cecal perforation due to abdominal tuberculosis. Keywords: case reports; cecum; intestinal perforation; tuberculosis.

Abdominal visceral tuberculosis: a malignancy mimic.

The purpose is to discuss abdominal tuberculosis mimicking malignancy involving the abdominal viscera. TB of the abdominal viscera is common, especially in countries where tuberculosis is endemic and in pockets of non-endemic countries. Diagnosis is challenging as clinical presentations are often non-specific. Tissue sampling may be necessary for definitive diagnosis. Awareness of the early and late disease imaging appearances of abdominal tuberculosis involving the viscera that can mimic malignancy can aid detecting TB, providing a differential diagnosis, assessing extent of spread, guiding biopsy, and evaluating response.