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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 9  |  Issue : 4  |  Page : 448-450

Gastric tuberculosis masquerading as advanced malignancy in a young male


1 Department of Medical Gastroenterology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India
2 Department of Surgical Gastroenterology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India
3 Department of Radiology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India
4 Department of Pathology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India

Date of Submission06-Sep-2020
Date of Decision30-Oct-2020
Date of Acceptance22-Sep-2020
Date of Web Publication15-Dec-2020

Correspondence Address:
Abhijit Acharya
Department of Surgical Gastroenterology, Kalinga Institute of Medical Sciences, Bhubaneswar - 751 024, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmy.ijmy_167_20

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  Abstract 


Gastrointestinal tuberculosis usually involves ileum and cecum in three-fourth of cases. Isolated gastric involvement is uncommon in the absence of pulmonary tuberculosis or immunodeficiency in affected individuals. Here, we describe a case of tuberculosis involving stomach and colon in an immunocompetant young patient who presented to us with dyspeptic symptoms, pain abdomen, and melena. Morphologically, the lesion mimicked as advanced malignancy, but laparoscopic biopsy confirmed the diagnosis. The patient responded well to medical treatment. It should be emphasized that tuberculosis can involve any part of gastrointestinal tract including stomach even in immunocompetent individuals, and it should be kept as differential diagnosis of any chronic inflammatory lesion of stomach, especially in endemic countries as medical treatment is usually sufficient to provide a cure.

Keywords: Gastric tuberculosis, infiltrative mass, malena


How to cite this article:
Praharaj DL, Acharya A, Mohapatra V, Das S, Pradhan P, Mohapatra MK. Gastric tuberculosis masquerading as advanced malignancy in a young male. Int J Mycobacteriol 2020;9:448-50

How to cite this URL:
Praharaj DL, Acharya A, Mohapatra V, Das S, Pradhan P, Mohapatra MK. Gastric tuberculosis masquerading as advanced malignancy in a young male. Int J Mycobacteriol [serial online] 2020 [cited 2021 Jan 24];9:448-50. Available from: https://www.ijmyco.org/text.asp?2020/9/4/448/303441




  Introduction Top


Primary or secondary tuberculosis of stomach is extremely rare constituting about 1% of gastrointestinal tuberculosis.[1] It is because of hostile acidic milieu of stomach along with scarcity of lymphoid tissue in gastric mucosa and the rapid emptying of gastric contents. The involvement of stomach may be either secondary to pulmonary tuberculosis or in individuals with immunodeficiency disorders. Gastric tuberculosis usually involves antrum though involvement of prepyloric region and fundus has also been reported rarely. Presentation in these cases is usually a nonhealing or difficult to treat ulcer. Rarely, hypertrophic lesion causing gastric outlet obstruction has been reported. Here, we report a case of gastric tuberculosis that morphologically mimicked advanced malignancy in immunocompetent young male.


  Case Report Top


A 20-year-old male with no prior comorbidities or addictions presented to outpatient department of Kalinga Institute of Medical Science with dyspeptic symptoms (burning sensation in upper abdomen, bloating, belching, nausea, and early postprandial fullness) and pain abdomen for 1 year. Pain was localized to upper abdomen, dull aching in nature, mild intensity, nonradiating without any specific aggravating and relieving factors. In the past 6 months of illness, he had a significant loss of appetite along with weight loss of 10 kg. In the last 1 month of illness, he developed low-grade fever. There was no history of vomiting or constipation. With these symptoms, he was first shown to local medical practitioner. He was prescribed antacids and proton pump inhibitors. With this, there was no improvement in symptoms. Following this, he underwent gastroduodenoscopy which showed an ulcerative lesion with luminal narrowing in the first part of duodenum with surrounding nodularity over stricture margin. Multiple biopsies were taken from the lesion which was reported as suspicious of malignancy. Contrast-enhanced computed tomography scan of abdomen showed a circumferential thickening at antrum and pylorus of length 3.8 cm and thickness 12 mm with gastric outlet obstruction [Figure 1]a. There were also multiple periportal and paraaortic lymph nodes and infiltration of lesion to hepatic flexure. Following this, he had one episode of melena and he was referred to our center. On examination, he had thin built. He had pallor. However, there was no icterus, clubbing, cyanosis, or lymphadenopathy. On examination of abdomen, it was soft, nondistended. A J-shaped loop with peristalsis was visible in upper abdomen. There was no palpable lump or tenderness. Bowel sounds were present. The rest of systemic examination was normal.
Figure 1: (a) Contrast-enhanced CT scan of abdomen showing antral thickening. (b) Gastroscopy showing the ulceroproliferative leison involving antrum with narrowing of pylorus. (c) Section from mesenteric lymph node reveals caseating necrosis. (d) Section from mesenteric lymph node reveals epitheloid granulomas with Langhans giant cells

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Laboratory investigations showed hemoglobin of 8.2 g/dL, total leukocyte count of 8.1 × 109/L, and platelet count 234 × 109/L. Erythrocyte sedimentation rate was elevated 60 mm/h. Liver function and renal function tests were within normal limits. Chest X-ray was normal. Gastrodudenoscopy was done. It showed food residues in fundus of stomach. A ulceronodular proliferative involving antrum and prepyloric region was also seen [Figure 1]b. The lesion was encroaching upon pylorus causing significant narrowing of pylorus beyond which endoscope could not be negotiated. Based on the clinical examination and investigation, possibility of carcinoma of stomach was considered. Other entities such as gastric lymphoma and tuberculosis were also thought of. Multiple deep biopsies were taken from the lesion. Serum carcinoembryonic antigen and CA19-9 were within normal limits. The microscopic examination of biopsy specimen showed focal surface ulceration and intraepithelial neutrophilic infiltration. Lamina propria showed moderate to dense mixed inflammatory cell infiltration, cryptitis along with regenerative atypia of glands. There was no evidence of granuloma, dysplasia, or malignancy. It was reported as chronic active inflammation. Repeat multiple deep biopsies were taken from the lesion. It was also inconclusive. Finally, to confirm diagnosis, he underwent exploratory laparotomy. It revealed a hard growth of size 5 cm × 7 cm involving pylorus and the first part of the duodenum. Matted Lymphnodes along the common hepatic artery,Superior mesenteric artery, Ileocolic and middle colic vessels and subpyloric region. Examination of these lymph nodes revealed caseating material. The mass also infiltrated into medial one-third and lateral two-third of transverse colon. Retrocolic gastrojejunostomy and primary repair of colon were done. Subpyloric lymph nodes and lymph nodes along spinal muscular atrophy were sent for histopathological examination. The section from mesenteric lymph node revealed multiple coalescent caseating granuloma [Figure 1]c and epitheloid granulomas with Langhans giant cells [Figure 1]d.

Section from subpyloric lymph node also showed similar findings. Ziehl–Neelsen (ZN) stain was negative in both specimens. Mantoux test was done which was positive. He was started on antitubercular treatment (ATT). Gradually, he became afebrile, dyspeptic symptoms and pain abdomen subsided. His appetite improved, and he gained weight of about 6 kg in the next 2 months.


  Discussion Top


Pulmonary tuberculosis is quite common in developing nations with poor hygiene, low socioeconomic status, and poor access to health-care facilities.[2] Since the late 20th century, incidence and prevalence of both pulmonary and extrapulmonary tuberculosis have increased owing to the increased prevalence of human immunodeficiency virus infection and travel to endemic countries. Other common risk factors for acquiring the infection include ethanol abuse, intravenous drug abuse, older age, and diabetes mellitus.[3]

Tuberculosis can involve any part of gastrointestinal tract. However, ileum and cecum are involved in 75% of cases.[4] Both primary and secondary involvement of stomach and duodenum are rare (1% each). The involvement of stomach and duodenum is uncommon in the absence of immunodeficiency or pulmonary tuberculosis.[1] In various autopsy series, the incidence of gastric TB is only 0.03%–0.21% without diagnosed pulmonary TB and 0.3%–2.3% with known pulmonary disease.[5],[6] In our case, the patient had neither any immunodeficiency nor pulmonary disease.

Isolated gastric tuberculosis is uncommon due to hostile acidic environment of stomach and paucity of lymphoid tissue. Patients may develop bovine tuberculosis by consuming unpasteurized milk.[6] In case like ours, lymph nodal involvement is usually extensive and route of spread is probably from celiac nodes. Other possible mechanism may include hematogeneous spread, direct mucosal invasion, or rarely superinfection of preexisting ulcer or malignancy.[1]

Coming to clinical presentation, most common symptoms are abdominal pain. Other common symptoms include dyspepsia, fever, loss of appetite, and weight loss.[7],[8] All these symptoms were seen in our patient. Our patient had melena which is extremely uncommon. Although there is increased vascularity is common in these lesions, obliterative vasculitis characteristics of tuberculosis probably result in lower incidence of bleeding manifestations.

Common differential diagnosis that should be considered includes adenocarcinoma and gastric lymphoma.[6] Endoscopy plays an important role in diagnosis. Nodular proliferative lesions in antrum encroaching on pylorus causing its narrowing are common as is the ulceration of these lesions.[1] Fistulizing lesions may also be seen which are not specific and may also be seen in Crohn's disease.[9]

Definitive diagnosis relies upon histopathologic examination of involved tissue along with ZN staining and culture. Caseating granuloma in histopathologic examination is specific feature of tuberculosis though sometimes it may be found in Crohn's disease.[9] Positive ZN staining and culture also confirms diagnosis. However, diagnostic yield of endoscopic specimen is extremely poor due to scanty tissue material obtained by this method. In our case, endoscopic biopsy was done thrice and was inconclusive. For this reason, exploratory laparotomy had to be done to confirm diagnosis. In exploratory laparotomy, involvement of colon was also confirmed. In a series of fifty patients with colonic tuberculosis, colonic biopsy specimen showed features of tuberculosis-like caseation, positive ZN staining, and culture was positive in only 18% patients.[10] Polymerase chain reaction of biopsy specimen can be helpful in diagnosis. It has a specificity of 100% but sensitivity of only 27%. It has also other advantage that it provides a rapid diagnosis in 48 h.[11] Regarding our case, diagnosis was based on the finding of caseating granuloma, Langhans giant cells in laparotomy specimen, positive Mantoux test, and excellent response to ATT.

To conclude, we reported a rare and interesting presentation of tuberculosis involving stomach and colon resembling advanced malignancy in a young immunocompetent patient. Although uncommon, it should be reemphasized that tuberculosis can involve any part of gastrointestinal tract including stomach. It should be always kept as a differential diagnosis of chronic infiltrative, proliferative, and nodular lesion of stomach, especially in endemic countries as the condition can be managed medically, and response to treatment is usually excellent.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Amarapurkar DN, Patel ND, Amarapurkar AD. Primary gastric tuberculosis–report of 5 cases. BMC Gastroenterol 2003;3:6.  Back to cited text no. 1
    
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Sáenz EV, Magro PM, Fernández JF, Ovalle MV. Colonic tuberculosis. Dig Dis Sci 2002;47:2045-8.  Back to cited text no. 2
    
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Uygur-Bayramicli O, Dabak G, Dabak R. A clinical dilemma: Abdominal tuberculosis. World J Gastroenterol 2003;9:1098-101.  Back to cited text no. 3
    
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Bhansali SK. Abdominal tuberculosis. Experiences with 300 cases. Am J Gastroenterol 1977;67:324-37.  Back to cited text no. 4
    
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Bandyopadhyay SK, Bandyopadhyay R, Chatterjee U. Isolated gastric tuberculosis presenting as haematemesis. J Postgrad Med 2002;48:72-3.  Back to cited text no. 5
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6.
Lin OS, Wu SS, Yeh KT, Soon MS. Isolated gastric tuberculosis of the cardia. J Gastroenterol Hepatol 1999;14:258-61.  Back to cited text no. 6
    
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Mukewar S, Mukewar S, Ravi R, Prasad A, S Dua K. Colon tuberculosis: Endoscopic features and prospective endoscopic follow-up after anti-tuberculosis treatment. Clin Transl Gastroenterol 2012;3:e24.  Back to cited text no. 7
    
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Makharia GK, Srivastava S, Das P, Goswami P, Singh U, Tripathi M, et al. Clinical, endoscopic, and histological differentiations between Crohn's disease and intestinal tuberculosis. Am J Gastroenterol 2010;105:642-51.  Back to cited text no. 8
    
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Settbas Y, Alper M, Akcan Y, Gurbuz Y, Oksuz S. Massive gastrointestinal tuberculosis in a young patient without immunosuppression. World J Gastroenterol 2003;9:2382-4.  Back to cited text no. 9
    
10.
Shah S, Thomas V, Mathan M, Chacko A, Chandy G, Ramakrishna BS, et al. Colonoscopic study of 50 patients with colonic tuberculosis. Gut 1992;33:347-51.  Back to cited text no. 10
    
11.
Lau CF, Wong AM, Yee KS, Loo CK, Hui PK, Lam KM. A case of colonic tuberculosis mimicking Crohn's disease. Hong Kong Med J 1998;4:63-6.  Back to cited text no. 11
    


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