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.
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
5 years ago
really important key messages. I wonder if you might ask the IBD WG who may consider a national audit?
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
5 years 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.
Hello Dr. Findlay. A very interesting case and an important lesson for us all! A couple of questions:
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.
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!
really important key messages. I wonder if you might ask the IBD WG who may consider a national audit?
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.
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.