Gastrointestinal: Tuberculosis with anal fistula and multisegmental damage in the digestive tract involving the stomach, ileocecum, and colon

A 52-year-old man from Lincang, China, was admitted to our hospital because of abdominal pain and perianal disease. The patient suffered abdominal pain for 30 years. Four years ago, abdominal distension, perianal pain and ulcers with suspicious fecal fluid were observed. One of the fistulas was located on the left side of the anus, and the other was located to the right of the anus (Fig. 1a). The fecal occult blood test was positive, and the ESR was higher than the reference range. The EB-DNA, HCMV-DNA, anti-neutrophil cytoplasmic antibody, antinuclear antibody, tumor marker, and rheumatoid factor results were normal. It is noteworthy that the T-SPOT.TB test was positive. MRI suggested perianal soft tissue swelling with fistula formation (Fig. 1b). The multiple stages of damage in the digestive tract were found by endoscopic (Fig. 1c–e). CT showed an enhanced and thickened intestinal wall, the narrowed intestinal (Fig. 1d). (Fig. 1k,l). For this patient, the ulcer in the ascending colon exhibited a ring shape, which is a characteristic of ITB. The pathological results showed a high degree of granulomatous inflammation in both inguinal lymph nodes and skin lesions (Fig. 1f). The diameter of the granuloma was more than 0.4 mm, which were significantly larger than those small granulomas commonly seen in CD, and there was no definite pathological evidence of CD found in the pathological section. Meanwhile, the mycobacterium tuberculosis DNA fragments were detected in the tissues. The incidence of TB in China is still high, and the possibility of TB must be considered. Diagnostic anti-tuberculosis therapy (ATT) was established for patient. Six months and 18 months after the first visit, the patient's symptoms improved significantly, the two fistulas around the anus had healed (Fig. 1g), CRP and ESR returned to normal, MR showed that the peri-anall swelling and fistular tract had healed (Fig. 1h) Upper endoscopy revealed that the ulcers were at the scar stage (Fig. 1i). CT showed that the intestinal wall was thinner and has no further wall enhancement (Fig. 1j). Repeat colonoscopy confirmed that the large ulceration at the ileo-caecal valve had completely healed (Fig. 1k). In conclusion, as typical manifestations of CD, multistage digestive tract damage and perianal lesions are extremely rare in ITB. Tuberculosis should be considered for patients with multistage digestive tract damage and perianal lesions in areas with a high incidence of tuberculosis.