Beyond Ulcerative Colitis: An Inflammatory Enigma

Abstract

Inflammatory bowel disease (IBD), which primarily includes ulcerative colitis, Crohn’s disease, and indeterminate colitis, comprises a group of chronic, relapsing, immune-mediated disorders characterized by gastrointestinal tract inflammation and a multifactorial etiology. Methods:  We report the case of a 49-year-old male with a history of ulcerative colitis (Mayo III pancolitis) receiving treatment with infliximab and azathioprine. After achieving clinical remission, he developed fever of unknown origin, weight loss, and obstructive gastrointestinal symptoms. Laboratory tests, acute-phase reactants, colonoscopies, computed tomography, magnetic resonance enterography, and a GeneXpert molecular assay were performed. Results:  GeneXpert confirmed the presence of Mycobacterium tuberculosis. Despite initiation of anti-tuberculosis therapy, the patient progressed to acute intestinal obstruction. A right hemicolectomy was performed, and histopathological examination revealed granulomatous inflammation with caseous necrosis and multinucleated giant cells involving the ileocecal region and regional lymph nodes, confirming superimposed intestinal tuberculosis. Following surgery and completion of anti-tuberculosis treatment, the patient achieved satisfactory nutritional recovery and successful intestinal continuity restoration while maintaining control of his IBD with biologic therapy. Conclusion: This case highlights the need for strict screening and continuous surveillance for opportunistic infections in patients with IBD receiving biologic therapy. Intestinal tuberculosis may mimic stenosing progression of IBD, requiring a multidisciplinary approach to ensure timely diagnosis and prevent potentially fatal outcomes