The challenge in diagnosing Crohn ’ s disease in TB endemic region – A case report with review of literature

The challenge in diagnosing the regional ileitis existed since 1932 when Crohn, Ginzberg and Oppenheimer first reported their case1. Many Indian researchers accepted that during last decade there was considerable increase in the incidence of Crohn’s disease (CD) in India which poses great challenge in diagnosing it, due to high prevalence of tuberculosis2. In this perspective we report a case which made a stimulus to review the literature. The purpose of this manuscript is 1. To document the occurrence of an additional case of CD in India, 2. To report that CD can rarely present as post operative enterocutaneous fistula, 3. To discuss the criteria in diagnosing the CD in Tuberculosis (TB) endemic area. Correspondence to: Dr. S. Suban Mohammed Gouse, Dept. of Pathology, Assistant Professor, Head of the Pathology Division, Department of Pathology and Microbiology, Ibn Sina National College for Medical Studies, Kingdom of Saudi Arabia. Email: dr.subanmd@gmail.com 1. Dr. S. Suban Mohammed Gouse, Dept. of Pathology, Assistant Professor, Head of the Pathology Division, Department of Pathology and Microbiology, Ibn Sina National College for Medical Studies, Kingdom of Saudi Arabia 2. Dr. Hemalatha Ganapathy, Dept. of Pathology, Professor* 3. Dr. Bhuvanamha Devi, Dept. of Pathology, Assistant Professor* 4. Dr. G. Bheema Rao, Dept. of Pathology, Associate Professor* 5. Dr. B.O. Parijatham, Dept. of Pathology, Professor* Department of Pathology, Shree Balaji Medical College and Hospital, 7, Works Road, Chrompet, Chennai – 600044 #Head of the Pathology Division, Department of Pathology and Microbiology, Ibn Sina National College for Medical Studies, Kingdom of Saudi Arabia Case report Clinical Details: A 35-year-old male presented with complaint of faecopurulent discharge from the right iliac fossa and below the umbilicus. Ten months back, he underwent an emergency laporatomy for acute abdomen at outside hospital, image studies and peroperative findings were not provided. The patient started to have faecopurulent discharge, few weeks of the surgery. Further he revealed that for past 2 years he gets on and off chronic abdominal pain, diarrhoea and vomiting. Fistulography done, confirmed it as enterocutaneous fistula. Patient underwent fistulectomy, ileal resection and end to end anastomosis. Pathological Investigations: The resected ileum showed stricture, proximal dilated part and creeping fat (Fig 1). The histograph showed distortion of mucosal architecture along with normal mucosa, Fissures & ulcers, non caseasting granuloma in the submucous & muscularis layer and transmural inflammation (Fig 2). The section stained for acid fast bacilli showed negativity. The rest of the laboratory investigations were unremarkable. Diagnosis & Management: With these above findings, we came to the diagnosis of Crohn’s Disease. Patient was treated with antibiotics for postoperative stage, prednisone and sulfasalazine (as per the limited resource management guidelines) with every one month follow-up. Discussion In India, CD was considered nonexistent until 1986 3, even though it’s existence was debated over past four decades4. Previous studies from India (1976 – 1998) showed CD was rare5, but the recent multi centric studies and case reports shows that there is Bangladesh Journal of Medical Science Vol. 17 No. 04 October’18. Page : 688-690 DOI: http://dx.doi.org/10.3329/bjms.v17i4.38340


Case report
Clinical Details: A 35-year-old male presented with complaint of faecopurulent discharge from the right iliac fossa and below the umbilicus.Ten months back, he underwent an emergency laporatomy for acute abdomen at outside hospital, image studies and peroperative findings were not provided.The patient started to have faecopurulent discharge, few weeks of the surgery.Further he revealed that for past 2 years he gets on and off chronic abdominal pain, diarrhoea and vomiting.

Discussion
In India, CD was considered nonexistent until 1986 3 , even though it's existence was debated over past four decades 4 .Previous studies from India (1976 -1998) showed CD was rare 5 , but the recent multi centric studies and case reports shows that there is a progressive increase in the incidence of CD 6 .The reason for increase in the incidence of CD is well correlated with increased industrialization, improved sanitation and hygiene status of the country which favours the 'Hygiene Hypothesis' of CD 7,8 .
The age incidence of CD in India is less than 40 years with male predominance in contrast to female predominance in the western literature.The common symptoms are diarrhoea, abdominal pain and weight loss for longer duration.Entero cutaneous fistula was uncommon in Indian literature 6 .Patients present with above said complaints, undergoes endoscopic biopsy and have Granulomatous lesion without caseation necrosis are huge diagnostic challenge for the pathologists, physicians and surgeons because they have to differentiate between gastrointestinal tuberculosis (GITB) and CD (Table 1) 4,9,10 .It has become important because both have different outcome and treatment.GITB is entirely curable and steroid is not indicated where as CD require long term treatment, follow up and steroid is given 9 .
To overcome this challenge WHO devised the objective diagnostic criteria based on integrated approach to minimise the confusion and misdiagnosis.It consists of 1. Discontinuous or segmental lesions 2. Cobble stoning or longitudinal ulcers 3. Transmural inflammation or strictures 4. Non Caseasting granuloma 5. Fissures or Fistula 6. Peri anal disorders.A definite diagnosis was made when either 1+2+3 were present with any of the 4/5/6 or when 4 was present with any 1/2/3 6 .
Management consensus of IBD devised the specific criteria for Asia Pacific region which says 4 -8 weeks of ATT should be given and response to ATT taken into count.Majority of authors agree as benefit of treatment should be given to the curable condition i.e. tuberculosis 6,9,11 .
Serological investigations for Anti Saccharomyces cerevisiae Anti body (ASCA) was not useful because it does not differentiate GITB and CD 12 .PCR DNA assay for mycobacterium tuberculosis with specific primers showed good sensitivity and specificity 13 .
Das et al specifically says that CD in India is similar to other regions except for delay in diagnosis which leads to further complication 6 .This is due to under diagnosis (assuming CD is rare but the literature evidence showed otherwise) and misdiagnosis (in the favour of tuberculosis).
In conclusion, by integrating the simple clinical parameters such as absence of fever, hematochezia, diarrhoea and longer duration of symptoms with classic radiological, endoscopic and pathological findings will help to arrive at the definite diagnosis of CD 2,9 .But in case of diagnostic confusion it will be more appropriate to start ATT and analysing the response to the therapy.In future the most promising molecular methodologies may help to avoid unnecessary ATT given to the unfortunate CD patients.
Fistulography done, confirmed it as enterocutaneous fistula.Patient underwent fistulectomy, ileal resection and end to end anastomosis.Pathological Investigations: The resected ileum showed stricture, proximal dilated part and creeping fat (Fig 1).The histograph showed distortion of mucosal architecture along with normal mucosa, Fissures & ulcers, non caseasting granuloma in the submucous & muscularis layer and transmural inflammation (Fig 2).The section stained for acid fast bacilli showed negativity.The rest of the laboratory investigations were unremarkable.Diagnosis & Management: With these above findings, we came to the diagnosis of Crohn's Disease.Patient was treated with antibiotics for postoperative stage, prednisone and sulfasalazine (as per the limited resource management guidelines) with every one month follow-up.