Case Study: Coexistence of tuberculosis and adenocarcinoma in the colon

Summary

The occurrence of tuberculosis with adenocarcinoma is rare, but it has been observed by many. This association has been debated extensively in the literature [1-3]. Here I present a case with similar association, where extended right hemicolectomy was performed, and the diagnosis came only after histopathology. Colonoscopy, colonoscopic biopsy, imaging and other preliminary investigations failed to pick up the pathology because of the inherent complex pathogenesis. Therefore, the concurrent existence of tuberculosis and colon cancer should be kept in mind while dealing with certain clinical history!

Background

Tuberculosis has a predilection for the small intestine, especially the ileo-cecal junction, so patients presenting with features of stricture generally do undergo the appropriate investigations. In cases of severe fibrosis and narrowing of the lumen, it is difficult to get the exact diagnosis preoperatively. In the absence of regional lymphadenopathy and appropriate microbiological studies, tuberculosis might just remain a strong clinical suspicion. Further, the situation is very complicated if well-differentiated carcinoma develops in the narrowed lumen. It is impossible to diagnose if deeper stroma is absent in the biopsy, which is quite likely in cases of stricture. In such cases, we have to keep the possibility of the coexistence of tuberculosis and adenocarcinoma in the ascending colon.

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Case Presentation

A 42-year-old female presented with low-grade fever, loss of appetite, indigestion, constipation and chronic ill health, especially weakness and pallor for last 18 months. There was no lymphadenopathy clinically.

Investigations

  1. Routine hemogram revealed lymphocytic leucocytosis, high ESR and microcytic hypochromic anemia.
  2. Monteux test: negative
  3. Chest X-ray: normal
  4. Stool and urine studies: positive for occult blood in stool
  5. Abdominal ultrasonography: insignificant retro-peritoneal lymphadenopathy
  6. Colonoscopy: multiple ulcers and strictures in the ascending colon
  7. Colon biopsy: severe acute-on-chronic inflammation, no granuloma, no malignancy

Differential Diagnosis

  1. Crohn’s disease
  2. Ulcerative colitis
  3. Tuberculosis
  4. Colonic polyps
  5. Ameobic colitis
  6. Malignancy

Treatment

Extended right hemicolectomy followed by antitubercular drugs and additional work-up for residual malignant lesion(s) and chemotherapy by a medical oncologist.

Outcome and Follow-Up

The patient is currently discharged from the hospital with an uneventful post-op recovery.

Discussion

As the colonic mucosa is covered by acute inflammatory cells, and the wall is fibrosed, it is unlikely to pick up granulomas in colonoscopic biopsies, and thus the diagnosis of tuberculosis could not be made pre-operatively in this case. Eleven lymph nodes that were less than 1 cm in diameter revealed epithelioid cell granulomas, thus confirming the possibility of tuberculosis. Histology also revealed granulomas in all layers from different areas of the colon. The narrowest area, which probably was not sampled while performing colonoscopic biopsy, was nothing but a well differentiated adenocarcinoma infiltrating up to the serosa. One of the lymph nodes contained tubercular granuloma, as well as metastatic adenocarcinoma, which is a rare finding (See Figure 1). Sometimes tuberculosis might be diagnosed preoperatively, but a second surgery is required, as anti-tubercular drugs do not cure the second pathology (adenocarcinoma) [1]. The differential diagnoses were excluded after gross and microscopic examination of the specimen. Since a preoperative diagnosis is usually not possible, as other observers suggest [2, 3], we should consider a case of right iliac fossa lump or vague lump with clinical evidence of tuberculosis as a complex one. If the patient fails to respond to anti-tubercular drugs then he or she must be investigated for co-existing malignancy.

Learning Points/Take Home Messages

Clinical tuberculosis with abdomino-pelvic lump: suspect co-existing malignancy

About The Author

Dr-Swapan-Samanta-64x80
Dr. Samanta, MBBS, MD is currently a consultant at Suraksha diagnostic PVT. LTD. Kolkata, India for histopath, cytopath and hematology. His other interests are: oncopathology, bone marrow and neuropathology.

 

References (click to show/hide)

  1. Issacs P, Zissis M. Colonic tuberculosis and adenocarcinoma: An unusual presentation. Eur J Gastroenterol hepatol. 1997; 9:913–15
  2. Kaushik R, Sharma R, Attri AK. Coexisting tuberculosis and carcinoma of the colon: A report of two cases and a review of the literature. Trop Gastroenterol. 2003; 24:137–39.
  3. Chakravartty S, Chattopadhyay G, Ray D, Choudhury C R, Mandal S. Concomitant Tuberculosis and Carcinoma Colon: Coincidence or Causal Nexus? Saudi J Gastroenterol. 2010; 16: 292–94.


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