title: Intestinal tuberculosis in a child living in a country with a low incidence of tuberculosis: a case report.
abstract: BACKGROUND
  Relatively common in adults, intestinal tuberculosis is considered rare in children and adolescents. The protean manifestations of intestinal tuberculosis mean that the diagnosis is often delayed (sometimes even for years), thus leading to increased mortality and unnecessary surgery. The main diagnostic dilemma is to differentiate intestinal tuberculosis and Crohn's disease because a misdiagnosis can have dramatic consequences.
  
  
  METHODS
  A 13-year-old Caucasian, Italian female adolescent attended the Emergency Department complaining of abdominal pain, a fever of up to 38 °C, night sweats, diarrhea with blood in stool, and a weight loss of about three kilograms over the previous two months. Physical examination revealed a marked skin pallor and considerable abdominal distension with relevant discomfort in all the abdominal quadrant. Laboratory tests revealed a decreased white blood cell count with anemia and increased C-reactive protein levels. The Mantoux tuberculin skin test was negative. A chest X-ray and an abdominal ultrasonography did not reveal any significant findings. The patient underwent colonoscopy that showed diffuse mucosal congestion and significant blood loss, and laparatomy showed small bowel and colon loops with a whitish appearance. A biopsy of the ileal mucosa revealed inflammation with noncaseating granulomas possibly due to bacterial infection. Given the suspicion of an opportunistic bacterial infection in a child with chronic inflammatory bowel disease (possibly Crohn's disease), treatment with a third-generation cephalosporin was started. However, the abdominal pain, fever and poor general condition persisted and so, after 11 days, the patient underwent total body computed tomography and magnetic resonance imaging of the brain. On the basis of the radiological findings, miliary tuberculosis was suspected and bronchoscopy was performed and resulted positive for Mycobacterium tuberculosis. Miliary tuberculosis was confirmed and an effective treatment with four drugs was started.
  
  
  CONCLUSIONS
  This case shows that the manifestations of intestinal tuberculosis can be very difficult to diagnose and mimic those of Chron's disease. Total body computed tomography and laparotomy with an intestinal biopsy for the detection of Mycobacterium tuberculosis are the means of avoid the risks of a misdiagnosis in children with unexplained chronic abdominal problems.
authors.forename: Piera
authors.initials: P
authors.lastname: Dones
authors.forename: Maria
authors.initials: M
authors.lastname: Di Gangi
authors.forename: Maria Concetta
authors.initials: MC
authors.lastname: Failla
authors.forename: Selene
authors.initials: S
authors.lastname: Genova
authors.forename: Caterina
authors.initials: C
authors.lastname: Giannitto
authors.forename: Giovanni
authors.initials: G
authors.lastname: Corsello
authors.forename: Nicola
authors.initials: N
authors.lastname: Principi
authors.affiliation: Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, University of Milan, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Commenda 9, 20122 Milano, Italy. susanna.esposito@unimi.it.
authors.forename: Susanna
authors.initials: S
authors.lastname: Esposito
mesh_terms: D000293:Adolescent; D000995:Antitubercular Agents / Q000627:therapeutic use; D001706:Biopsy; D003424:Crohn Disease / Q000175:diagnosis; D003937:Diagnosis, Differential; D003951:Diagnostic Errors; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D007077:Ileal Diseases / Q000175:diagnosis* / Q000188:drug therapy / Q000453:epidemiology / Q000382:microbiology; D015994:Incidence; D007558:Italy / Q000453:epidemiology; D009169:Mycobacterium tuberculosis / Q000302:isolation & purification; D011237:Predictive Value of Tests; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D014385:Tuberculosis, Gastrointestinal / Q000175:diagnosis* / Q000188:drug therapy / Q000453:epidemiology / Q000382:microbiology; D014391:Tuberculosis, Miliary / Q000175:diagnosis* / Q000188:drug therapy / Q000453:epidemiology / Q000382:microbiology; D051598:Whole Body Imaging / Q000379:methods
chemical_list: D000995:Antitubercular Agents