Brucellosis,a diagnostic dilemma,presenting atypically in a child with terminal ileitis:A case report

BACKGROUND Brucellosis is endemic in India with seropositivity rates as high as 10%in children in the eastern states,yet the disease is not on the radar when a differential diagnosis of pyrexia of unknown origin(PUO)is being considered,especially in children in urban set-up.This may be because of the non-specific multitude of systemic symptoms seen in this disease and the lack of awareness among clinicians.CASE SUMMARY We present a case of a 13-year-old boy,who came with a history of undulating fever for the past three and a half months,loss of appetite,and abdominal pain.The child had visited several pediatricians and was even admitted to a tertiary care hospital for PUO evaluation,but to no avail.He presented to us after three and half months of suffering and weight loss of more than 10%of body weight.His ultrasonography revealed thickening of the terminal ileum.His blood culture grew Brucella melitensis.A diagnosis of Brucellosis with terminal ileitis was made.Brucella serology by enzyme-linked immunoassay(ELISA)was positive for both IgG and IgM.He was treated with doxycycline and Rifampicin along with syrup multivitamin and zinc,for 6 wk.There was remarkable improvement with gain in 4 kg body weight within 2 mo of completing treatment.History revealed consumption of unpasteurized milk and contact with cattle.CONCLUSION Clinical suspicion,detailed history,appropriate laboratory investigations are the three pillars for diagnosing Brucellosis in patients presenting with vague symptoms.

Tuberculosis terminal ileitis:A forgotten entity mimicking Crohn's disease

Intestinal tuberculosis(TB) is an uncommon lesion for which differential diagnosis can be difficult. We present a case of a 53-year-old male and a systematic review of the literature, from clinical symptoms to differential diagnosis, unusual complications and therapy. The patient was admitted to the hospital with signs of acute abdomen as a result of a perforated terminal ileitis. Based on the skip lesions of the terminal ileum and cecum, Crohn's disease(CD) was clinically suspected. An emergency laparotomy and right colectomy with terminal ileum resection was performed and systematic antibiotherapy was prescribed. The patient's status deteriorated and he died 4 d after the surgical intervention. At the autopsy, TB ileotyphlitis was discovered. The clinical criteria of the differential diagnosis between intestinal TB and CD are not very well established. Despite the large amount of published articles on this subject, only 50 papers present new data regarding intestinal TB. Based on these studies and our experience, we present an update focused on the differential diagnosis and therapy of intestinal TB. We highlight the importance of considering intestinal TB as a differential diagnosis for inflammatory bowel disease. Despite the modern techniques of diagnosis and therapy, the fulminant evolution of TB can still lead to a patient's death.

Role of colonoscopy in diagnosis of capecitabine associated ileitis:Two case reports

BACKGROUND Capecitabine is considered a first line agent in adjuvant therapy for breast and colorectal cancer. However,cases of severe diarrhea have been reported with increasing frequency in recent years. When diarrhea is severe and prolonged,capecitabine associated ileitis should be considered as a possible etiology.CASE SUMMARY Herein,we present two cases of capecitabine ileitis,specifically involving the terminal ileum and ascending colon. We will demonstrate the disease course and treatment modalities applied to alleviate this condition,as well as discuss the merits of using colonoscopy to aid in diagnosis.CONCLUSION Ultimately our cases demonstrate that symptomatic management with traditional anti-diarrheal medications is largely ineffective. Prompt recognition and discontinuation of capecitabine is an imperative step in proper management of this condition and colonoscopy with biopsy can be helpful when the diagnosis is unclear.

Diversion colitis and pouchitis: A mini-review

Diversion colitis is characterized by inflammation of the mucosa in the defunctioned segment of the colon after colostomy or ileostomy. Similar to diversion colitis, diversion pouchitis is an inflammatory disorder occurring in the ileal pouch, resulting from the exclusion of the fecal stream and a subsequent lack of nutrients from luminal bacteria. Although the vast majority of patients with surgically-diverted gastrointestinal tracts remain asymptomatic, it has been reported that diversion colitis and pouchitis might occur in almost all patients with diversion. Surgical closure of the stoma, with reestablishment of gut continuity, is the only curative intervention available for patients with diversion disease. Pharmacologic treatments using short-chain fatty acids, mesalamine, or corticosteroids are reportedly effective for those who are not candidates for surgical reestablishment; however, there are no established assessment criteria for determining the severity of diversion colitis, and no management strategies to date. Therefore, in this mini-review, we summarize and review various recently-reported treatments for diversion disease. We are hopeful that the information summarized here will assist physicians who treat patients with diversion colitis and pouchitis, leading to better case management.

Early surgery in Crohn's disease a benefit in selected cases

AIM: To compare the outcomes of a cohort of Crohn's disease(CD) patients undergoing early surgery(ES) to those undergoing initial medical therapy(IMT).METHODS: We performed a review of a prospective database CD patients managed at a single tertiary institution. Inclusion criteria were all patients with ileal or ileocolonic CD between 1995-2014. Patients with incomplete data, isolated colonic or perianal CD were excluded. Primary endpoints included the need for, and time to subsequent surgery. Secondary endpoints included the number and duration of hospital admissions, and medical therapy. RESULTS: Forty-two patients underwent ES and 115 underwent IMT. The operative intervention rate at 5 years in the ES group was 14.2% vs IMT 31.3%(HR = 0.41, 95%CI: 0.23-0.72, P = 0.041). The ES group had fewer hospital admissions per patient [median 1 vs 3(P = 0.012)] and fewer patients required anti-TNF therapy than IMT(33.3% vs 57%, P = 0.003). A subgroup analysis of 62 IMT patients who had undergone surgery were compared to ES patients, and showed similar 5 year(from index surgery) re-operation rates 16.1% vs 14.3%. In this subset, a significant difference was still found in median number of hospital admissions favouring ES, 1 vs 2(P = 0.002).CONCLUSION: Our data supports other recent studies suggesting that patients with ileocolonic CD may have a more benign disease course if undergoing early surgical intervention, with fewer admissions to hospital and atrend to reduced overall operation rates.