Abstract Tuberculosis is a major global health concern, particularly among immigrants from endemic regions. Extrapulmonary involvement specifically poses diagnostic challenges. A 32-year-old Nepalese man, living in Portugal for nine years, was hospitalized with hematochezia and hemodynamic instability. Imaging revealed generalized lymphadenopathy involving the axillary, mediastinal, hilar, mesenteric, hepatic hilum, celiac trunk, and iliac regions. Colonoscopy showed a circumferential stenosis of the distal transverse colon with extensive areas of inflamed and ulcerated mucosa; biopsy demonstrated a poorly formed non-necrotizing epithelioid granuloma and molecular testing identified Mycobacterium tuberculosis complex without rifampicin or isoniazid resistance. Axillary lymph node excisional biopsy revealed confluent epithelioid granulomas with Langerhans-type giant cells and focal necrosis; no microorganisms were identified using histochemical stains. Interestingly, stool examination also identified Taenia spp., for which treatment with praziquantel was initiated. The findings supported the diagnosis of probable intestinal and lymph node tuberculosis. First-line antituberculous therapy with pyridoxine supplementation was initiated and the patient was referred to our outpatient tuberculosis clinic. Culture from the colon biopsy later confirmed the presence of Mycobacterium tuberculosis sensitive to all first-line drugs, thus confirming the diagnosis of intestinal tuberculosis. After 68 days of treatment, the patient developed a generalized pruritic vesicular rash including scalp, face, palms, and soles, with asthenia, myalgia and fever. His children had been diagnosed with varicella three weeks earlier. Dermatology consult confirmed varicella, and antiviral therapy was started. Shortly thereafter, he developed worsening dyspnea. Chest imaging revealed bilateral micronodularity with a miliary pattern, consistent with severe varicella pneumonia. Despite dyspnea and need for intravenous antiviral therapy, he remained non-hypoxemic. The hepatocellular and cholestatic changes observed during this episode led to a temporary suspension of antituberculous therapy. These were later attributed to antiviral treatment, as they did not worsen after the patient resumed isoniazid, rifampicin, and pyridoxine. The patient completed one year of treatment with clinical recovery. Follow-up colonoscopy is planned to exclude concomitant inflammatory bowel disease. We report the case of a patient who developed intestinal and lymph node tuberculosis, whose management was complicated by taeniasis and severe varicella-zoster infection. It illustrates the diagnostic challenges of extrapulmonary tuberculosis in non-endemic settings, particularly intestinal involvement, which can resemble inflammatory bowel disease and must be distinguished from parasitic infections. It also emphasizes the importance of vigilant monitoring during antituberculous therapy, as intercurrent infections and drug toxicity can complicate management. Early recognition and appropriate treatment adjustments enabled a successful therapeutic regimen with favorable clinical outcome. This abstract is funded by: None
Pimentel et al. (Fri,) studied this question.