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Tuberculosis, Intestinal

For further information, see CMDT Part 15-31: Intestinal Tuberculosis

Key Features

  • Common in developing nations; rare in the United States, except in immigrant groups or in patients with untreated AIDS

  • Caused by Mycobacterium tuberculosis and Mycobacterium bovis

Clinical Findings

  • Active pulmonary tuberculosis in < 50%

  • Most common intestinal involvement is ileocecal

  • Chronic abdominal pain, obstructive symptoms, weight loss, diarrhea

  • Abdominal mass palpable

  • Complications include

    • Intestinal obstruction

    • Hemorrhage

    • Fistula formation

  • Differential diagnosis

    • Crohn disease

    • Carcinoma

    • Lymphoma

    • Intestinal amebiasis

Diagnosis

  • PPD skin test may be negative, especially in weight loss or AIDS

  • Abdominal CT

  • Colonoscopy

  • Definitive diagnosis is by either endoscopic or surgical biopsy revealing acid-fast bacilli and caseating granuloma or by positive biopsy cultures

  • Detection of tubercle bacilli in biopsy specimens by polymerase chain reaction

Treatment

Table 9–14.Characteristics of antituberculous medications.
View Table||Download (.pdf)
Table 9–14. Characteristics of antituberculous medications.
Medication Most Common Side Effects Tests for Side Effects Drug Interactions Remarks
Isoniazid Peripheral neuropathy, hepatitis, rash, mild CNS effects. AST and ALT; neurologic examination. Phenytoin (synergistic); disulfiram. Bactericidal to both extracellular and intracellular organisms. Pyridoxine, 25–50 mg orally daily is given as prophylaxis for neuropathy; 50–100 mg orally daily as treatment for it.
Rifampin Hepatitis, fever, rash, flu-like illness, gastrointestinal upset, bleeding problems, kidney failure. CBC, platelets, AST and ALT. Rifampin inhibits the effect of oral contraceptives, quinidine, corticosteroids, warfarin, methadone, digoxin, oral hypoglycemics; aminosalicylic acid may interfere with absorption of rifampin. Significant interactions with protease inhibitors and nonnucleoside reverse transcriptase inhibitors. Bactericidal to all populations of organisms. Colors urine and other body secretions orange. May discolor contact lenses.
Rifapentine Bone marrow suppression, hematuria/pyuria, hepatitis, gastrointestinal upset, flu-like illness. CBC, platelets, AST and ALT. Strong cytochrome P450 inducer with multiple drug interactions. Use in HIV patients receiving antiretroviral therapy should be limited to experts in antiretroviral therapy. Bactericidal to both extracellular and intracellular organisms. Colors urine and other body secretions orange. Long half-life, can be administered weekly in LTBI prophylaxis. Not for use in induction phase of therapy.
Pyrazinamide Hyperuricemia, hepatotoxicity, rash, gastrointestinal upset, joint aches. Uric acid, AST, ALT. Rare. Bactericidal to intracellular organisms.
Ethambutol Optic neuritis (reversible with discontinuance of drug; rare at 15 mg/kg); rash. Red-green color discrimination and visual acuity. Rare. Bacteriostatic to both intracellular and extracellular organisms. Mainly used to inhibit development of resistant mutants. Use with caution in kidney disease or when ophthalmologic testing is not feasible.
Streptomycin Eighth nerve damage, nephrotoxicity. Vestibular function (audiograms); BUN and creatinine. Neuromuscular blocking agents may be potentiated and cause prolonged paralysis. Bactericidal to extracellular organisms. Use with caution in older patients or those with kidney disease.

ALT, alanine aminotransferase; AST, aspartate aminotransferase; BUN, blood urea nitrogen; CBC, complete ...

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