Digestive Diseases and Sciences, Vol. 51, No. 6 (June 2006), pp. 1039–1042 (C 2006) DOI: 10.1007/s10620-006-8002-2
Colonic Tuberculosis Mimicking Tumor
Perforation: A Case Report and Review
of the Literature
FUSUN BE ˘GENDIK C ¨OMERT, MD,* MUSTAFA C ¨OMERT, MD,† CANAN K ¨ULAH, MD,* ¨
OGE TAS¸CILAR, MD,† GAMZE NUMANO ˘GLU, MD,‡ and SELIM AYDEMIR, MD§
KEY WORDS: colon; adenocarcinoma; tuberculosis; perforation; PCR.
Although the exact relationship between colonic tuber-culosis and carcinoma of the colon is not well known, a number of studies published in the literature have re-ported that these two pathologies can be found at the same patient, coincidentally. Coexistence of colonic adenocar-cinoma, tuberculosis, and abscess at the same anatomic location in a patient is an extremely rare condition. We herein report the second case of colonic adenocarcinoma together with colonic tuberculosis and abscess , which was diagnosed by polymerase chain reaction (PCR) identifica-tion of Mycobacterium tuberculosis of paraffin-embedded biopsy specimens, mimicking the tumor perforation.
CASE REPORT
A 74-year-old woman visited our clinic in February 2003be-cause of weakness, night swelling, continuous left flank pain, progressive constipation, and loss of appetite and weight. She had had no gas or stool passage for 4 days. Family history was unremarkable. Physical examination revealed mild abdominal distension, hyperactivation of intestinal movement, and severe left flank pain.
The laboratory data showed no abnormality except for an el-evated sedimentation rate of 90 mm/hr. There was no elevation of tumor markers CEA and CA19-9. Chest x-ray was normal. Abdominal ultrasonography and computerized tomography re-vealed a mass of approximately 10 cm in its largest diameter just distal to the splenic flexure of the colon. Additionally, a cystic le-sion measuring 6.0 × 5.0 × 4.5 cm located between the colonic
Manuscript received September 29, 2004; accepted January 7, 2005. From the Departments of *Microbiology, †Surgery, ‡Pathology, and §Gastroenterology, Zonguldak Karaelmas University, School of Medicine, 67600 Kozlu/Zonguldak, Turkey.
This case was presented as a poster at the Third European Meeting on Molecular Diagnostics, Scheveningen, the Netherlands, October 16, 2003.
Address for reprint requests: Mustafa C¨omert, MD, Zonguldak Karaelmas University, School of Medicine, Department of Surgery, 67600 Kozlu/Zonguldak, Turkey; mustafacomert@hotmail.com.
mass and the anterior surface of the left kidney was reported (Figure 1). A circumferential vegetative hemorrhagic mass le-sion was seen at the splenic flexure on colonoscopy (Figure 2). Endoscopic biopsy specimens showed a well-differentiated ade-nocarcinoma of the colon.
During the operative procedure we encountered an abscess pouch between the anterior surface of the left kidney and the pos-terior wall of the tumor. Approximately 30 ml of viscous, grayish white–colored, milky, scentless fluid was aspirated. There was no micro-organism in aerobic and anaerobic bacteriologic cul-ture studies of this fluid. A standard radical left hemicolectomy was performed for the patient’s tumor. Histopathologic exam-ination of the resected specimen revealed a well-differentiated Aster–Coller B2 adenocarcinoma of the colon and noncaseating chronic granulomatouse colitis (Figure 3). There was no nodal in-volvement but noncaseating granulomatouse lymphadenitis was detected in 3 of 42 resected lymph nodes. There was no gross or microscopic tumor perforation at the resected colon.
The recovery period after the operation was not successful, and the patient suffered from progressive weakness. We inves-tigated any other factor that could have resulted in the chronic granulomatous colitis, lymphadenitis, and intra-abdominal ab-scess. A tuberculin skin test was positive and the diameter of induration was measured as 45 mm at hour 72 of the test. Tuberculosis was suggested but the cultures of gastric aspirate and sputum were negative for acid-fast bacillus. Colonic and nodal biopsy specimens were negative for Zeihl–Neelsen stain-ing. We tried to determine the existence of mycobacterial DNA in paraffin-embedded colonic and nodal specimens (1). DNA extraction and PCR were performed on these biopsy specimens, which showed noncaseating granulomas, to amplify a 178-bp fragment of the IS6110 insertion sequence of Mycobacterium
tuberculosis. Mycobacterial DNA was detected in two of the
paraffin-embedded sections. One of these sections was from an area showing granulomatous colitis adjacent to the tumor, and the other was from a lymph node showing a granulomatous reaction which was located just next to the tumor mass. The patient was diagnosed with colonic tuberculosis and antituberculosis treat-ment was given. She tolerated the treattreat-ment well and almost all of her complaints were corrected progressively. The patient was followed up for 19 months and was still alive, without any recurrence of the cancer or tuberculosis.
Digestive Diseases and Sciences, Vol. 51, No. 6 (June 2006)
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C ¨OMERT ET AL.
Fig 1. Computed tomography (CT) scan shows a mass which is located just distal to the splenic flexure of colon.
L, liver; LK, left kidney; St, stomach.
Fig 2. Endoscopic appearance of the circumferential ulcerovegetative colonic mass.
COLONIC ADENOCARCINOMA AND TUBERCULOSIS
Fig 3. Resected biopsy specimen shows submucosal noncaseating, epitheloid granulomas and
Lang-hans’ giant cells by hematoxylin and eosin staining. (A) Colon; (B) lymph node. (Original magnifi-cation,×400.)
C ¨OMERT ET AL.
DISCUSSION
Tuberculous involvement of the colon is rare even in the presence of extensive pulmonary disease. Tuberculosis of the colon comprises only 3 to 4% of intestinal tuberculosis (2). Intestinal tuberculosis commonly occurs in the second and third decades of life. Only 2% of cases present after the age of 60 years (2). Tuberculosis of the colon occurring together with colorectal cancer is an uncommon event (3), and just a few reports of both diseases occurring simul-taneously are on record (4–6). Coexistence of these two diseases at the same site is extremely rare (2). Although the exact relationship between colonic tuberculosis and colon cancer is not well known and is speculative, some authors think that association of these two pathologies has the possibility of a cause-and-effect relationship (7).
The most common presenting complaints of intestinal tuberculosis are abdominal pain, anorexia, weight loss, and fever. All of these symptoms are nonspecific. Al-though the disease is Al-thought to be primary to the lungs and is carried to the intestinal tract by swallowing of spu-tum, it has been reported that an abnormal chest x-ray was detected in only a minority of patients (8). A positive tu-berculin skin test may be useful, but it does not establish the specific diagnosis.
The definitive diagnosis can be made only by endo-scopic biopsy that reveals caseating tuberculous granulo-mas and acid-fast bacilli or by culture of M. tuberculosis from tissue specimens (8). Demonstration of caseating granulomas or a positive Zeihl–Neelsen stain is difficult to obtain from colonic biopsy specimens (9).
In our case, both the adenocarcinoma and the tuber-culosis were detected at the splenic flexure of the colon. Additionally, we detected an abscess pouch adjacent to the posterior surface of the tumor mass mimicking the tumor perforation during the operative procedure. Aerobic and anaerobic bacteriological culture studies of the abscess material were negative. Histopathologic examination of the resected specimen showed an adenocarcinona of the splenic flexure coincident with the noncaseating chronic granulmatous colitis and lymphadenitis. Although we sug-gested colonic tuberculosis, confirmation of the diagnosis was not achieved by routine study such as the isolation of bacilli or Zeihl–Neelsen staining of granulomas.
Recently, several studies have reported the use of PCR for diagnosis of mycobacterial infections (1, 10–12). Kim et al. reported that the positivity of PCR in paraffin-embedded samples was higher than in fresh biopsy mate-rials (12). We performed PCR of the paraffin-embedded specimens, which showed noncaseating epithelioid cell granulomas and Langhans-type giant cells and detected mycobacterial DNA. PCR can detect low numbers of
acid-fast organisms in paraffin sections and confirm and presumptively speciate mycobacterial infection when cul-tures are negative or not obtained (13). The diagnosis can be established or confirmed within days by the use of such techniques, compared with the 3–10 weeks required for diagnosis by culture.
Only one patient who had these three pathologies (car-cinoma, tuberculosis, and abscess) at the same location in the colon has been reported in the English literature pre-viously (14). Our case is the second. Isaaks et al. reported the first case, who had adenocarcinoma of the cecum coex-isting with ileocecal tuberculosis and abscess of the right iliac fossa (14).
An abscess due to tuberculosis which locates adjacent to an adenocarcinoma may easily be confused with an ab-scess due to a tumor perforation. Hence, this rare condition presents a difficult problem for surgeons to solve.
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