THE GREAT IMITATOR IS NOT ONLY LUPUS.

Introduction. Distinguishing Crohn's disease (CD) and intestinal tubeculosis (ITB) may represent a remarkable clinical dilemma in Romania, an endemic country for tuberculosis which has experienced at the same time a significant increase in the incidence of inflammatory bowel disease. Case presentation. A 22 years-old female presented in our unit for abdominal pain, diarrhea (3-4 stools/day) and weight loss (7 kg.) since approximately 9 months ago. Previous investigations from another hospital included an abdominal ultrasound which revealed thickened enteral loops with intensified parietal Doppler signal suggestive of inflammation; fecal calprotectin was extremely elevated (>20.000 ug/mg). In our unit, we ordered stool tests that were negative for bacterial, viral or parasitic infections. Complete blood count, renal, liver and coagulations tests were within normal limits. We decided to perform colonoscopy; ileocecal valve stenosis was noted due to marked edematous mucosal changes, ulcerations and nodularity. Passage of the endoscope in the terminal ileum was not possible due to the ulcerohypertrophic lesions, but multiple biopsies were taken from the stenotic area. Even though Crohn's disease was highly suspected we decided to perform chest X-ray since intermittent cough and night chills were also noted during hospitalization. Radiographical findings consisted of numerous small nodular opacities up to 3-5mm diameter scattered throughout both lungs highly suggestive of miliary TB. Both sputum culture (intense BAAR reaction), CT scan and biopsies confirmed tuberculosis with extraintestinal manifestations. Our patient is currently under antimycobacterial treatment with favorable clinical outcome. A further follow-up to reassess the ileocecal valve stenosis is expected. Discussions. Intestinal tuberculosis and Crohn's disease have multiple overlapping features in terms of symptoms, radiologic, endoscopic and even histological findings. Misdiagnosis can be a crucial error, since immunosuppressive therapy for CD may favor the spread of tuberculosis and worsens prognosis. There are case reports in the literature with disseminated tuberculosis after anti-TNF therapy for suspected CD. Miliary tuberculosis with extraintestinal manifestations is not frequently encountered in immunocompetent patients. Nevertheless, initial results (including HIV testing and CT scan) did not identify any potential deficiency of the immune system in our patient. Conclusions. Judicious clinical examination merged with radiological, endoscopic and histological findings is of utmost importance in proper distinction between intestinal tuberculosis and Crohn's disease, to a great degree in Romania which is still endemic for the former. [ABSTRACT FROM AUTHOR]