NEJM: 肠结核

A 36-year-old woman presented to the emergency department with a 1-day history of severe abdominal pain and a 2-week history of fever and cough. She had no known medical history and worked as a physician. On physical examination, diffuse, severe abdominal tenderness with rebound and guarding was observed. Computed tomography of the chest showed a miliary pattern of pulmonary nodules and subdiaphragmatic free air, which prompted urgent transfer to the operating room. On gross pathological examination, six perforations were seen in the terminal ileum (Panel A). Intestinal resection of the distal ileum with an ileostomy was performed. Histopathological examination showed submucosal necrotizing granulomatous inflammation (Panel B; the asterisk indicates a granuloma). Cultures and real-time polymerase-chain-reaction testing of peritoneal fluid and intestinal tissue revealed Mycobacterium tuberculosis. A diagnosis of disseminated tuberculosis with tuberculous ileitis was made. Testing for human immunodeficiency virus was negative. In intestinal tuberculosis, the ileocecal area is the most commonly involved region, and infection there may initially be misdiagnosed as appendicitis or inflammatory bowel disease. This patient completed 9 months of antituberculous therapy and underwent ileostomy closure 6 months after her initial operation. At a follow-up visit 12 months after her initial presentation, she had completely recovered.

患者女，36岁，因剧烈腹痛1天，发热、咳嗽2周急诊。患者无已知病史，并作为一名医生工作。体格检查：可见弥漫性、重度腹部压痛伴反跳痛和僵硬。胸部ct示：肺结节粟粒样，膈下游离气体，促使急转入手术室。在大体病理学检查中，在回肠末端观察到6例穿孔（A组）。行回肠远端肠切除加回肠造瘘术。组织病理学检查显示粘膜下坏死性肉芽肿性炎症（图B；星号表示肉芽肿）。腹腔液和肠组织的培养和实时聚合酶链反应检测显示结核分枝杆菌。诊断为播散性结核合并结核性回肠炎。人类免疫缺陷病毒检测结果为阴性。在肠结核中，回盲部是最常受累的区域，感染最初可能被误诊为阑尾炎或炎症性肠病。该患者完成了9个月的抗结核治疗，并在初次手术后6个月接受了回肠造口术闭合。在初次就诊后12个月的随访访视时，她完全恢复。