Pediatric Crohn’s Disease in Ethiopia: A Diagnostic Challenge in a High Tuberculosis Prevalence Setting

Differentiating Crohn's disease from intestinal tuberculosis can be particularly challenging in regions where tuberculosis is endemic and gastrointestinal symptoms overlap. We report the case of a nine-year-old Ethiopian girl who presented with a five-month history of cramping periumbilical abdominal pain and two months of intermittent bright red, blood-tinged stools, initially treated for parasitic infections and peptic ulcer disease without improvement. Physical examination was unremarkable except for mild lower abdominal tenderness. Laboratory studies, chest radiography, and abdominal ultrasound were normal. Colonoscopy revealed multiple areas of cobblestoning in the terminal ileum. Histopathology demonstrated mucosal and submucosal lymphocytic infiltrates with prominent lymphoid follicles and no granulomas. GeneXpert MTB/RIF (Cepheid, Sunnyvale, CA, USA) testing and immunohistochemistry were negative. Based on these findings, a diagnosis of Crohn's disease was established, and the patient was started on azathioprine, prednisolone, and cotrimoxazole prophylaxis, with subsequent marked clinical improvement. This case highlights the diagnostic challenge of differentiating pediatric Crohn's disease from intestinal tuberculosis in endemic regions and underscores the importance of maintaining a broad differential diagnosis. Timely, systematic evaluation using clinical, endoscopic, histopathological, and microbiological data can facilitate accurate diagnosis and effective management, even in resource-limited settings. Increased awareness and reporting of pediatric inflammatory bowel disease in sub-Saharan Africa are essential for earlier recognition, appropriate treatment, and improved patient outcomes.