S5019 Ileal Tuberculosis Masquerading as Inflammatory Bowel Disease in a Patient With Protein-Losing Enteropathy: A Diagnostic Dilemma

Introduction: Ileal tuberculosis (TB) and Crohn’s disease can share overlapping clinical, endoscopic, and histopathological features, posing a diagnostic challenge, particularly in regions endemic to TB. We present a case of a 60-year-old man with ileal ulcers, small bowel obstruction, and protein-losing enteropathy, initially suspected as Crohn’s disease but later diagnosed as intestinal TB. Case Description/Methods: A 60-year-old man with type 2 diabetes, hypothyroidism, ischemic heart disease (post-PTCA, post-PPM), and hypertension presented with persistent hiccups, weight loss (∼4 kg in 3 weeks), anorexia, abdominal pain, vomiting, and hypoalbuminemia. He had a history of small bowel obstruction involving 2 ileal segments and post-polypectomy colonic changes. Labs revealed hypoalbuminemia (2.0–2.6 g/dL), low total protein (4.6 g/dL), and hyponatremia. Imaging showed hepatomegaly. Ileocolonoscopy revealed healed ileal ulcers and cecal scarring. Biopsies showed chronic inflammation with granulomas. GeneXpert® for MTB was negative. Based on histology and endemic context, empirical anti-tubercular therapy (AKURIT-T4) was initiated. He was concurrently treated with mesalamine (Pentasa), albucare powder, and symptom control agents. His symptoms, weight, and albumin levels improved (to 2.6–2.8 g/dL). Protein-losing enteropathy was monitored via urine ACR and 24-hour urinary protein. He remained hemodynamically stable on follow-up. Discussion: Intestinal TB often mimics Crohn’s disease with ileocecal ulcers and granulomas. However, TB typically presents with transverse ulcers, necrosis, and acute onset. Negative AFB or GeneXpert® does not exclude TB, especially in healed disease. Histology and clinical response to therapy guide diagnosis. This patient responded well to ATT within 6–8 weeks. Protein-losing enteropathy, though uncommon, can arise from chronic ileal inflammation. Persistent hiccups were likely due to diaphragmatic irritation or TB-related motility issues and resolved with treatment. Conclusion: In TB-endemic regions, intestinal tuberculosis should remain high on the differential for IBD-like presentations. Empirical ATT may be warranted in equivocal cases with supportive histology and epidemiological context. Accurate differentiation avoids unnecessary immunosuppression.