Intestinal Tuberculosis Mimicking Crohn’s Disease with Concomitant Axial Spondyloarthritis: A Diagnostic and Therapeutic Challenge

Intestinal tuberculosis (ITB) represents a major diagnostic challenge in endemic regions owing to its substantial clinical and endoscopic overlap with Crohn’s disease (CD). This complexity is further amplified when ITB is accompanied by inflammatory musculoskeletal manifestations that resemble axial spondyloarthritis (axSpA), thereby increasing the risk of diagnostic misclassification and potentially hazardous therapeutic decisions, particularly with respect to the use of immunosuppressive agents. A clinical case is presented involving a young woman with chronic diarrhea and progressive inflammatory back pain. The diagnostic workup comprised laboratory investigations, imaging studies, colonoscopy with histopathological analysis, microbiological testing, and longitudinal monitoring throughout the course of anti-tuberculous therapy. Colonoscopy revealed inflammatory lesions suggestive of CD; however, histopathological examination demonstrated large confluent granulomas with central necrosis and acid-fast bacilli (AFB) positivity, establishing the diagnosis of ITB despite initially negative molecular assays and cultures. Radiological findings, inflammatory back pain, and HLA-B27 positivity were consistent with axSpA. Anti-tuberculous therapy led to marked mucosal improvement, although persistent microbiological evidence necessitated extension of treatment duration to nine months. Management of spondyloarthritis was initiated only after adequate control of the tuberculous infection had been achieved. This case underscores the need for heightened vigilance for ITB in patients presenting with Crohn’s-like colitis and inflammatory musculoskeletal symptoms in tuberculosis-endemic settings. Histopathological evaluation remains pivotal when microbiological investigations are inconclusive. A stepwise, “infection-first” approach is essential to avoid premature immunosuppression and to ensure safe and effective management of coexisting inflammatory conditions. • Intestinal tuberculosis can closely mimic Crohn’s disease clinically and endoscopically, particularly in tuberculosis-endemic regions. • Tuberculosis-related inflammatory musculoskeletal manifestations may obscure or delay recognition of concomitant axial spondyloarthritis. • Histopathological evidence of necrotizing granulomas with acid-fast bacilli remains the most reliable diagnostic discriminator when molecular tests are negative. • Infection-driven elevation of inflammatory markers may falsely inflate disease activity indices and misguide immunosuppressive treatment decisions.