GASTROINTESTINAL TUBERCULOSIS PRESENTING AS INTESTINAL OBSTRUCTION IN A 16-YEAR-OLD FILIPINO WITH PEDIATRIC SYSTEMIC LUPUS ERYTHEMATOSUS

PV293 / #569 Case Report Poster Topic: AS18 - Pediatric SLE Introduction Systemic lupus erythematosus (SLE) is a systemic disease, which can affect multiple organ systems. Gastrointestinal (GI) involvement is rare in pediatric SLE and is under-recognized. On the other hand, gastrointestinal tuberculosis (TB) is also a rare disease that can be easily missed clinically. Consequently, intestinal pseudo-obstruction in SLE and GI TB are both rare diseases and usually misdiagnosed, which may result in delay in treatment. Case Presentation With Investigation A 16-year-old Filipino female diagnosed with SLE 1 month prior to onset of GI symptoms. She presented with prolonged fever, joint pains, malar rash, weight loss, easy fatigability, increased hair fall, and positive antinuclear antibody (ANA) and anti-double-stranded DNA. She was also diagnosed with latent TB infection that time due to more than 10-millimeter (mm) induration on tuberculin skin test. She was subsequently started on isoniazid, rifampicin, hydroxychloroquine, and oral corticosteroids. She had generalized abdominal pain, nausea, and vomiting 1 month from SLE diagnosis. Whole abdominal computed tomography (CT) scan showed enhancing circumferential wall thickening involving the terminal ileum with subsequent proximal dilatation of the more proximal segments with possible reactive cecal and proximal ascending colon involvement. She underwent emergency exploratory laparotomy, segmental ileocecal resection, and double barrel ileocolostomy. The histopathologic findings showed the ileocecal segment with chronic granulomatous inflammation, ulceration, abscess formation, and acute serositis, consistent with ileocecal TB. She was discharged improved and with complete resolution of GI symptoms. Literature Review Gastrointestinal tuberculosis (TB) accounts for 1% to 3 % of all TB cases worldwide. It can occur in the context of active pulmonary disease or as a primary infection without pulmonary involvement. Diagnosis is challenging and is often delayed due to its nonspecific presentation. The terminal ileum and ileocecal valve are the commonly involved segments. Differentiating the symptoms of IPO and GI TB can be difficult, as both have similar nonspecific symptoms such as nausea, vomiting, abdominal pain, abdominal distention, and anorexia. Acute abdomen in patients with SLE is a challenging diagnostic and therapeutic problem. Medications such as steroids and immunosuppressive drugs, mask the physical findings of obstruction, perforation, and ischemia. Thus, early recognition and prompt management for both entities are lifesaving. Discussion The incidence and prevalence of GI involvement in SLE vary widely – this could be due to less attention being paid to GI manifestations than other organ symptoms. The most prevalent GI symptoms are nonspecific and include nausea, vomiting, anorexia, and abdominal pain. Our patient was on prednisone at 1 mg/kg/day and hydroxychloroquine which could have masked the features of GI perforation and ischemia. IPO can be diagnosed based on clinical manifestations, physical findings, and radiological examinations such as abdominal radiography and CT. Both disease entities, gastrointestinal tuberculosis and SLE IPO, is a diagnostic challenge as both typically presents with nonspecific clinical and radiologic features. The diagnosis is often delayed due to its vague presentation resulting in various complications. A high index of clinical suspicion and appropriate use of various investigative modalities can aid in early diagnosis, thereby reducing associated morbidity and mortality.