Use of Steroids in Diagnostic Confusion between Intestinal Tuberculosis and Crohn's Disease: A Brief Experience

Abstract

Background Differentiating intestinal tuberculosis (TB) from Crohn's disease (CD) is challenging. Even after complete workup, the underlying diagnosis can often remain unclear. Traditionally, trial of antitubercular therapy (ATT) is resorted to in such situations, but the use of ATT could increase stricturing complications in CD. Methods We report findings from our cohort of patients with ileocecal ulcers. Among patients with a diagnostic confusion between intestinal TB and CD, steroids were started in an in-hospital setting under close observation. We report a brief series of patients with a close overlap in terms of disease presentation, behavior, laboratory, and histopathological findings. All the cases had skip lesions in the colon with inconclusive final diagnosis. We attempted to differentiate between the two by a short trial of steroids for 2 weeks. Results Of the 30 patients with ileocecal ulceration, the diagnosis remained uncertain between intestinal TB and CD in three patients. All three patients received steroids for 2 weeks. Eventually, all were diagnosed to have TB. Administration of steroids helped increase microbiological yield with all three having a positive microbiological diagnosis at 2 weeks. However, one patient developed dissemination (pulmonary lesions). Conclusion With a definitive risk of flare of TB with steroid, we encountered a positive diagnosis with repeat colonoscopy biopsy, positive result in bronchoalveolar lavage, and in third case positive report of cartridge-based nucleotide acid amplification test on repeat colonoscopy biopsy. In cases where differentiation of ileocecal TB from CD is not possible confidently, using a steroid-first approach increases the microbiological yield with a potential risk of dissemination.