Contributed by Irina Pushkar, MD and A. William Pasculle, ScD
Published on line in March 2001
The patient is a 42-year-old African male who presented to the Emergency Department complaining of intermittent fevers, up to 104 degrees of Fahrenheit, occasional chills, night sweats and rigors, periods of diarrhea, dysuria, and generalized malaise. He had a low abdominal discomfort but denied any nausea or vomiting. He had a decreased appetite, but denied any weight loss. He denied any palpitations, chest pain, shortness of breath, or chronic cough. He also denied flank pains.
The patient's illness started two months prior to his presentation to the Emergency Department and was accompanied with a period of watery stools. He was initially seen in an outpatient clinic and treated empirically with a two-week course of ciprofloxacin for presumed bacterial gastroenteritis. One month later, he returned to an outpatient clinic and was noted to have fever, some loose stools, dysuria, and hematuria with large amounts of blood, a proteinuria of 3+ and moderate leukocyte esterase in his urine. A urine culture grew 73,000 CFU of a viridans Streptococcus and he was treated again with a two-week course of ciprofloxacin. Stool cultures, ova and parasites, and Cryptosporidium were negative.
The patient had a past medical history of malaria (species unknown) two years ago, treated with chloroquine. He denies any tobacco use and his alcohol use is occasional. He denied history of intravenous drug use or blood transfusions.
Physical examination demonstrated a cachectic gentleman in no acute distress. The conjunctivae were pale and mucous membranes were dry. There was no jaundice. The neck was supple and free of adenopathy or bruits. The lungs were clear bilaterally. The heart rate was regular and there were no murmurs. The abdomen was soft, non-tender, non-distended, without hepatosplenomegaly, and bowel sounds were present. The patient was noted to have Hemoccult-positive stool, and when a Foley was inserted, it was noted that the Foley could be palpated freely in the rectum, documenting presence of a vesicorectal fistula. The remainder of the review of systems and physical examination was unremarkable.
RBC were 2.67, hemoglobin was 5.7 and hematocrit 16.8, MCV 63, MCH 21.3, MCHC 33.8, RDW 21.4. Reticulocyte count was 2.0.
Serum B12 was 641 and folate 15.5. Serum ferritin was 3018. Serum iron was 13 and TIBC 48. Iron saturation was 27%.
WBC were 4,900, with differential of neutrophils 79%, bands 10%, monocytes 4%, lymphocytes 6%, eosinophils 1%, basophils 1%. The platelet count was 272.
Sodium 129, potassium 4.3, chloride 92, CO2 26, BUN 12, creatinine 1.0, and glucose 99.
HIV Western blot is positive
CD4 counts are markedly low at 82.
CHEST X-RAY: Demonstrated abnormal findings of somewhat nodular opacity involving both apices and upper lobes bilaterally, consistent with acute inflammatory process (Figure 1)
CT CHEST, ABDOMEN AND PELVIS:
ABDOMEN: Multiple low-density lymphadenopathy of the mesentery and retroperitoneum consistent with Mycobacterial infection either from tuberculosis or atypical Mycobacterial infection such as MAI. Thickening of the ileo-cecal bowel wall is a nonspecific finding but can be seen in gastrointestinal tuberculosis (Figure 4 and 5).
PELVIS: Foley catheter balloon is noted within the rectum, findings consistent with vesicoenteric fistula. The fistula is likely from lower GU tract such as urethra/bladder base to the rectum. Small amount of gas is present within the bladder. Low-density extensive lymphadenopathy is present in bilateral common and external iliac and inguinal regions, consistent with mycobacterial infection. Given the constellation of findings, the vesico-enteric fistula may be secondary to GU involvement with tuberculosis (Figure 6 and 7).
PROCTOSCOPY delineated the large fistulous communication, between urethra and the rectum.
LAPAROTOMY demonstrated ascites, multiple deposits on the small bowel, suggestive of peritoneal tuberculosis, massively enlarged mesenteric lymph nodes, which were caseating. Small bowel deposits were biopsied and sent for pathological evaluation and culture. A decompression loop ileostomy was constructed.
MICROSCOPIC AND MICROBIOLOGICAL FINDINGS