Case Presentation:

A 64‐year‐old male without a significant past medical history presented with a complaint of rectal pain. The pain was worse with bowel movements, and as a result the patient reported a fear of eating. The patient denied any associated nausea, vomiting, fevers, chills, melena, or bright red blood per rectum. He did report a 2‐week history of a dry nonproductive cough. Additionally, he reported a 50 pack‐year smoking history and multiple sexual partners. On examination the patient was hypotensive with a blood pressure of 80/60 mm Hg, tachycardic, and had a documented decrease in weight from 60 to 45 kg in less than 6 months. Breath sounds were clear and rectal exam revealed a 4 by 4 cm rectal ulceration. Stool exam was brown and guaiac positive. Laboratory examination revealed a mild leukocytosis with normal differential and a chest x‐ray with diffuse patchy opacifications. A presumptive diagnosis of human immunodeficiency virus (HIV) infection and Pneumocystis jiroveci pneumonia was made. The patient was started on trimethoprim‐sulfamethoxazole and admitted for further evaluation. The patient's low blood pressure responded to fluids. He was evaluated by gastroenterology and infectious disease services. HIV testing was negative. A new working diagnosis of rectal malignancy with lymphangitic spread to the lungs was made. The patient underwent colonoscopy with biopsies. Sigmoid ulcerations were also noted. Rectal biopsies revealed 2+ acid fasi bacilli (AFB) and sputum obtained was 4+ AFB. The patient was placed in isolation and started on a 4‐drug regimen for treatment of miliary tuberculosis (TB).


National tuberculosis surveillance data reveals that almost one‐fifth of tuberculosis cases in the United States are extrapulmonary. Gastrointestinal TB is a diagnostic challenge in the absence of a pulmonary infection. Only 2% of gastrointestinal TB cases present after 60 years of age. Most commonly the intestinal lesions are ulcerative. Symptoms include abdominal pain, diarrhea, weight loss, fever, melena, and rectal bleeding. Rectal lesions usually present as anal fissures, fistulas, or perirectal abscesses. It is essential to distinguish TB enteritis from inflammatory bowel disease such as Crohn's disease as the initiation of immunosuppressive therapy in a patient with tuberculosis can lead to dissemination. Our patient presented with rectal involvement and likely had disseminated or miliary TB. Classic miliary TB is defined as milletlike seeding of TB bacilli in the lung and is seen in 1%–3% of all TB cases. It can mimic many diseases, and in some cases up to 50% are diagnosed antemortem. A high index of clinical suspicion is important as early diagnosis and treatment correlate with improved outcomes.


Miliary TB is rare. A case of undiagnosed miliary TB presenting as a perianal ulcer is reported.

Author Disclosure:

I. Krokos, none.