A 33-year-old woman presented to the emergency department with abdominal pain and constipation alternative  with diarrhea that had progressively worsened over a period of 5 years. The patient has had a fever since two months ago, and she has suffered from a recurrent cough and expectoration for half a month. Progressive and significant weight loss was observed in the past five years. She had a 3-year history of amenorrhea with denial of history of gynecological, respiratory and digestive tract disease. Her temperature was 38.1°C, the pulse 82 beats per minute, and the blood pressure 108/63 mm Hg. A physical examination revealed obviously anemic appearance. Auscultation of the lungs revealed bilateral crepitant rales. Her abdomen was soft, with mild right lower quadrant abdominal tenderness and normal bowel sounds. The rest of the physical examination was unremarkable. Computed tomography (CT) of the chest revealed multiple, patchy, infiltrative and nodular shadows scattered in the upper lobe of both lungs, as well as cavity in the left lung (Figure 1A). Colonoscopy confirmed ulcer in the terminal ileum (Figure 1B). The histopathological detection of an incisional biopsy sample separated from the terminal ileum revealed the typically characteristic caseous necrosis and granulomatous inflammation (Figure C). Direct microbiologic detection was positive for Mycobacterium tuberculosis in sputum, and T-SPOT. TB assay was also positive. A diagnosis of cavernous pulmonary tuberculosis accompanied by intestinal tuberculosis was made. Tuberculosis (TB) remains a major global public health issue, which is the second leading cause of death world-wide [1- 3]. Extrapulmonary tuberculosis (EPTB) is significant increasing and accounts for one in five registered TB patients [4-6]. Intestinal tuberculosis (ITB) is the sixth most prevalent presentation of EPTB [7]. Meanwhile, the symptoms of ITB mimic those of inflammatory bowel diseases, especially Crohn’s Disease [8-10]. However, effective treatment of drug-susceptible TB requires at least 6 months of daily therapy with multiple orally administered antibiotics, which makes it one of the longest courses of antibiotic therapy needed to treat an infectious disease [11-13]. After a well-informed discussion of options for anti-TB drugs with the patient, the decision was made to pursue a 1-year course of anti- TB treatment. After the procedure, she clinically recovered with outpatient follow-up.

Acknowledgements

Funding: This work was supported by National Natural Science Foundation of China (31600134).

Conflicts of Interest: The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects  of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Written informed consent was obtained from the patient for publication of this “Images”.