Ileal tuberculosis presenting with severe unexplained anemia and unusual pseudo-tumoral imaging features: A case report

Abstract

Intestinal tuberculosis is an uncommon form of extrapulmonary tuberculosis that may mimic neoplastic or inflammatory disorders, leading to diagnostic delays. In endemic regions, recognition of atypical imaging presentations remains challenging. We report the case of a 58-year-old man with severe unexplained anemia, progressive asthenia, and weight loss without overt gastrointestinal bleeding. Contrast-enhanced abdominal computed tomography revealed focal involvement of the distal ileum extending over approximately 150 mm, characterized by marked circumferential mural thickening measuring up to 41 mm, associated with focal pseudoaneurysmal dilatation, moderate-to-large volume ascites, and mesenteric lymphadenopathy with subtle central necrosis. These findings resulted in a pseudotumoral appearance, raising the differential diagnoses of intestinal tuberculosis and gastrointestinal lymphoma. Histopathological examination demonstrated epithelioid and multinucleated giant-cell granulomas with caseous necrosis. Microbiological confirmation was obtained by positive Ziehl–Neelsen staining, positive GeneXpert MTB/RIF assay for Mycobacterium tuberculosis complex without rifampicin resistance, and positive mycobacterial culture. The patient showed a favorable clinical, biological, and radiological response following standard antituberculous therapy. Ileal tuberculosis may exceptionally present with severe anemia and unusual pseudo-tumoral imaging features, including focal pseudoaneurysmal dilatation. To our knowledge, based on the available literature, this imaging pattern appears to be exceptionally uncommon. Awareness of atypical CT manifestations and correlation with histopathological and microbiological findings are essential for accurate diagnosis and appropriate management, particularly in tuberculosis-endemic areas.