Phlegmonous gastritis (PG) is a rare and serious bacterial infection of the gastric submucosa. Diagnosis is often delayed due to nonspecific symptoms, but if recognized early, PG may be treated successfully with medical therapy alone. We describe a case of a 47-year-old patient admitted with gastrointestinal symptoms and sepsis. He was found to have beta-hemolytic streptococcus bacteremia with a purulent gastric ulcer on endoscopic evaluation, consistent with the diagnosis of PG. Though surgical evaluation is often required in cases of PG, our patient quickly improved with parenteral antibiotic therapy. This case highlights an uncommon source of sepsis and demonstrates the success of antibiotic monotherapy with early recognition.

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INTRODUCTION: Abdominal tuberculosis (TB) comprises 5% of all tuberculosis cases and can involve organs such as the intestinal tract, peritoneum, and liver. One of the many risk factors for development is use of an anti-tumor necrosis factor agent. We present a rare case of disseminated tuberculosis involving the peritoneum in a young female with well-controlled Crohn’s disease on biologic therapy. CASE DESCRIPTION/METHODS: A 44-year-old female with Crohn’s pan-colitis (in remission; on maintenance Azathioprine and Adalimumab since 2015); presented with worsening abdominal pain and distension over three weeks. She reported fever, chills, and night sweats. On arrival, she had a low-grade fever with diffuse abdominal tenderness to palpation and shifting dullness. Laboratory tests revealed a CRP of 115, CA-125 of 472, and an indeterminate Quantiferon-Gold. A CT abdomen/pelvis showed ileocecal valve inflammatory changes, nodular omental thickening with ascites and a pleural effusion (Figures 1–3). A transvaginal ultrasound was normal. A diagnostic paracentesis revealed lymphocyte predominant ascitic fluid with a SAAG of 0.4. Fluid cytology was unremarkable; however, the culture returned positive for Mycobacterium TB. An omental biopsy was performed and was positive for AFB with necrotizing granulomas. AFB sputum culture was also positive. She was started on RIPE therapy for disseminated TB. There was low concern for an IBD flare and given on-going treatment of active tuberculosis, no additional therapy was initiated. DISCUSSION: Abdominal tuberculosis can occur by a few mechanisms and can involve multiple sites, one being the intestines. Both intestinal tuberculosis and Crohn’s disease may present with abdominal pain, diarrhea, bleeding, constitutional symptoms, and even fistula formations. Imaging and endoscopy are usually needed to differentiate the two. In tuberculosis, the ileocecal region is affected in 75% of cases, the ulcers are transverse, and bowel wall thickening is asymmetric. Ascites is usually present, with a SAAG of < 1.1. In Crohn’s disease, the ulcers are longitudinal, bowel wall thickening is symmetric, and there is no ascites. It is important to recognize these distinctions given the clinical overlap of disease and symptomology. TNF alpha-inhibitors increase the risk of developing tuberculosis. There is little data available to assist in reinitiating biologics in the setting of disseminated TB. Most often these medications are restarted after the completion of TB therapy with close follow-up.

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