A 55‐year‐old man with a history of peptic ulcer disease, status post‐Bill roth I gastrectomy in 1997, presented with a 15‐day history of fevers, chills, night sweats, weight loss, productive cough, and progressive shortness of breath. The patient was homeless but denied other risk factors for tuberculosis (TB). He was febrile at 38.3°C, but vital signs were otherwise normal. General exam revealed a weak, cachectic, chronically ill‐appearing man. Diffuse crackles and expiratory wheezes were noted in the lungs. The abdomen was scaphoid with a midline scar from his Billroth I procedure. Chest X‐ray revealed multilobar infiltrates. Initial laboratory results revealed the following: hemoglobin = 8.5 g/dL, hematocrit = 28.1%, mean corpuscular volume = 62 fL, albumin = 2.0 g/dL, and total protein = 5.5 g/dL. The patient was placed in respiratory isolation to rule out TB. On hospital day 2, sputum smears returned positive for acid‐fast bacillus (AFB), and subsequent Mtb probe confirmed Mycobacterium tuberculosis. Rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE) therapy was initiated. The patient was discharged on hospital day 9 with RIPE therapy as well as iron supplements.
The relationship between gastrectomy and TB was first proposed in 1927 by Winkelbauer and Frisch, who reported that 4 patients developed fulminant TB after partial gastrectomy. In 1956, Forsgren found that postgastrectomy patients were 10 times more likely to develop pulmonary TB than the general population. More recently, a 2005 study by Ashino et al. demonstrated that patients who had undergone gastrectomy had lower antibody titers in response to TB antigens than did normal subjects. Although these data do suggest cause and effect, gastrectomy may simply be a marker for chronic malnutrition. The Billroth I partial gastrectomy is associated with multiple nutritional deficiencies, and up to 50% of patients experience weight loss and steatorrhea after surgery. Malnutrition also leads to impairment in cell‐mediated immunity. This relationship has been borne out in multiple ecological human studies, such as the observation that during World War II, Russian prisoners of war (POWs) in German camps had significantly higher rates of TB (15%–19%) than did their British POW counterparts (1.2%), who received nutritional supplementation from the Red Cross. Additionally, the Centers for Disease Control (CDC) now includes intestinal bypass or gastrectomy as a risk factor for reactivation of latent TB.
Gastrectomy is a significant risk factor in the progression of latent to active pulmonary TB and may simply be a marker for chronic malnutrition, which is known to impair cell‐mediated immunity. Close follow‐up after gastrectomy is imperative to assess nutritional status and to prevent subsequent TB infection.
D. Marcus, none; L. Johnson, none; N. Winawer, none.
To cite this abstract:Winawer N, Johnson L, Marcus D. Tuberculosis: A Gutless Opportunist. Abstract published at Hospital Medicine 2009, May 14-17, Chicago, Ill. Abstract 212. Journal of Hospital Medicine. 2009; 4 (suppl 1). https://www.shmabstracts.com/abstract/tuberculosis-a-gutless-opportunist/. Accessed July 20, 2019.