|Year : 2014 | Volume
| Issue : 3 | Page : 190-193
Coexistent colonic tuberculosis and mucinous adenocarcinoma: A causal or a casual link?
Zeeba S Jairajpuri, Safia Rana, Sujata Jetley
Department of Pathology, Hamdard Institute of Medical Sciences and Research, Jamia Hamdard, New Delhi, India
|Date of Web Publication||13-Aug-2014|
Department of Pathology, Hamdard Institute of Medical Sciences and Research, Hamdard Nagar, New Delhi - 110 062
Source of Support: None, Conflict of Interest: None
Tuberculosis (TB) is known to involve any part of the body. Intestinal TB accounts for the majority of extrapulmonary TB, ileocecal region is the most common site with involvement of the sigmoid colon a rare occurrence. TB has been known to be associated with various types of malignancy. The most common association is malignancy and pulmonary TB. However, association of extra pulmonary TB and malignancy at the same site is relatively uncommon and cases of colonic TB associated with mucinous adenocarcinoma are extremely rare. Involvement of sigmoid colon is even rarer and to the best our knowledge, the present case is the first reported case from India of coexistent adenocarcinoma and TB in the sigmoid colon. We report here an interesting case of coexistent colonic TB and malignancy in a 23-year-old female presenting to the emergency room with features of intestinal obstruction.
Keywords: Mucinous adenocarcinoma, sigmoid colon, tuberculosis
|How to cite this article:|
Jairajpuri ZS, Rana S, Jetley S. Coexistent colonic tuberculosis and mucinous adenocarcinoma: A causal or a casual link?. Int J Health Allied Sci 2014;3:190-3
|How to cite this URL:|
Jairajpuri ZS, Rana S, Jetley S. Coexistent colonic tuberculosis and mucinous adenocarcinoma: A causal or a casual link?. Int J Health Allied Sci [serial online] 2014 [cited 2020 Jan 17];3:190-3. Available from: http://www.ijhas.in/text.asp?2014/3/3/190/138605
| Introduction|| |
Carcinoma and tuberculosis (TB) of the bowel are very common conditions, but the sites of predilection differ with carcinoma being more common in the distal large bowel and TB in the terminal ileum or ileocecal junction. Both occurring at the same site is a rare entity.  Although few cases have been reported in literature, no cause-effect relation could be defined. TB is known to involve any part of the body and there are case reports of TB coexisting with malignancy in most body organs, the most common association being with pulmonary TB. However, association of extra pulmonary TB and malignancy in the same site is comparatively rare.  A few examples in the Indian context are on record; however, cases of TB and colonic carcinoma are exceedingly rare. Inflammatory bowel diseases can progress to malignant diseases due to mucosal dysplastic change. Similarly, intestinal TB can cause chronic inflammation, but the exact relationship between intestinal TB and colon cancer is currently obscure. 
| Case report|| |
A 23-year-old female patient presented to the emergency room with complaints of pain in the left lower abdomen, vomiting along with symptoms of bowel obstruction. She gave history of fever and dull aching pain in the abdomen off and on. There was history of loss of weight and appetite. Laboratory investigation revealed hemoglobin of 10.8 g% and total leukocyte count 13,200 cells/cumm; differential leukocyte count showed neutrophilia (86%), erythrocyte sedimentation rate (ESR) 58 mm/h, chest X-ray was within normal limits; however, plain X-ray abdomen showed multiple fluid levels.
A clinical impression of acute on chronic intestinal obstruction was made, and patient was taken up for an emergency exploratory laparotomy. Limited colectomy was done keeping in view the age and the suspicion of acute intestinal obstruction of tubercular etiology. Multiple lymph nodes (12 in number) were also isolated. The specimen was sent to the laboratory for histopathological evaluation.
Gross examination of the specimen on cutting open showed a circumferential thickening of the intestinal wall narrowing the lumen [Figure 1] along with overlying mucosa showing ulceration. Histopathological examination showed mucinous adenocarcinoma with sheets and nests of signet ring cells and mucin lakes [Figure 2] extending from the mucosa, dissecting through the muscle into the serosa along with interspersed numerous coalescing epithelioid cell granulomas with large areas of caseous necrosis and many Langhan's giant cells [Figure 3] and [Figure 4] stain for acid-fast bacilli was positive. Eight lymph nodes isolated showed a reactive change, while four showed granulomatous lesions with necrosis.
|Figure 1: Gross photograph of segment of rectosigmoid region with narrow constricted area (thin long arrows) and thickened wall (thick arrow)|
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|Figure 2: Microphotograph showing mucin lakes with tumor cells (H and E, ×10). Inset shows numerous signet ring cells (arrows) lying in between malignant glands (H and E, ×20)|
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|Figure 3: Microphotograph showing mucin lakes (long thin arrows) with caseating epithileoid cell granulomas (short thick arrows) (H and E, ×10)|
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|Figure 4: Microphotograph showing mucinous carcinoma with caseating granulomas and Langhans giant cells (H and E, ×10). Inset shows malignant mucin secreting glands (H and E, ×20)|
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After the diagnosis of adenocarcinoma with TB was established, patient was referred to the State Cancer Institute for further management.
| Discussion|| |
Both TB and carcinoma of the bowel are fairly common conditions, but the sites of predilection for the two differ, namely TB is common in the ileum, while carcinoma in the large bowel. Colonic TB is a rare extrapulmonary form of the disease, comprising only 3-4% of intestinal TB.  Even in colon, sigmoid colon is an unusual site, and its association with malignancy is even more uncommon. A few reports of both diseases occurring simultaneously are on record, , but coexistence of the two at the same site is very rare.
Intestinal TB frequently occurs in adults, and its male-to-female ratio is 1:2. It has generally nonspecific symptoms, which include chronic abdominal pain, weight loss, diarrhea, nausea, vomiting, and fever; although, it is known to most frequently invade the ileocecal area, involvement of the ascending colon, colon, appendix, duodenum, stomach is seen in that order with involvement, sigmoid colon involvement is rarely seen.  As regards the distribution of adenocarcinoma of the large intestine, approximately 65% occur in the rectosigmoid area, 5% in the caecum and the rest are distributed in other areas of the colon.  10% of these cases are of mucinous type with the substantial amount of mucin production. Colorectal adenocarcinomas occurring in the first three decades of life have a propensity to be of the mucinous type. 
Ileocecal TB is very common in India. However, its association with carcinoma is extremely rare and very few cases are reported from Indian literature,  involvement of sigmoid colon is even rarer and to the best our knowledge, the present case is the first reported case from India of coexistent adenocarcinoma and TB in the sigmoid colon.
A female preponderance with right colon involvement has been reported by many authors , Review of literature in a Japanese study discussed several points regarding the epidemiological and morphological features in a colon carcinoma associated with TB, they reported a female predominance with a ratio of 17:9 in such cases and involvement of the right side of the colon in 17 out of 26 cases has been reported, The most characteristic histological finding is that of a well-differentiated adenocarcinoma with a tendency to produce mucin.  The present case was also seen in a 23-year-old female with mucin producing adenocarcinoma, however in discordance with other authors the twin pathology was confined to the left colon.
It is estimated that over 20% of malignancies worldwide can be attributed to infectious agents.  Indeed, there is a large body of evidence regarding the role of viruses such as hepatitis B virus, Epstein-Barr virus and human papilloma virus in the complex processes of carcinogenesis. However, other microorganisms have also been implicated in carcinogenesis, several findings have led to the suggestion that mycobacterium TB can be instrumental in the development of malignant diseases. 
The association of these two conditions has been a matter of discussion, some Indian authors have suggested that coexistence of the two is more coincidental than causal as the incidence of abdominal TB in India is far more as compared to very few cases of coexisting TB and malignancy.  This argument may be acceptable when the two diseases occur at different sites; however, the simultaneous occurrence of the two at the same site is debatable. According to researchers, any connection between active TB and malignancy is attributed to reactivation of infection in immune-compromised patients suffering from cancer rather than to a cause-and-effect relationship between infection and neoplasm.  Mycobacterium TB is associated with lung cancer, albeit probably not etiopathogenetically. A considerable number of bacterial and parasitic infections are associated with the development of cancer, and further research into these associations with cancer will help in understanding these disease processes and in the development of therapeutic measures to fight these cancers. 
It is a well-known fact that chronic inflammatory diseases like ulcerative colitis and Crohn's disease are known to predispose to malignancy, chronic inflammatory mucosal damage initiate a sequence of metaplasia and dysplasia leading to neoplastic change, drawing parallels, it may be postulated that the ulcerative lesions of intestinal TB are precursors of carcinoma. , Although there is no evidence to indicate a higher incidence of colonic carcinoma in TB, facilitation of entry of tubercle bacilli with development of secondary infection in patient with carcinoma is one plausible cause.  However, this may be of significance only in those cases in which TB is occurring at an unusual site like left-sided colon as in the present case or at an unusual age like in older patients. Since most of the cases in literature belong to a younger age group with involvement of the right-sided colon, it may be an indication that TB, is a predisposing factor for malignancy, either by lowering immunity or because of chronic ulceration. 
| Conclusions|| |
The association of these two conditions has been a matter of debate. The coexistence of TB and carcinoma in the colon may be simply a coincidence. On the other hand, one disease process might have initiated the second. Chronic inflammatory mucosal damage initiate a sequence of metaplasia and dysplasia leading to neoplastic change, but still no definitive cause-effect relation has been ascertained. Although several plausible causes have come to light, further research into establishing exact association between these two diseases is needed.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]