Correct!
5. All of the above
Assessment for inflammatory bowel disease markers [such as neutrophil specific antigen, Saccharomyces cerevisiae IgA and IgG antibody, C-reactive protein, and the erythrocyte sedimentation rate), repeat colonoscopy to obtain samples for infection, and assessment of the stool for various fungal and mycobacterial pathogens are appropriate measures to pursue.
All the inflammatory bowel disease serologies were positive. Repeat colonoscopy using techniques to collect samples for infection did not reveal fungus or mycobacteria, nor was there evidence of viral infection, such as cytomegalovirus or herpes simplex, although the repeat biopsy again showed non-necrotizing granulomatous inflammation similar to what was seen at the first colonoscopy procedure. The cecum could not be intubated due to the presence of a stricture. No Splendore-Hoeppli phenomenon (asteroid bodies) - the in vivo formation of intensely eosinophilic material around microorganisms (fungi, bacteria and parasites) or biologically inert substances- was seen. A QuantiFERON test was negative. Characteristic features of basidiobolomycosis, including an eosinophilic-rich infiltrate in the biopsied material and peripheral eosinophilia, were lacking. During this period when the next steps in management were being contemplated, stool culture was reported positive for mycobacteria, speciated as Mycobacterium tuberculosis, subsequently shown to be pan-sensitive. Four-drug therapy employing rifampin, isoniazid, ethambutol, and ezetimibe with B6 supplementation was begun. Subsequent bronchoscopy with bronchial lavage also showed acid-fast bacilli with growth in culture and treatment was continued with the patient in respiratory isolation.
Diagnosis: Mycobacterium tuberculosis infection of the lungs with dissemination to the terminal ileum.
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