Assuntos
Antituberculosos , Humanos , Antituberculosos/uso terapêutico , Tuberculose/tratamento farmacológico , Masculino , Mycobacterium tuberculosis/isolamento & purificação , Mycobacterium tuberculosis/efeitos dos fármacos , Adulto , Tuberculose Miliar/diagnóstico , Tuberculose Miliar/tratamento farmacológico , Tuberculose Miliar/diagnóstico por imagem , FemininoRESUMO
PURPOSE: Tuberculous meningitis (TBM) causes significant morbidity and mortality in young children. Early treatment can be initiated with magnetic resonance (MR) imaging diagnosis. We present MR-detectable miliary meningeal TB in two patients. CASE 1: A 9-year-old girl developed fevers, cough, lethargy, and seizures. Brain MRI demonstrated multiple, small, T2-dark, rim-enhancing lesions, associated with cranial nerve and leptomeningeal enhancement. CSF showed pleocytosis, low glucose, and high protein. Chest CT showed mediastinal lymphadenopathy, multiple small interstitial lung nodules, and a splenic hypo enhancing lesion. Serial bronchoalveolar lavage studies were Xpert MTB/RIF and acid-fast negative. Endobronchial US-guided biopsy of a subcarinal lymph node was positive for Xpert MTB PCR. She was started on a 4-drug treatment for TBM and dexamethasone. Contact tracing revealed a remote positive contact with pulmonary tuberculosis. CASE 2: A 17-year-old female with Crohn's disease on adalimumab developed refractory ear infections despite multiple courses of antibiotics. She underwent myringotomy, with negative aerobic ear fluid culture. Brain MRI, obtained due to persistent otorrhea, showed multiple, small, round, T2-dark lesions. CSF studies were normal. CT chest, abdomen, and pelvis to assess for disseminated disease showed left upper lobe tree-in-bud nodules, hypoattenuating splenic lesions and a left obturator internus abscess with adjacent osteomyelitis. She underwent CT-guided aspiration of the obturator muscle collection, bronchoscopy with bronchoalveolar lavage, biopsy of two preexisting chronic skin lesions, and ear fluid aspiration. QuantiFERON Gold was positive. Ear fluid was Xpert MTB/RIF assay and acid-fast stain positive. Cultures from the ear fluid, skin tissue, muscle tissue, and alveolar lavage showed growth of acid-fast bacilli. She was started on 4-drug therapy and prednisone. CONCLUSION: Our cases highlight that TBM in many cases remains a diagnostic dilemma - both our patients presented in a prolonged atypical manner. The term miliary TB not only refers to a pattern of interstitial nodules on chest radiographs but also indicates the hematogenous spread of the disease and concurrent pulmonary and extrapulmonary involvement with high risk of TB meningitis. We promote the use of the term miliary meningeal TB - in both cases, the neuroimaging diagnosis of TB preceded both chest imaging and laboratory confirmation of the disease. Miliary meningeal nodules on MRI may have characteristic T2 low signal and may be more conspicuous in children and immunocompromised individuals where background basal meningeal enhancement is less prominent.
Assuntos
Imageamento por Ressonância Magnética , Tuberculose Meníngea , Humanos , Feminino , Criança , Tuberculose Meníngea/diagnóstico por imagem , Adolescente , Tuberculose Miliar/diagnóstico por imagem , Tuberculose Miliar/diagnósticoRESUMO
The patient was an 81-year-old man. In his 20s, he had been treated with pharmacotherapy for pulmonary tuberculosis for 1 year. He presented to the Department of Respiratory Medicine with a chief complaint of dyspnea. The possibility of respiratory disease appeared to be low, but hepatic impairment was detected. The patient was thus referred to our department. Though the cause of hepatic impairment was unknown, the soluble interleukin-2 receptor level was elevated, suggesting malignant lymphoma. 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)-computed tomography (CT) revealed diffuse, homogenous, intense FDG uptake in the entire liver, and transjugular liver biopsy confirmed the diagnosis. Histopathological examination revealed an epithelioid granuloma, and auramine staining was positive for bacilli suggestive of tuberculosis. CT revealed diffuse micronodular shadows in the lung, yielding a diagnosis of miliary tuberculosis. Therefore, the patient was prescribed antituberculosis medication by the Department of Respiratory Medicine. His subsequent clinical course was good. The miliary (hepatic) tuberculosis was typical based on the diffuse, homogenous, intense FDG uptake throughout the liver observed on PET-CT.
Assuntos
Fluordesoxiglucose F18 , Fígado , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada , Compostos Radiofarmacêuticos , Tuberculose Miliar , Humanos , Masculino , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada/métodos , Idoso de 80 Anos ou mais , Tuberculose Miliar/diagnóstico por imagem , Tuberculose Miliar/diagnóstico , Tuberculose Miliar/tratamento farmacológico , Fígado/patologia , Fígado/diagnóstico por imagem , Biópsia/métodos , Antituberculosos/uso terapêutico , Tuberculose Hepática/diagnóstico por imagem , Tuberculose Hepática/tratamento farmacológico , Tuberculose Hepática/diagnósticoAssuntos
Neoplasias Pulmonares , Tuberculose Miliar , Humanos , Criança , Tuberculose Miliar/diagnóstico por imagem , Mediastino/diagnóstico por imagem , Ultrassonografia , Ultrassonografia de Intervenção , Biópsia , Aspiração por Agulha Fina Guiada por Ultrassom Endoscópico , Broncoscopia , Neoplasias Pulmonares/patologiaAssuntos
Hepatopatias , Tuberculose Miliar , Trombose Venosa , Humanos , Veia Porta/diagnóstico por imagem , Tuberculose Miliar/diagnóstico , Tuberculose Miliar/diagnóstico por imagem , Trombose Venosa/complicações , Trombose Venosa/diagnóstico por imagem , Hepatopatias/complicações , Cirrose Hepática/complicaçõesRESUMO
BACKGROUND: Miliary tuberculosis (TB) is one of the severest manifestations of TB that can be lethal when concomitant with the central nervous system (CNS) involvement. Bacteriological, biochemical and radiological methods for find CNS comorbidity in miliary TB was evaluated in this study. METHODS: Consecutive miliary TB adults were retrospectively enrolled from two designated TB hospitals in China. The capacities of examinations of cerebrospinal fluid (CSF), cerebral computed tomography (CT) and magnetic resonance imaging (MRI) for diagnosis of CNS involvement were assessed. RESULTS: Assessment of CNS involvement with a lumbar puncture and/or neuroimaging was undertaken in 282 out of 392 of acute miliary TB. Of these 282 patients, 87.59% (247/282) had CNS involvement. Cerebral contrast-enhanced MRI (96.05%, 170/177) and MRI (93.15%, 204/219) yielded significantly higher sensitivities over CSF examination (71.92%, 146/203, P < 0.001) and CT (34.69%, 17/49, P < 0.001). The sensitivity of CSF examination was superior to CT scan (P < 0.001). Although 59.65% (134/225) miliary TB patients acquired bacteriological evidence with sputum examination, the positivity was only 8.82% (21/238) for CSF examination by conventional and molecular tests. CONCLUSION: Almost all miliary TB had CNS involvement and MRI demonstrated outstanding potential over other methods. Therefore, a routinely screening of CNS TB should be strongly suggested in miliary TB and MRI could be used as the initial approach in resources rich settings.
Assuntos
Tuberculose Miliar , Adulto , Sistema Nervoso Central/patologia , Humanos , Imageamento por Ressonância Magnética , Neuroimagem , Estudos Retrospectivos , Tuberculose Miliar/complicações , Tuberculose Miliar/diagnóstico por imagemRESUMO
BACKGROUND: Wallgren's tuberculosis (TB) timetable demonstrated co-occurrence of miliary TB and tuberculous meningitis in children. To verify the same in immunocompetent adults, we prospectively evaluated the prevalence and spectrum of central nervous system (CNS) involvement in patients with pulmonary miliary TB. MATERIALS AND METHODS: This was a tertiary care, University hospital-based, prospective evaluation performed from December 2018 to June 2020. Newly diagnosed patients with pulmonary miliary TB were subjected to a detailed clinical, laboratory and MRI-based evaluation. All patients received treatment as per WHO guidelines. RESULTS: Out of 342 patients with pulmonary TB, 53 patients met the eligibility criteria. The median age at presentation was 32 y and approximately two-thirds of patients were female. Clinically, only two-fifths of patients had features of CNS involvement. Cerebrospinal fluid (CSF) and imaging abnormalities were noted in 46 patients each. Twelve (23.5%) patients were diagnosed with definite-category tuberculous meningitis. Presence of an infarct significantly correlated with neurological features. Mantoux positivity correlated significantly with the presence of choroid tubercles, CSF changes and brain tuberculomas. CONCLUSION: This is the first study to endorse Wallgren's observations in immunocompetent adults. A high index of suspicion, even in asymptomatic patients, may uncover tuberculous lesions involving the CNS and guide optimal monitoring of patients.
Assuntos
Tuberculose Meníngea , Tuberculose Miliar , Tuberculose Pulmonar , Adulto , Sistema Nervoso Central , Criança , Feminino , Humanos , Imageamento por Ressonância Magnética , Tuberculose Meníngea/diagnóstico , Tuberculose Meníngea/diagnóstico por imagem , Tuberculose Miliar/diagnóstico , Tuberculose Miliar/diagnóstico por imagem , Tuberculose Pulmonar/diagnóstico , Tuberculose Pulmonar/diagnóstico por imagemRESUMO
Los antagonistas del Factor de Necrosis Tumoral-α, son medicamentos que en los últimos años han tenido un incremento de su uso en pacientes con condiciones inflamatorias inmunomediadas en pediatría, como la Artritis Idiopática Juvenil y la Enfermedad Inflamatoria Intestinal. El uso de estos medicamentos en adultos tiene una fuerte asociación con la primoinfección o reactivación por Mycobacterium tuberculosis, pero en niños la evidencia es limitada. Se presentan 2 casos de pacientes tratados con adalimumab, quienes, a pesar de un buen control de su enfermedad y una prueba de tuberculina negativa al inicio de la terapia, desarrollaron tuberculosis miliar en el seguimiento, con importantes implicaciones para su salud. El tamizaje de tuberculosis latente con tuberculina/IGRAS (Interferón-γ release assays, por sus siglas en inglés) y un alto índice de sospecha de tuberculosis, son las herramientas disponibles para una adecuada identificación de la tuberculosis en pacientes que reciben crónicamente estas terapias.
Tumor Necrosis Factor-α antagonists are drugs that in recent years have seen an increase in their use in patients with immune-mediated inflammatory conditions in pediatrics such as Juvenile Idiopathic Arthritis and Inflammatory Bowel Disease. The use of these drugs in adults has a strong association with primary infection or reactivation by mycobacterium tuberculosis, but in children the evidence is limited. We present 2 cases of patients treated with adalimumab who, despite good control of their disease and a negative tuberculin test at the beginning of therapy, developed miliary tuberculosis during follow-up with important implications for their health. Screening for latent tuberculosis with tuberculin / IGRAS (Interferón-γ release assays) and a high index of suspicion for tuberculosis are the tools available for an adequate identification of tuberculosis in patients who receive these therapies chronically.
Assuntos
Humanos , Masculino , Feminino , Criança , Adolescente , Tuberculose Miliar/induzido quimicamente , Fator de Necrose Tumoral alfa/antagonistas & inibidores , Adalimumab/efeitos adversos , Artrite Juvenil/tratamento farmacológico , Tuberculose Miliar/diagnóstico por imagem , Doença de Crohn/tratamento farmacológicoRESUMO
Pulmonary tuberculosis is the most common in children and its extrapulmonary manifestations are present in 30% to 40% of cases. We present the case of an indigenous girl with disseminated tuberculosis: pulmonary, brain, medullary, and musculoskeletal with substantial neurodevelopmental sequelae. This case exemplifies the spectrum of pediatric extrapulmonary tuberculosis in endemic developing countries. Furthermore, it shows the severity of highly disabling neurological complications and stresses the importance of radiological imaging in guiding diagnostic suspicion of extrapulmonary involvement.
La tuberculosis pulmonar es la más común en niños y su forma extrapulmonar corresponde aproximadamente a 30 a 40 % de los casos. Se presenta el caso de una niña indígena con tuberculosis diseminada: pulmonar, cerebral, medular y musculoesquelética, con importantes secuelas en el neurodesarrollo. Este caso ilustra el espectro de la tuberculosis extrapulmonar pediátrica en países endémicos en desarrollo. Además, evidencia la gravedad de las complicaciones neurológicas causantes de grave discapacidad y resalta el valor de las imágenes radiológicas para orientar la sospecha diagnóstica de compromiso extrapulmonar.
Assuntos
Tuberculose Miliar , Tuberculose Osteoarticular , Tuberculose Pulmonar , Criança , Feminino , Humanos , Imageamento por Ressonância Magnética , Tuberculose Miliar/diagnóstico por imagem , Tuberculose Osteoarticular/diagnóstico por imagem , Tuberculose Pulmonar/diagnóstico por imagemRESUMO
La tuberculosis es una enfermedad granulomatosa, con espectro clínico variable. El objetivo es presentar un caso con tuberculosis miliar, una de las formas clínicas menos frecuente de la enfermedad y la utilización del método clínico proporcionó el diagnóstico certero. Se presenta un paciente masculino de 54 años, no fumador, alcohólico atendido en el Hospital Clínico Quirúrgico Hermanos Ameijeiras por referir historia de tos poco productiva, cefalea, fiebre, pérdida de apetito y de peso de dos meses de evolución. En la radiografía y tomografía de tórax se evidencia un patrón miliar y la baciloscopía directa confirma la presencia del Mycobacterium tuberculosis. La TB miliar es muy poco frecuente, pero se puede sospechar ante un patrón radiológico miliar y confirmar mediante análisis microbiológico.
Tuberculosis is a granulomatous disease with a variable clinical spectrum. The objective is to present a case with miliar tuberculosis, one of the least frequent clinical forms of the disease, and the use of the clinical method provided an accurate diagnosis. We present a 54-year-old male, non-smoker, alcoholic who attended in the Ameijeiras Brothers Surgical Clinical Hospital for referring to a history of unproductive cough, headache, fever, loss of appetite, and weight two months of evolution. Chest X-ray and CT showed a miliar pattern and direct bacilloscopy confirmed the presence of Mycobacterium tuberculosis. Miliar TB is very rare but can be suspected by a miliar radiological pattern and confirmed by microbiological analysis.
Assuntos
Humanos , Masculino , Pessoa de Meia-Idade , Tuberculose Miliar/diagnóstico por imagem , Radiografia Torácica/métodos , Tomografia Computadorizada por Raios X/métodosRESUMO
We present a 16-year-old girl with a history of well-controlled psoriasis, on immunosuppression, who sought evaluation in the emergency department for 4 months of fever, cough and unintentional weight loss. The patient had seen multiple providers who had diagnosed her with community-acquired pneumonia, but she was unimproved after oral antibiotic therapy. On presentation, she was noted to be febrile, tachycardic and chronically ill-appearing. Her chest X-ray showed diffuse opacities and a right upper lobe cavitary lesion concerning for tuberculosis. A subsequent chest CT revealed miliary pulmonary nodules in addition to the cavitary lesion. The patient underwent subsequent brain MRI, which revealed multifocal ring-enhancing nodules consistent with parenchymal involvement. The patient was diagnosed with miliary tuberculosis and improved on quadruple therapy. Though rates of tuberculosis are increasing, rates remain low in children, though special consideration should be given to children who are immunosuppressed.
Assuntos
Psoríase , Tuberculose Miliar , Adolescente , Criança , Feminino , Humanos , Hospedeiro Imunocomprometido , Imageamento por Ressonância Magnética , Psoríase/complicações , Psoríase/tratamento farmacológico , Tomografia Computadorizada por Raios X , Tuberculose Miliar/diagnóstico , Tuberculose Miliar/diagnóstico por imagemRESUMO
ABSTRACT: While chest CT provides important clue for diagnosis of miliary tuberculosis (TB), patients are occasionally missed on initial CT, which might delay the diagnosis. This study was to evaluate the clinical and radiological characteristics of radiologically missed miliary TB.Total 117 adult patients with microbiologically confirmed miliary TB in an intermediate TB-burden country were included. 'Missed miliary TB' were defined as the case in which miliary TB was not mentioned as a differential diagnosis in the initial CT reading. Clinical characteristics and radiologic findings including the predominant nodule size, demarcation of miliary nodules and disease extent on CT were retrospectively evaluated. Findings were compared between the missed and non-missed miliary TB groups. Multivariable analyses were performed to determine independent risk factors of missed miliary TB.Of 117 patients with miliary TB, 13 (11.1%) were classified as missed miliary TB; these patients were significantly older than those with non-missed miliary TB (median age, 71 vs 57 years, Pâ=â.024). There was a significant diagnostic delay in the missed miliary TB group (Pâ<â.001). On chest CT, patients with missed miliary TB had a higher prevalence of ill-defined nodules (84.6% vs 14.4%; Pâ<â.001), miliary nodule less than 2âmm showing granular appearance (69.2% vs 12.5%; Pâ<â.001), and subtle disease extent (less than 25% of whole lung field, 46.2% vs 8.7%; Pâ<â.001). Multivariable analysis revealed that only CT findings including ill-defined nodule (Odd ratios [OR], 15.64; Pâ=â.002) and miliary nodule less than 2âmm (OR, 10.08; Pâ=â.007) were independently associated with missed miliary TB.Approximately 10% of miliary TB could be missed on initial chest CT, resulting in a delayed diagnosis and treatment. Caution is required in patients with less typical CT findings showing ill-defined miliary nodules less than 2âmm showing granular appearance and follow-up CT might have a benefit.
Assuntos
Tuberculose Miliar/diagnóstico , Tuberculose Miliar/patologia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Diagnóstico Tardio , Erros de Diagnóstico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Centros de Atenção Terciária , Tomografia Computadorizada por Raios X , Tuberculose Miliar/diagnóstico por imagemRESUMO
BACKGROUND: Disseminated tuberculosis (TB) is a fatal disease resulting from hematogenous dissemination of Mycobacterium tuberculosis. Spontaneous pregnancy rate of women with TB is low; furthermore, live birth, spontaneous abortion or ectopic pregnancy may be the outcomes even if pregnancy occurs. CASE PRESENTATION: We report a case of a woman with disseminated TB who had a series of complications including preterm delivery with congenital TB and infant death of pulmonary TB, fallopian tube pregnancy. She was treated by in vitro fertilization-embryo transfer (IVF-ET), and gave birth to a healthy baby. CONCLUSION: Disseminated TB has a significant impact on female fertility. We should take more active efforts to diagnose and treat this disease in a timely fashion. Moreover, IVF treatment is a feasible approach for an infertile woman after TB.