[A case of esophageal and intestinal tuberculosis that occurred during treatment of rheumatoid arthritis with etanercept].

An 88-year-old woman with rheumatoid arthritis who had started etanercept treatment in July 2011 was referred to our hospital in February 2012 for right-sided pleural effusion. Chest computed tomography showed right pleural effusion, partial swelling of a calcified mediastinal lymph node, and mid-esophageal thickening of the mucosal wall. Gastroendoscopy showed mid-esophageal ulceration. Histological examination of biopsy specimens from this ulceration revealed noncaseating granulomas with Langhans giant cells. Ziehl-Neelsen staining of this section was positive for acid-fast bacilli. Polymerase chain reaction analysis of gastric juice was positive for Mycobacterium tuberculosis; we therefore diagnosed the patient with esophageal tuberculosis. However, since abdominal computed tomography showed swelling of mesenteric lymph nodes, we also suspected intestinal tuberculosis. Colonoscopy showed multiple ileal erosions; histological analyses of biopsied specimens revealed granulomas with Langhans giant cells, similar to the esophageal findings. We finally diagnosed the patient with both esophageal and intestinal tuberculosis. After anti-tuberculosis treatment, the right pleural effusion disappeared and the abdominal lesions improved. Although mycobacterial involvement of both the esophagus and intestine is rare in immunocompromised and immunocompetent hosts, differential diagnosis of these diseases is likely to become more important.

Abdominal tuberculosis following kidney transplantation: clinicopathologic features and follow-up in a unique case series.

BACKGROUND: Kidney transplant recipients are at a high risk of opportunistic infection. The aims of this study were to describe the epidemiology, clinical features, and prognosis of abdominal tuberculosis (TB) in kidney transplant recipients. METHODS: All cases of abdominal TB that occurred in kidney transplant recipients at our center between 1998 and 2010 were retrospectively reviewed. Detailed demographic data, clinical profile information, and the treatment response were recorded. RESULTS: Among the 7833 kidney transplantations performed during the study period, eight patients (0.1%) developed abdominal TB. There were four men and four women in this group. The mean age of the patients was 44 ± 12 yr. The time from kidney transplantation to TB was 6.7 ± 3.4 yr. The symptoms were weight loss (87.5%), diarrhea (87.5%), fever (75%), abdominal pain (62.5%), and lower gastrointestinal bleeding (37.5%). The delay between the identification of the clinical symptoms and the diagnosis was an average of six months. The diagnosis was confirmed histopathologically for most patients. The cecum and ascending colon were the most common sites involved. Two patients required surgical intervention. Five patients received a 4-drug regimen, and three had hepatotoxicity. The median length of antituberculous therapy was nine (6-12) months. Five patients lost their graft. Overall, the hospital mortality was 12.5%. CONCLUSIONS: Kidney transplantation increases the risk of TB, particularly as an extrapulmonary disease. The symptoms of infection are often attenuated, leading to delayed diagnosis. Therefore, a careful approach to the patient and supportive data are necessary to make the final and timely diagnosis.

Unusual presentation of tuberculosis in an infliximab-treated patient--which is the correct TB screening before starting a biologic?

Infliximab is an anti-TNFalpha chimeric monoclonal antibody, commonly used in the treatment of moderate to severe psoriasis. TNFalpha is a pro-inflammatory cytokine which play a key role in host defense from infections by intracellular bacteria, such as Listeria monocytogenes, Histoplasma Capsulatum and especially Mycobacterium Tuberculosis. Infliximab therapy increases the risk of tuberculosis due mainly to the reactivation of latent TB infection (LTBI) and, therefore, it is mandatory to screen patients for LTBI prior to starting a treatment with anti-TNFalpha agents. We report the case of a psoriatic patient, who, despite a negative screening for infection by M. tuberculosis including both tuberculin skin test (TST) and chest X-ray, developed after 4 months of infliximab treatment, a severe pulmonary, lymphnodal and intestinal tuberculosis during infliximab treatment.

[The pathogenesis of the bowel infection with the Mycobacterium tuberculosis].

The prevalence of primary intestinal tuberculosis is increasing with social change and medical progress. However, it remains unknown whether or not primary intestinal tuberculosis exists without the involvement of other internal organs. This review verifies hypotheses about infectious courses of intestinal tuberculosis. We also evaluate the significance of bowel infection. As a result, we found some patients with intestinal tuberculosis who do not have tuberculosis lesions in other internal or external organs, and the tubercle bacillus, which is ordinarily transmitted with airborne droplet nuclei, might cause oral transmission by several factors.

Intestinal tuberculosis in a patient with end-stage renal disease on hemodialysis: A case report.

RATIONALE: Intestinal tuberculosis (TB) is rarely seen in patients with end-stage renal disease (ESRD). We report an intestinal TB case with a clinical presentation similar to that of colon cancer in a patient with ESRD on hemodialysis. PATIENT CONCERNS: A 49-year-old man presented with a 3-month history of general weakness and anorexia. He had been treated for stage 5 chronic kidney disease (CKD) due to diabetic nephropathy for the last 3 years. His blood urea nitrogen and serum creatinine levels were 96.9 and 8.1 mg/dL, respectively, at the time of admission; azotemia was accompanied by severe anemia, hypoalbuminemia, hyperkalemia, and metabolic acidosis. Hemodialysis was initiated for suspected exacerbation of uremia; however, intermittent fever, night sweats, and abdominal discomfort persisted. DIAGNOSES: Abdominal computed tomography (CT) and whole-body F-fluorodeoxyglucose positron emission tomography were indicative of ascending colon cancer with lymph node metastases. However, colonoscopy with biopsy revealed the formation of submucosal caseating granuloma and acid-fast bacillus. INTERVENTIONS: We initiated quadruple therapy with isoniazid, rifampicin, pyrazinamide, and ethambutol. The patient continued the quadruple regimen for the first 2 months before switching to dual therapy and received anti-TB medications for a total of 12 months. OUTCOMES: After 9 months of standard anti-TB chemotherapy, polypoid residual lesions were noted during follow-up colonoscopy. Laparoscopy-assisted ileocecal resection was performed. No findings suggestive of recurrence of colonic TB were observed on follow-up abdominal CT at 6 months after discontinuation of anti-TB medications. LESSONS: If non-specific uremic symptoms persist in patients with advanced CKD, the possibility of extrapulmonary TB such as intestinal TB must be considered. Also, in patients with radiologic suspicion of colon cancer, endoscopy with biopsy should be performed promptly to exclude colonic TB with similar clinical manifestations.

A rare cause of anemia due to intestinal tuberculosis in a renal transplant recipient.

A renal transplant recipient with stable allograft function presented with massive hemorrhagic diarrhea and severe anemia. No microbial infection could be found in stool cultures. Early colonoscopy showed severe colitis with ulceration. Histological samples confirmed granulomatous inflammation with acid-resistant Ziehl-Neelson-positive microorganisms of mycobacterial type. Polymerase chain reaction (PCR) analysis of native mucosal biopsies specified the infectious organism as Mycobacterium tuberculosis complex. The patient responded well to antimycobacterial therapy and was still asymptomatic after 6 months with a stable graft function. Our case shows that tuberculosis can be a severe clinical problem in transplant recipients. Most of the patients with intestinal tuberculosis, reported to literature, were diagnosed post mortem or after explorative laparotomy and bowel resection. Thus, intestinal tuberculosis should be considered when a transplant recipient shows abdominal symptoms with no clear evidence of another infection. Proper diagnosis and treatment resulted in a beneficial outcome in our patient.

[Abdominal tuberculosis in patients with acquired immunodeficiency syndrome]. / Tuberculosis abdominal en los pacientes con síndrome de inmunodeficiencia adquirida.

BACKGROUND: In individuals with HIV infection, extrapulmonary forms of tuberculosis are considered as opportunistic infections and are included in the diagnosis of AIDS. They often have atypical clinical features. Abdominal participation is uncommon and its diagnosis may be difficult. METHODS: The clinical, radiological and pathological features of patients with a diagnosis of AIDS with abdominal tuberculosis in a series of 254 AIDS cases in a general hospital from 1984 to October 1990 were reviewed. RESULTS: Tuberculosis developed in 104 (41%) of AIDS patients. In 25 (24%) the disease was exclusively pleuropulmonary and in 79 (76%) extrapulmonary tuberculosis was present, either alone or in association. Extrapulmonary tuberculosis was the first opportunistic infection in 66 AIDS cases (26%). The abdominal participation was demonstrated in 19 patients, with the following localizations: lymph nodes (9), liver (8), spleen (5), ileum (1) and peritoneum (1). Four patients with splenic tuberculosis also had multifocal nodular lesions. CONCLUSIONS: Abdominal participation was found in 19 of the 104 AIDS patients with tuberculosis (18%). Lymph node involvement was the most common type. Hepatosplenic tuberculosis had a miliary form or showed multifocal images in echography or computed tomography.

[Anti-TNF alpha monoclonal antibodies (infliximab) and tuberculosis: apropos of 3 cases]. / Anticorps anti-TNF alpha (infliximab) et tuberculose: à propos de trois cas.

INTRODUCTION: Monoclonal TNF alpha antibodies are a new treatment of severe rheumatoid arthritis. One of the possible side effects is the appearance of opportunistic infections. We report here on three cases of disseminated tuberculosis observed in patients undergoing treatment with infliximab. EXEGESIS: A 45-year-old woman, treated with infliximab, was hospitalised after five infusions for fever and dyspnoea. The exams showed pulmonary and peritoneal tuberculosis. The second case is a 75-year-old woman whose symptoms were fever, cough and cervical adenopathy after three infliximab infusions. Diagnosis was disseminated tuberculosis. The third case is a 59-year-old man who was hospitalised for an infectious syndrome with dyspnoea, after two infliximab infusions. We discovered pulmonary tuberculosis. CONCLUSION: These three cases added to the 68 cases of tuberculosis registered with the treatment of infliximab. This confirms the risk of severe opportunist infectious side effects. TNF alpha is a cytokine which has anti-infectious properties. These tuberculoses are severe and generalized. It is recommended to search for an active or latent tuberculosis before beginning treatment with infliximab, and to check these patients frequently.

[A case of tuberculous anal fistulae complicated by pulmonary tuberculous].

Tuberculous involvement of the anus is very rare at present as the result of BCG-Vaccination and improvement of public health. We report a juvenile case of tuberculous anal fistulae complicated to pulmonary tuberculosis. A 22-year-old male was admitted with symptoms of 13 month- history of intermittent anal pain, low grade fever and cough. Chest X-ray showed bilateral middle zone infiltrates with cavitation. Perianal inspection revealed a large ulcer with purulent exudate and a few fistulae. Sputum smears showed acid fast bacilli. A biopsied specimen of perianal fistulae showed granulomatous lesions with central necrosis, epitheloid cells and multi-nucleated giant cells. With three-drug antituberculous regimen, his symptoms resolved, radiographic infiltrates improved, and the perianal fistulae were cured. It was speculated that the tuberculous anal fistulae in this case were caused by the dissemination from the pulmonary focus via the hematogeneous and lymphogeneous routes, because any tuberculous lesion was not detected in the gastrointestinal tract and rectum.

Protean manifestations of gastrointestinal tuberculosis.

We present 11 cases to illustrate the protean presentations of gastrointestinal tuberculosis. The patients presented with perianal fistula, appendicitis, ascites, rectal, intestinal or gastric 'growth', "ulcerative colitis", or recurrent anemia. In some of these cases there was no conclusive proof of infection with Mycobacterium tuberculosis but they responded well to empirical treatment with anti-tuberculous therapy. These cases illustrate that because signs and symptoms of intestinal tuberculosis are non-specific and even histology can be misleading, the diagnosis of gastrointestinal tuberculosis requires a high index of suspicion. A therapeutic trial of antituberculous drugs should be considered for patients with a high clinical suspicion of tuberculosis.