Miliary tuberculosis diagnosed by diffuse hepatic uptake on PET/CT and transjugular liver biopsy.

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.

Tuberculosis miliar en pacientes en tratamiento con adalimumab, una asociación no tan frecuente en pediatría / Miliary tuberculosis in patients treated with adalimumab, an association not so frequent in pediatrics

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.

Tuberculosis miliar, un hallazgo clínico-radiológico: a propósito de un caso / Miliary tuberculosis, a clinical-radiological finding: about a case

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.

Transbronchial Cryobiopsy for Miliary Tuberculosis Mimicking Hypersensitivity Pneumonitis.

Miliary tuberculosis is a potentially lethal type of tuberculosis that results from the hematogenous dissemination of Mycobacterium tuberculosis bacilli. We herein describe the case of a 34-year-old man that presented with a one-month history of cough and fever, while his sputum smear results were negative. Chest computed tomography revealed bilateral centrilobular ground-glass opacification (GGO), suggestive of hypersensitivity pneumonitis; thus, bronchoscopy was performed. Cryobiopsy specimens revealed necrotic granulomas. A re-examination of sputum after bronchoscopy identified Mycobacterium tuberculosis, and miliary tuberculosis was diagnosed. A cryobiopsy might be useful for diagnosing miliary tuberculosis pathologically, particularly when miliary nodules may be masked by GGO.

Use of steroids to treat anti-tumor necrosis factor α induced tuberculosis-associated immune reconstitution inflammatory syndrome: Case report and literature review.

INTRODUCTION: Individuals with tuberculosis (TB) who are being treated with anti-tumor necrosis factor α (anti-TNFα) for coexisting conditions may experience unexpected exacerbations of TB after the initiation of antituberculous therapy, so-called anti-TNFα-induced TB-immune reconstitution inflammatory syndrome (anti-TNFα-induced TB-IRIS). Anti-TNFα-induced TB-IRIS is often treated empirically with corticosteroids; however, the evidence of the effectiveness of corticosteroids is lacking and the management can be a challenge. PATIENT CONCERNS: A 32-year-old man on long-term infliximab therapy for Crohn disease visited a clinic complaining of persistent fever and cough that had started 1 week previously. His most recent infliximab injection had been administered 14 days before the visit. A chest X-ray revealed a left pleural effusion, and he was admitted to a local hospital. DIAGNOSIS: A chest computed tomography (CT) scan revealed miliary pulmonary nodules; acid-fast bacilli were found in a sputum smear and a urine sediment sample; and polymerase chain reaction confirmed the presence of Mycobacterium tuberculosis in both his sputum and the pleural effusion. He was diagnosed with miliary TB. INTERVENTIONS: Antituberculous therapy was started and he was transferred to our hospital for further management. His symptoms initially improved after the initiation of antituberculous therapy, but 2 weeks later, his symptoms recurred and shadows on chest X-ray worsened. A repeat chest CT scan revealed enlarged miliary pulmonary nodules, extensive ground-glass opacities, and an increased volume of his pleural effusion. This paradoxical exacerbation was diagnosed as TB-IRIS associated with infliximab. A moderate-dose of systemic corticosteroid was initiated [prednisolone 25 mg/day (0.5 mg/kg/day)]. OUTCOMES: After starting corticosteroid treatment, his radiological findings improved immediately, and his fever and cough disappeared within a few days. After discharge, prednisolone was tapered off over the course of 10 weeks, and he completed a 9-month course of antituberculous therapy uneventfully. He had not restarted infliximab at his most recent follow-up 14 months later. CONCLUSION: We successfully managed a patient with anti-TNFα-induced TB-IRIS using moderate-dose corticosteroids. Due to the limited evidence currently available, physicians should consider the necessity, dosage, and duration of corticosteroids for each case of anti-TNFα-induced TB-IRIS on an individual patient-by-patient basis.

Haemophagocytic lymphohistiocytosis (HLH) secondary to miliary tuberculosis.

HLH is a rare, life-threatening, hematologic disorder resulting from prolonged and excessive activation of antigen presenting cells (macrophages, histiocytes) and CD8+ T cells. It is characterized by fever, pancytopenia,splenomegaly and haemophagocytosis in bone marrow,liver or lymph node. This hyperinflammatory condition is often triggered by a variety of agents or events, mostly genetic or infectious. HLH secondary to TB, have 100 % mortality in absence of anti-tubercular treatment .Since it mimics other disorders, its timely diagnosis remains a challenge. We report a case of hemophagocytic syndrome associated with disseminated tuberculosis in an immunocompetent man managed with anti-tubercular treatment and corticosteroid as immune modulator.

Myelofibrosis: An unusual presentation of disseminated tuberculosis.

Disseminated tuberculosis (DTB) often presents with protean clinical manifestations that often leads to potential diagnostic dilemmas. The nonspecific features may include pyrexia of unknown origin, hepatosplenomegaly, lymphadenopathy, meningitis, and a variety of hematological abnormalities, namely anemia, pancytopenia, and leukemoid reaction. Tuberculosis is one of the nonhematopoietic diseases that has been reported in conjunction with myelofibrosis. We, hereby, report a case of DTB with massive splenomegaly, severe pancytopenia, and marrow fibrosis.

Diagnostic utility of PET/CT in a patient with miliary tuberculosis.

A 63-year-old male presented with loss of appetite, subfebrile fever, swelling of the right hand and dyspnea on exertion for three months. Past medical history revealed methotrexate treatment of six months for rheumatoid arthritis. Chest radiography and computed tomography (CT) revealed diffuse miliary nodules. PET/CT scan demonstrated diffuse FDG uptake in both lungs, in the spleen, in the right hand, the mediastinal and the axillary lymph nodes. MR of the right hand showed inflammatory arthritis. Histopathology of the right hand tru-cut biopsy revealed degenerative changes. Culture of the hand biopsy tissue was positive for mycobacterium tuberculosis. PET/CT may determine the biopsy and the sampling sites for the early diagnosis of patients with suspected miliary tuberculosis where lesion identification on other modalities may be difficult or unfeasible. High sensitivity for inflammatory diseases makes PET/CT a useful diagnostic utility for enabling early diagnosis in miliary tuberculosis which is a diagnostic predicament.

Atypical serious hematochezia and rare imaging feature in gastrointestinal tuberculosis.

A young patient had serious hematochezia for nearly 2 months without obvious cause. Abdominal CT images showed rare features such as serious hemorrhage and multiple miliary nodules in the small bowel. The colonoscopy showed multiple lymphoid follicles in the terminal ileum. The laparotomy showed adverse adhesion in the abdominal cavity and multiple miliary noduli in the surfaces of small bowel wall. The pathology suggested tuberculosis. This patient received anti-TB therapy and the condition improved gradually. There are many variants of GI tuberculosis demonstrating uncommon and rare imaging features. It turned to be difficult in diagnosis when it showed the rare appearance, such as the great amount of intestinal bleeding and multiple noduli in our case. The reason why gastrointestinal bleeding might be attributed to the invasiveness of submucosal vessels by the tuberculosis bacteria. And the multiple noduli on the bowel wall might be the granuloma formation. Therefore, from the experience of our case, gastrointestinal tract might also be the first and only involved site, and it may cause great amount of bleeding to a life danger, even in young people.

Miliary tuberculosis developing during adalimumab treatment for Behçet's disease with uveitis.

Tumour necrosis factor-alpha (TNF-α) is a key proinflammatory cytokine in non-infective uveitis (NIU). Adalimumab, an anti-TNF-α monoclonal antibody, is approved for the treatment of severe NIU by the European Medicines Agency. There is a recognised risk of serious infections, including tuberculosis (TB), during anti-TNF-α therapy in systemic immune-mediated diseases. We describe miliary pulmonary TB during adalimumab therapy for severe NIU. To our knowledge, this is the first detailed report of this complication in a patient with uveitis. We present the challenges of managing vision-threatening uveitis during life-threatening infection necessitating withdrawal of adalimumab and oral immunosuppression therapy. Uveitis activity was controlled during anti-TB therapy with oral corticosteroid therapy.

Disseminated tuberculosis masquerading as a neuroendocrine tumour.

We describe the case of a 61-year-old man from the Dominican Republic admitted with diarrhoea, fevers and weight loss who was found to have lab studies and imaging (including radiolabeled somatostatin positron emission tomography/CT scan) initially consistent with a metastatic neuroendocrine tumour. However, after weeks of workup and multiple inconclusive biopsies, he was diagnosed with disseminated extrapulmonary tuberculosis. Here we examine the data for neuroendocrine tumour and tuberculosis labs and imaging to delineate where these studies overlap. We also analyse the biases and pitfalls in this case that led to a protracted diagnosis.

Manifestaciones tomográficas extrapulmonares de TBCy algunas de sus complicaciones asociadas / Extrapulmonary TB Tomography and some Associated Complications

La Tuberculosis (TBC) es una patología infecto-contagiosa de alta morbimortalidad en Chile y en el mundo, siendo la segunda causa de muerte por cuestión infecciosa y es considerada una patología de alta relevancia a nivel de salud pública. Es causada por una bacteria de alta virulencia y contagio llamada mycobacterium tuberculosis. En la actualidad contamos con protocolos de detección y tratamiento muy eficaces, que la convierten en una enfermedad prevenible y curable. El diagnóstico se realiza con estudios bacteriológicos específicos frente a una sospecha clínica-epidemiológica sugerente. Sin embargo, el uso de imágenes forma parte casi obligatoria de su estudio y control. Debido a que el órgano diana de la TBC es el pulmón, es habitual utilizar como apoyo diagnóstico una radiografía de tórax, la cual es útil, en caso de TBC pulmonar, al presentar hallazgos característicos y orientadores para su diagnóstico. Es importante destacar que el mycobacterium tuberculosis tiene alto potencial de diseminación por contigüidad, vía linfática y/o hematógena, siendo esa última vía la causante de la mayoría de las TBC extrapulmonares, las cuales se presentan en un 20% de pacientes inmunocompetentes y hasta en un 60% de inmunocomprometidos. La principal localización de una TBC extrapulmonar es a nivel pleural, seguida del compromiso ganglionar, urogenital y osteoarticular, siendo el resto de las localizaciones muy infrecuentes. Para esos casos la tomografía computada (TC) es el estudio por imágenes de elección para el diagnóstico y control, además de ser una herramienta muy útil para la detección de complicaciones.

Tuberculosis (TB) is an infectious disease of high morbility and mortality in Chile and in the world. It is the second cause of death due to infectious causes in the world, and is considered of high relevance to public health. TB is caused by a highly pathogenic and virulent bacterium denominated mycobacterium tuberculosis. Nowadays, there are effective protocols for detection and treatment of this disease, which make it preventable and curable. Diagnosis is reached by specific bacteriological studies in the presence of a clinical epidemiological suspicion. Nevertheless, imagining methods are almost an obligatory part of tuberculosis study and control. Since the lung is the target organ of TB, chest X-ray is commonly used as a support for diagnosis, which is very useful in case of pulmonary TB because it provides characteristic findings to guide diagnosis. It is important to highlight that the mycobacterium tuberculosis has a high potential for dissemination by contiguity, via lymphatic and/or haematogenous, the latter being the cause of the majority of extrapulmonary TB, which are presented in 20% of immunocompetent patients and by up to 60% of immunocompromised. The main site of extrapulmonary TB is into the pleural space, followed by the lymph node, urogenital and osteoarticular involvement, the remainder being infrequent localizations. In these cases, a computed tomography (CT) study based on the selection of images, is the tool used for diagnosis and control, which is also useful for the detection of complications.

Miliary tuberculosis: Epidemiologicaland clinical analysis of large-case series from moderate to low tuberculosis endemic Country.

The aim of this study was to determine the clinical features, and outcome of the patients with miliary tuberculosis (TB).We retrospectively evaluated 263 patients (142 male, 121 female, mean age: 44 years, range: 16-89 years) with miliary TB. Criteria for the diagnosis of miliary TB were at least one of the followings in the presence of clinical presentation suggestive of miliary TB such as prolonged fever, night sweats, anorexia, weight loss: radiologic criterion and pathological criterion and/or microbiological criterion; pathological criterion and/or microbiological criterion.The miliary pattern was seen in 88% of the patients. Predisposing factors were found in 41% of the patients. Most frequent clinical features and laboratory findings were fever (100%), fatigue (91%), anorexia (85%), weight loss (66%), hepatomegaly (20%), splenomegaly (19%), choroid tubercules (8%), anemia (86%), pancytopenia (12%), and accelerated erythrocyte sedimentation rate (89%). Tuberculin skin test was positive in 29% of cases. Fifty percent of the patients met the criteria for fever of unknown origin. Acid-fast bacilli were demonstrated in 41% of patients (81/195), and cultures for Mycobacterium tuberculosis were positive in 51% (148/292) of tested specimens (predominantly sputum, CSF, and bronchial lavage). Blood cultures were positive in 20% (19/97). Granulomas in tissue samples of liver, lung, and bone marrow were present in 100% (21/21), 95% (18/19), and 82% (23/28), respectively. A total of 223 patients (85%) were given a quadruple anti-TB treatment. Forty-four (17%) patients died within 1 year after diagnosis established. Age, serum albumin, presence of military pattern, presence of mental changes, and hemoglobin concentration were found as independent predictors of mortality. Fever resolved within first 21 days in the majority (90%) of the cases.Miliary infiltrates on chest X-ray should raise the possibility of miliary TB especially in countries where TB is endemic. Although biopsy of the lungs and liver may have higher yield rate of organ involvement histopathologicaly, less invasive procedures including a bone marrow biopsy and blood cultures should be preferred owing to low complication rates.

Unusual presentation of a young man with disseminated tuberculosis and right ventricular mass.

We report a 22-year-old man who presented to the emergency department with worsening shortness of breath and chronic fever for 2 months. Physical examination was unremarkable except for raised jugular venous pressure and palpable liver. Echocardiogram showed a large right ventricular mass causing obstruction at tricuspid valve. A subsequent chest CT scan confirmed the presence of a large mass in the right ventricle. There were multiple enlarged lymph nodes and consolidation in the right upper lobe. Diagnosis of disseminated tuberculosis (TB) was made and later confirmed by histopathology of lymph node biopsy along with positive sputum culture for acid-fast bacilli. Remarkable recovery was observed on antituberculous therapy, with complete disappearance of the cardiac mass on echocardiogram, at 1-year follow-up. Although unusual and rare, myocardial involvement as a large mass should be kept in mind while treating patients with disseminated TB.