The Great Masquerader - TB Osteoarthritis.

OBJECTIVES: TB arthritis is a rarely reported entity in Western literature and its ability to masquerade as many other diseases makes it difficult to diagnose. We report an interesting case of TB arthritis of the ankle. METHODS: We present a 44 year-old diabetic Chinese male with a recent history of worsening pain, swelling, and redness in his left foot with an abscess and X-ray findings consistent with Charcot foot. RESULTS: At first, the presentation was believed to be Charcot's foot with MSSA osteomyelitis but after the wound culture and bone biopsy were both positive for Mycobacterium tuberculosis as well, the diagnosis of tuberculous arthritis was confirmed. CONCLUSIONS: While the prevalence of TB and other diseases is low in the majority of the United States, we still need to be aware of such diseases in populations with increasing migration and be cognizant of the potential impact of a patient's background on a diagnosis is critical to properly diagnosing and treating patients. Vascular surgeons may be seeing patients with abscesses of the lower extremities and may miss the diagnosis if cultures for TB are not sought.

Miliary Sarcoidosis: does it exist? A case series and systematic review of literature.

BACKGROUND AND OBJECTIVES: Sarcoidosis typically presents with peribronchovascular and perilymphatic nodules on high-resolution computed tomography (HRCT); a miliary pattern is reported but not well described. DESIGN SETTING: We describe four patients with miliary sarcoidosis and results of a systematic review of all previously reported cases from 1985 onwards. RESULTS: We identified only 27 cases of "miliary" sarcoidosis in the HRCT era. These patients were older (85.2% older than 40 years), had more co-morbidities (72.7%) and were symptomatic compared to "typical" sarcoidosis. Respiratory symptoms were present in 61.9% at diagnosis. Hypercalcemia was seen in 28.5%. On review of HRCT images, only 34.6% (9/26) had a "true miliary" pattern without fissural nodules. In our series, prominent perivascular granulomas were seen on histopathology in all. 44.4% (12/27) had tuberculosis preceding or concurrent to miliary sarcoidosis. Of the eight true associations, tuberculosis preceded sarcoidosis by 52 (median, IQR 36) weeks in six and occurred concurrently in another two. The diagnosis of tuberculosis was clinical in all with concurrent diagnosis of tuberculosis and sarcoidosis. Treatment with steroids had 100% response and 14.2% relapse. CONCLUSIONS: A true miliary pattern in the HRCT era is very rare in sarcoidosis and subtle perilymphatic pattern is nearly always seen; this should be labeled "pseudo-miliary". Prominent perivascular granulomas are associated with true miliary pattern. Miliary sarcoidosis patients are older and symptomatic, needing treatment at diagnosis. "Miliary" sarcoidosis may follow treatment for tuberculosis; concurrent cases possibly indicate the difficulty in differentiating both or a "tuberculo-sarcoid" presentation. (Sarcoidosis Vasc Diffuse Lung Dis 2020; 37 (1): 53-65).

[Disseminated tuberculosis mimicking metastatic gastric cancer - a case report]. / Disseminierte Tuberkulose imitiert metastasiertes Magenkarzinom ­ ein Fallbericht.

Increasing numbers of active tuberculosis in Germany were recorded in the last years. Thus, also extrapulmonary manifestations of tuberculosis gain clinical significance as differential diagnoses, especially when a metastatic tumor disease is suspected. We report the case of a 77-year-old male patient who presented with unilateral leg pain and B symptoms. Further investigations revealed an osteolytic mass in the sacrum as well as CT-morphological findings consistent with metastatic gastric cancer. However, transgastric biopsies showed necrotising granuloma with giant cells leading to molecular and cultural detection of Mycobacterium tuberculosis instead of suspected neoplastic tissue. A nine-month treatment regimen for suspected disseminated tuberculosis with bone involvement was initiated according to national guidelines. Clinical and radiological follow up examinations after treatment completion showed complete remission.

BCG-osis following intravesical BCG treatment leading to miliary pulmonary nodules, penile granulomas and a mycotic aortic aneurysm.

A 69-year-old male patient who was treated with intravesical BCG for carcinoma in situ of the bladder, went on to develop systemic features of BCG-osis. This diagnosis was supported by significant radiological and clinical findings. These systemic features include pulmonary miliary lesions, a mycotic abdominal aortic aneurysm and penile lesions. Owing to a breakdown in the relationship between the patient and the National Health Service, the patient has declined BCG treatment. This case highlights the potential rare side effects of intravesical BCG treatment and the risk associated with non-treatment of BCG-osis.

Acute respiratory distress syndrome in disseminated tuberculosis: an uncommon association.

OBJECTIVE: To analyse clinicopathological features of acute respiratory distress syndrome (ARDS) in disseminated tuberculosis (TB) at autopsy. METHODS: A retrospective analysis of an autopsy database of disseminated TB from 1990 to 2010 was conducted. ARDS cases were assessed for histological changes of diffuse alveolar damage (DAD) and other pathological pulmonary features. RESULTS: Disseminated TB was diagnosed in 196 cases. The clinical diagnosis of disseminated TB was made in 67% of cases. Of the 196 cases, 10 met the clinical criteria for ARDS, 60% of whom showed histological evidence of DAD. One case of DAD was diagnosed on histology alone. DAD was thus found in 7/196 cases of disseminated TB. Other pulmonary changes included necrotising granulomas (n = 10), tuberculous bronchopneumonia (n = 4), tuberculous vasculitis (n = 3), infarction (n = 1) and aspergilloma (n = 1). Histopathological diagnosis other than DAD was found in 4/10 cases and disseminated TB was presumed clinically in only 4/10 cases of ARDS. CONCLUSION: Disseminated TB may be clinically missed and diagnosed only post mortem. Disseminated TB is a relatively uncommon cause of ARDS; however, it should always be presumed clinically as it is a potentially treatable cause. DAD is a rare histological feature of disseminated TB and there may not always be a clinicopathological correlation between ARDS and DAD.

Tuberculous Conjunctivitis in an Anophthalmic Socket.

Tuberculous (TB) conjunctivitis was not an uncommon condition before the early 20(th) century but is currently a rare occurrence, especially in the developed countries. We report a 27-year-old Saudi female who underwent enucleation of the right eye at the age of 20 following a penetrating eye injury. She had a history of miliary TB that was treated at the age of 22. She was presented with chronic purulent discharge from her right an anophthalmic socket for 2 months. Cultures for bacteria and fungi were sterile. There was no response to empirical topical antibiotics and steroids. Direct microscopic examination of conjunctival scrapings with the Ziehl-Neelsen staining revealed no microorganisms. Histopathological examination revealed epithelioid granulomas. Polymerase chain reaction was negative for Mycobacterium tuberculosis DNA. TB conjunctivitis was suspected from the history of miliary TB and presence of epithelioid granulomas. The definitive diagnosis was made after prompt resolution of the ocular signs with no recurrence only after systemic anti-TB therapy.

Percutaneous breast implant herniation: a rare complication of miliary TB.

We describe the case of a 46-year-old female patient treated for disseminated tuberculosis (TB) infection involving the lungs, urinary tract and skin. Following initiation of antituberculous therapy, the patient's right breast implant eroded through the overlying skin and was seen to be herniating through the resulting defect. The breast implant was removed under local anaesthetic and histological analysis of the resected tissue demonstrated granuloma formation consistent with periprosthetic TB. Wound healing following implant removal was poor and future breast augmentation surgery was only considered following completion of 12 months anti-TB treatment. This case constitutes the first report in the literature of percutaneous breast implant herniation resulting from periprosthetic infection with TB. A high index of suspicion is required to ensure early detection and timely management of TB and, in cases where periprosthetic pus aspirate is sterile, mycobacterial infection must be actively excluded.

Intestinal tuberculosis in a child living in a country with a low incidence of tuberculosis: a case report.

BACKGROUND: Relatively common in adults, intestinal tuberculosis is considered rare in children and adolescents. The protean manifestations of intestinal tuberculosis mean that the diagnosis is often delayed (sometimes even for years), thus leading to increased mortality and unnecessary surgery. The main diagnostic dilemma is to differentiate intestinal tuberculosis and Crohn's disease because a misdiagnosis can have dramatic consequences. CASE PRESENTATION: A 13-year-old Caucasian, Italian female adolescent attended the Emergency Department complaining of abdominal pain, a fever of up to 38 °C, night sweats, diarrhea with blood in stool, and a weight loss of about three kilograms over the previous two months. Physical examination revealed a marked skin pallor and considerable abdominal distension with relevant discomfort in all the abdominal quadrant. Laboratory tests revealed a decreased white blood cell count with anemia and increased C-reactive protein levels. The Mantoux tuberculin skin test was negative. A chest X-ray and an abdominal ultrasonography did not reveal any significant findings. The patient underwent colonoscopy that showed diffuse mucosal congestion and significant blood loss, and laparatomy showed small bowel and colon loops with a whitish appearance. A biopsy of the ileal mucosa revealed inflammation with noncaseating granulomas possibly due to bacterial infection. Given the suspicion of an opportunistic bacterial infection in a child with chronic inflammatory bowel disease (possibly Crohn's disease), treatment with a third-generation cephalosporin was started. However, the abdominal pain, fever and poor general condition persisted and so, after 11 days, the patient underwent total body computed tomography and magnetic resonance imaging of the brain. On the basis of the radiological findings, miliary tuberculosis was suspected and bronchoscopy was performed and resulted positive for Mycobacterium tuberculosis. Miliary tuberculosis was confirmed and an effective treatment with four drugs was started. CONCLUSION: This case shows that the manifestations of intestinal tuberculosis can be very difficult to diagnose and mimic those of Chron's disease. Total body computed tomography and laparotomy with an intestinal biopsy for the detection of Mycobacterium tuberculosis are the means of avoid the risks of a misdiagnosis in children with unexplained chronic abdominal problems.

Rapidly progressive glomerulonephritis in tuberculosis.

Renal involvement in tuberculosis occurs due to lympho-hematogenous dissemination. However, glomerular involvement is an uncommon event. Crescentic nephritis complicating tuberculosis is a therapeutic dilemma and weighs the risk of worsening the infection after immunosuppressive therapy. We present here a case of miliary tuberculosis with immune complex crescentic nephritis with advanced renal injury requiring renal replacement therapy. A diagnosis of miliary tuberculosis was made on the basis of positive sputum AFB, lymph node biopsy showing caseating granulomas and urinary polymerase chain reaction being positive for mycobacterial antigens. The patient recovered renal function with anti-tuberculous therapy with-out requiring immunosuppressive therapy.

Pact with the devil: alemtuzumab therapy, immune suppression and infectious complications in chronic lymphocytic leukemia.

Infectious complications are an important cause of hospitalization in patients diagnosed with chronic lymphocytic leukemia. The pathogenesis of infection is complex, involving both disease-induced and treatment-related immune depression. During the last decade, the management of chronic lymphocytic leukemia (CLL) has been redefined by the approval of monoclonal antibody-based treatment, which resulted in improved therapeutic responses. Nonetheless, the profound lymphopenia induced by monoclonal agents was accompanied by increased incidence of infections caused by a new spectrum of opportunistic microorganisms. We report the case of a patient with hypercellular CLL who received Alemtuzumab as first line therapy and obtained a satisfactory therapeutic response, but developed subsequent atypical infectious complications.

Tumour necrosis factor-alpha and nitric oxide response in different categories of tuberculosis patients.

OBJECTIVE: To compare the magnitude of tumour necrosis factor alpha (TNF-α) and nitric oxide (NO) response in different categories of active tuberculosis (TB) patients by ex vivo experiment. DESIGN: New, relapsed (recurrent), miliary and pleural effusion TB cases were recruited with matched healthy controls. TNF-α and NO were measured from the culture supernatant of peripheral blood monocytes derived from cases and controls with and without challenge with live Mycobacterium tuberculosis H37Rv. RESULTS: TNF-α and NO production varied significantly among the different categories of TB patients. The magnitude was highest among patients with pleural effusion and lowest in miliary TB cases. In between, progressive decreases in response were noted in new and relapse cases. Overall, positive correlations between TNF-α and NO were noted among the diseased and healthy groups. CONCLUSION: Distinct TNF-α and NO levels appear to be associated with different clinical forms of TB and might help to assess prognosis and contribute to a better understanding of underlying immunopathological mechanisms.

Challenges in the diagnosis & treatment of miliary tuberculosis.

Miliary tuberculosis (TB) is a potentially lethal disease if not diagnosed and treated early. Diagnosing miliary TB can be a challenge that can perplex even the most experienced clinicians. Clinical manifestations are nonspecific, typical chest radiograph findings may not be evident till late in the disease, high resolution computed tomography (HRCT) shows randomly distributed miliary nodules and is relatively more sensitive. Ultrasonography, CT and magnetic resonance imaging (MRI) are useful in discerning the extent of organ involvement by lesions of miliary TB in extra-pulmonary locations. Fundus examination for choroid tubercles, histopathological examination of tissue biopsy specimens, conventional and rapid culture methods for isolation of Mycobacterium tuberculosis, drug-susceptibility testing, along with use of molecular biology tools in sputum, body fluids, other body tissues are useful in confirming the diagnosis. Although several prognostic markers have been described which predict mortality, yet untreated miliary TB has a fatal outcome within one year. A high index of clinical suspicion and early diagnosis and timely institution of anti-tuberculosis treatment can be life-saving. Response to first-line anti-tuberculosis drugs is good but drug-induced hepatotoxicity and drug-drug interactions in human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) patients pose significant problems during treatment. However, sparse data are available from randomized controlled trials to define the optimum regimen and duration of treatment in patients with drug-sensitive as well as drug-resistant miliary TB, including those with HIV/AIDS.

Disseminated kidney tuberculosis complicating autosomal dominant polycystic kidney disease: a case report.

Mycobacterium tuberculosis infection in patients with autosomal dominant polycystic kidney disease (ADPKD) is rare, and its diagnosis and treatment are difficult because numerous cysts are exposed to infection and antibiotics do not easily penetrate infected cysts. Here, we report the case of a 43-year-old Japanese man with disseminated urogenital tuberculosis (TB) and ADPKD without human immunodeficiency virus (HIV) infection. Delayed diagnosis and ineffective anti-TB chemotherapy worsened his condition. Finally, he underwent bilateral nephrectomy but experienced postoperative complications. In conclusion, kidney TB should be recognized as a cause of renal infection in ADPKD, and surgical treatment should be instituted without delay. The importance of early diagnosis and treatment cannot be overemphasized to prevent kidney TB deterioration.

Miliary tuberculosis complicated by pulmonary cavitations and pneumothorax in a 14-month old boy.

Surgical management of tuberculosis is uncommon in children. We report a case of a 14-month-old boy with miliary tuberculosis and recurrent pneumothorax due to cavities in the left lung. This boy had no previous medical history and was referred to our hospital for a severe pneumonia. Initial chest radiograph showed bilateral miliary pattern. Direct microscopy of gastric lavage showed the presence of tubercle bacilli, providing definitive diagnosis. In spite of effective medication, his status rapidly worsened. A cardiac resuscitation was followed by intubation, and he required high-pressure ventilation for four weeks. He developed left pneumothorax, for which several drainages were performed. Computed tomography revealed a huge cavern system involving the entire lingula and surrounded by the left pneumothorax. Eventually, a massive enlargement of the initial cavity necessitated a thoracotomy and wedge resection.

Autopsy cases of miliary tuberculosis: clinicopathologic features including background factors.

To assist physicians, especially young physicians, in identifying tuberculosis (TB) infection before the terminal stage, we analyzed 7 cases of numerous tuberculous granulomas in multiple organs and compared clinical and autopsy findings between cases. Patients ranged in age from 41 to 86 years at the time of death. The main chief complaint was fever of unknown origin (3 of 7 cases [43%]). The main underlying conditions were liver cirrhosis (2 of 7 cases [29%]) and chronic renal failure (2 of 7 cases [29%]). Two patients (29%) had been given methylprednisolone pulse therapy for various lung disorders. Active TB was not diagnosed before autopsy in 4 of 7 (57%) patients. Calcified lesions indicative of old TB were present in 4 of 7 (57%) patients. Thus, miliary tuberculosis may represent a re-emergence of latent TB infection in these cases. Various histologic features of nonreactive exudative inflammation were seen, along with granulomas containing Langhans giant cells with or without caseous necrosis in hypervascular organs, such as the lung, liver, and bone marrow. Physicians should be mindful of the possibility of miliary TB when older patients with hepatorenal disease and a history of TB infection have undergone immunosuppressive treatment. Active tuberculous infection can depend on the presence of an underlying disease and immunocompromise.

Sepsis tuberculosa gravissima: Una presentación infrecuente en paciente con tratamiento inmunosupresor / Severe disseminated tuberculosis in a patient on immunosuppressive treatment: Report of one case

Patients on immunosuppressive therapy are at increased risk of developing tuberculosis. We report a 39-year-old female with an ulcerative colitis receiving prednisone, azathioprine and azulfidine that was admitted to hospital due to fever, anemia, diarrhea and hematochezia. A chest CT scan showed multiple miliary micronodular images diffusely distributed and mediastinal enlarged lymph nodes with central necrosis, suggestive of disseminated tuberculosis. Antituberculous treatment was started but discontinued and the patient was treated as a bronchiolitis obliterans with methylprednisolone pulses and discharged. She was readmitted in shock one week later and died. After her death cultures for Mycobacterium tuberculosis were informed as positive. The clinical picture of the patient is known as sepsis tuberculosa gravissima.

[Miliary tuberculosis: a report of 49 cases]. / Miliaire tuberculeuse: à propos de 49 cas.

INTRODUCTION: Miliary tuberculosis is a severe, acute form of tuberculosis due to lymphohaematogenous dissemination of tubercle bacilli from a focal lesion. PATIENTS AND METHODS: A prospective study of was undertaken at the Pneumology Clinic of the National University Hospital Centre (CHUN) of Fann, over a period of 30 months (January 2007-June 2009), in order to assess the epidemiological, clinical, paraclinical and evolutionary aspects of miliary tuberculosis. RESULTS: Miliary tuberculosis accounted for 3.8% (n=49) of all diagnosed cases of tuberculosis. The sex-ratio was 1.7. The average age of patients was 37.5 years with a range of 15 to 70 years. The typical radiological appearances were present in 88% of cases whereas only 10% were positive on direct smear. HIV serology was positive in 29%. In the hospital environment, the mortality was 12.2%. CONCLUSION: Miliary tuberculosis is a severe form of the disease. The prognosis depends on early diagnosis and treatment.