[Multifocal tuberculosis despite immunocompetence]. / Tuberculose multifocale en dépit d'une immunocompétence.

Tuberculosis is one of the deadliest infectious disease. Its annual incidence was 10 million cases in 2019. We report the case of a 40 years old immunocompetent patient presenting with two large subcutaneous masses in his back. The diagnosis work-up will reveal multifocal tuberculosis with pulmmonary, vertebral, muscular and lymph node lesions. This case is unusual due to its presentation in an immunocompetent patient. Several laboratories have conducted experiments to isolate characteristics of the host that would allow the infection to spread despite the absence of an immunosuppressive medical condition. We also analyze the role of the PET scanner in the initial assessment and its interest in the monitoring of extra-pulmonary disease under anti-tuberculosis treatment. Multifocal tuberculosis cases are no longer the preserve of the immunocompromised and can be found in our industrialized countries. We must enonciate this diagnosis in front of unusual presentations. The delay in consultation, but also the delay of treatment, allows more widespread infections.

La tuberculose est une des maladies infectieuses les plus mortelles. Son incidence annuelle était de 10 millions de cas en 2019. Nous rapportons le cas d'un patient immunocompétent de 40 ans qui se présente avec deux volumineuses masses sous-cutanées au niveau du dos. La mise au point révélera une tuberculose multifocale avec une atteinte pulmonaire, vertébrale, ganglionnaire et des collections abcédées musculaires plurifocales. Ce cas est atypique de par sa présentation chez un patient immunocompétent. Plusieurs laboratoires ont essayé d'isoler des caractéristiques de l'hôte qui permettraient à l'infection une extension disséminée malgré l'absence de condition médicale immunodépressive. Nous analysons également le rôle du PET scanner dans le bilan initial et son intérêt dans le suivi des foyers extra-pulmonaires sous traitement anti-tuberculeux. Les cas de tuberculose multifocale ne sont plus l'apanage des patients immunodéprimés et peuvent se rencontrer dans les pays industrialisés. Le diagnostic doit pouvoir être évoqué devant des présentations atypiques. Le retard du diagnostic et de la prise en charge thérapeutique favorise des infections plus étendues.

Multifocal skeletal tuberculosis with mycobacteremia after kidney transplantation: A case report.

Solid organ transplant recipients have a higher risk of active Mycobacterium tuberculosis infection (TB) compared to the general population. Recognized risk factors are immunosuppressant use, graft dysfunction, diabetes mellitus, liver disease caused by the hepatitis C virus, and co-infections by other opportunists. Most of the active TB cases reported in solid organ transplant recipients occur in kidney transplant patients, especially if they come from M tuberculosis-endemic areas. Extrapulmonary and disseminated TB are among the wide spectrum of clinical presentations found, but the lungs are the most common organ affected. Disseminated disease occurs in up to a third of the affected population, however, multifocal osteoarticular TB with mycobacteremia is unusual. We report the case of a kidney transplant patient with disseminated M tuberculosis infection, who presented with multifocal skeletal TB.

Multifocal tuberculosis simulating a cancer-a case report.

BACKGROUND: Tuberculosis is a disease that may affect any organ of the body. Multifocal tuberculosis involving multiple systems with associated symptoms are rare, which makes the diagnosis challenging. Distinguishing multifocal tuberculosis from lesions metastatic from system malignancy is difficult. Single detection method is difficult to make a diagnosis. A combination of multiple methods is essential. CASE PRESENTATION: A 17-year-old male presented with a 20 days weakness of lower limbs, which aggravated for 6 days. The PET/CT showed increased metabolism of ileocecal intestinal and terminal ileum wall, multiple enlarged lymph node (LNs), multiple osteolytic bone lesions, and soft tissue intensity belong T7 and T8 vertebrae. To confirm the diagnosis of the disease, a biopsy of the mediastinum lymph nodes was carried out. Polymerase chain reaction (PCR) test of the specimen was positive for the Mycobacterium tuberculosis, the T-SPOT and Xpert MTB/RIF test were also positive, which suggested the presence of Mycobacterium tuberculosis. The final diagnosis was multifocal tuberculosis, the patients received the resection of the mass in the spine. Anti-tuberculosis drugs were given. The myodynamia and muscle tension of the patients recovered following the therapy. CONCLUSIONS: Our results indicated that Multifocal tuberculosis should also be taken into consideration when lesions metastatic from system malignancy were suspected from images results even without the clinical symptoms of tuberculosis, and combination of multiple diagnosis methods were essential for the diagnosis of multifocal disease.

Multifocal tuberculosis revealed by a sternal swelling in an immunocompetent child.

Tuberculosis (TB) is one of the most common pathogens of bacterial lung infections, especially in underdeveloped nations like Morocco, where the incidence of TB was 97 cases per 100 000 persons in 2019. Thanks to its national TB prevention and control plan, Morocco was able to achieve remarkable progress in the management of TB with an 80% reduction in the total number of patients diagnosed with TB between 1980 and 2018. The national plan also allowed us to reach and maintain a therapeutic rate above 86% since 2002. Sternal TB is a rare clinical condition accounting for 1% of all musculoskeletal TB cases. Due to its rarity and the lack of awareness of clinical presentations, the diagnosis of sternal TB can be quite complex. We describe the case of a 14-year-old Moroccan patient consulting in the Military Hospital Mohammed V-Rabat with central chest pain for 4 months which was not associated with breathing, physical exercise or eating. The patient also had a history of asthenia, fever and weight loss. A computed tomography scan of the chest showed a destructive lesion of the sternum. Afterward, a chirurgical biopsy was performed and enabled to confirm the microbiological diagnosis of TB with the realization of the real-time PCR. The antitubercular therapy was given to the patient who had complete resolution of symptoms. This condition should be included in the differential diagnosis of chronic chest pain that mimics costochondritis particularly in patients from endemic areas.

Atypical cutaneous tuberculosis with an unusual course.

Cutaneous tuberculosis represents the fifth extrapulmonary form in Morocco after pleural, lymph node, urogenital, and intestinal tuberculosis. It is recognized to form a continuous immunopathologic spectrum, ranging from a high intensity to a low intensity of cell-mediated immunity, which explains the multiplicity and heterogeneity of anatomo-clinical forms. Association of multiple forms in the same patient is really rare. In this regard, we report a case of scrofuloderma on axillary tuberculosis adenitis associated to a lupus vulgaris in an immunocompetent patient, which was confirmed by histology, QuantiFERON-TB Gold test, and polymerase chain reaction. He received an antituberculous therapy with clinical regression of the lesions. In conclusion, cutaneous tuberculosis is still endemic in developing countries.The diagnosis is difficult because of its clinical polymorphism. That's why it's should be suspected clinically in the presence of any destructive or verrucous skin lesion evolving without healing for a long period and confirmed by bacteriological examinations and histology.

Thyroid tuberculosis associated with papillary microcarcinoma: case report and review of literature.

Introduction: Thyroid tuberculosis (TB) is extremely rare. Infection may first occur in the thyroid gland or may be secondary to TB in other parts of the body. The diagnosis is rarely made clinically because the disease's variable presentation often resembles that of a malignancy or an euthyroid nodular goiter. Case report: We present the case of a 40-year-old woman, who presented multiple thyroid nodules in both lobes. Two of these nodules were classified as EU-TIRADS V (European Thyroid Imaging and Reporting Data System). The ultrasound also found an adenopathy of the inferior part of the jugular lymphatic chain, in favor of malignancy. The histopathological examination after total thyroidectomy showed thyroid TB, associated to a papillary microcarcinoma of the right thyroid lobe, and the final examination of the adenopathy showed similar granulomas with caseous necrosis, and no signs of metastasis. Clinical discussion: Thyroid TB is very rare. Its diagnosis is difficult due to a lack of specific signs and symptoms, which is why the diagnosis is most commonly made on pathological examination after thyroid surgery. It is well known that mycobacterial infection creates an environment of chronic and persistent inflammation, with possible DNA damage. This can create a microenvironment that is highly conductive to carcinogenesis, which could explain the discovery of papillary microcarcinoma in addition to thyroid TB in our patient. Conclusion: This report presents a rare case of malicious growth development of thyroid nodules and thyroid TB. Therefore, physicians must always be vigilant when managing thyroid nodules, as there is always the possibility of malignant lesions associated to an inflammatory or infectious cause.

Multifocal Tuberculous Spondylitis and Extensive Extraspinal Tubercular Osteomyelitis without Immunocompromise: Case Report and Literature Review.

Multifocal extensive spinal and extraspinal tuberculosis is very rare. So far, fewer than 10 cases have been reported. We hereby report two such cases to highlight their rarity, the diagnostic and therapeutic challenges they presented, and the overall prognosis of the condition. The two patients (a 19-year-old woman and another 20-year-old woman) had multifocal extensive tuberculosis involving spine and appendicular skeleton with neurological deficit. Both patients presented with back and neck pain and gradual neurological deficit. The insidious onset and malignancy-like spread pattern mimicked neoplasm. After thorough investigations with magnetic resonance imaging, positron emission tomography scan, and biopsy, antitubercular drug therapy was started, and debridement and fixation were done for significant thoracic and cervical vertebral lesions, respectively. Both patients showed excellent neurological recovery after the procedure. Early surgical treatment of the cases with large abscesses helped provide decompression and stabilization and prevented neurological deterioration and deformity. In patients with noncontiguous spinal tuberculosis, high percentage of surgical treatment may be required due to the aggressive behavior of the disease.

[Ear tuberculosis concomitant with pulmonary localization in an HIV-immunosuppressed patient, in Bamako, Mali]. / Tuberculose auriculaire concomitante à une localisation pulmonaire chez un patient immunodéprimé par le VIH, à Bamako, Mali.

Introduction/Rationale: Tuberculosis remains a major public health issue. It is an opportunistic pathology, very common in HIV-immunocompromised persons, classifying it at the WHO stage 4. Ear tuberculosis remains a rare and under-diagnosed clinical form. We report here a case of ear tuberculosis concomitant with pulmonary localization in an HIV-immunosuppressed person on triple antiretroviral therapy aged 32 years hospitalized in Bamako (Mali) to discuss the diagnostic and therapeutic difficulties posed by this rare localization. Description of the case: The patient had a chronic productive cough, otalgia and right chronic purulent otorrhea. The search for acid-resistant bacilli was positive for direct examination in gastric casing fluid and swabbing of the ear pus, confirming the diagnosis of tuberculosis. Anti-tuberculosis treatment instituted for 6 months associated with adjuvants resulted in complete healing of the patient. Discussion/conclusion: Although rare, ear localization must be actively sought. Etiological treatment must be instituted upon confirmation of the diagnosis to avoid complications and sequelae.

Macrophagic activation syndrome revealing disseminated multifocal tuberculosis: A case report of a rare clinical situation.

Introduction: Macrophage activation syndrome (MAS) is a rare but serious entity, sometimes triggered by an infectious agent, in particular by certain viruses or mycobacteria. Forms of tuberculosis complicated by MAS frequently occur in immunocompromised subjects. The disease is often disseminated, severe, and has a poor prognosis. Case presentation: We report a case of MAS complicating disseminated tuberculosis and revealing HIV in a previously healthy young patient. Discussion & conclusion: The management of macrophage activation syndrome related to tuberculosis is complex and not codified. On the one hand, the immunosuppressive treatment allows to slow down the macrophage activation syndrome and obtain a correction of cytopenia. On the other hand, there is a risk of aggravating tuberculosis by increasing the patient's immunodepression.

[Multifocal tuberculosis simulating multimetastatic colon cancer in an immunocompetent black African patient: a case report]. / Tuberculose multifocale simulant un cancer du côlon multi-métastatique chez un Noir africain immunocompétent: à propos d´un cas.

Multifocal tuberculosis is rare in immunocompetent subjects. It is characterized by the involvement of at least two extra-pulmonary sites, associated or not with lung disease. It is often difficult to diagnose. We here report a case of multifocal tuberculosis in a non-immunocompromised black African subject at the Hubert Koutoukou Maga National Hospital and University Center (CNHU-HKM) in Cotonou, Benin. The study involved a 23-year-old man, with no particular previous history, admitted with diffuse abdominal pain associated with alteration of general state. Clinical examination showed severe malnutrition and medium-volume ascites. Imaging tests (chest X-ray, ultrasound and computed tomography (CT) scan) showed multiple lung, liver, pancreatic, bone, lymph nodes and colic lesions suggesting multimetastatic tumor. Colonoscopy then showed budding lesion of the cecum. GeneXpert test showed Koch´s bacilli. The anatomo-pathological examination of colic biopsies and GeneXpert sputum test confirmed multifocal tuberculosis. The patient received antituberculosis treatment and nutritional support. However he died. Multifocal tuberculosis is a serious disease that is difficult to diagnose. Then it is frequently mis-diagnosed in tropical areas, especially when it occurs in immunocompetent patients.

A polymorphous cutaneous tuberculosis.

Cutaneous tuberculosis is uncommon, comprising 1%-2% of all extrapulmonary manifestations. It has a wide clinical spectrum. The clinical presentation depends on the route of the infection, the pathogenicity of the bacteria, and the immune status of the host. Association of multiple forms in a same patient is uncommon. We report a case of disseminated tuberculosis with polymorphous cutaneous lesions in an immunocompetent woman, combining scrofuloderma, gummas, and sporotrichoid lesions, along with tuberculous adenitis and bone tuberculosis.

rs6127698 polymorphism in the MC3R gene and susceptibility to multifocal tuberculosis in southern Chinese Han population.

OBJECTIVE: To investigate the relationship between melanocortin-3 receptor (MC3R) gene polymorphism and tuberculosis (TB) susceptibility in Han population in southern China. METHODS: A total of 341 patients with TB (173 with pulmonary TB and 168 with multifocal TB) and 359 healthy controls were enrolled. Genotyping was performed by PCR and DNA sequencing, and detection of protein was performed by western blot. RESULTS: The distributions of genotype and allele frequencies of rs6127698 differed significantly between the pulmonary and multifocal TB groups, and between the multifocal TB and control groups. The GG genotype was significantly more common among multifocal TB patients than among pulmonary TB patients (P = .009) and those in the control group (P = .001) under the recessive model. GG+GT genotype was more common in multifocal TB than in pulmonary TB (P < .01) and control group (P < .01) under the dominant model. G allele was more common in multifocal TB than in pulmonary TB (P < .0167) and control group (P < .0167). Patients with multifocal TB had an increased expression of MC3R protein than healthy controls (P < .05). CONCLUSIONS: In the southern Chinese Han population, the MC3R rs6127698 polymorphism, which accompanying an increased expression of MC3R protein,was associated with susceptibility to multifocal TB. Presence of the G allele increased the risk of developing multifocal TB.

A rare case of multiple lupus vulgaris in a multifocal tuberculosis pediatric patient.

Multifocal tuberculosis (TB) is rare. The risk of occurrence of multifocal TB is increasing in immunocompromised patients. Cutaneous entanglement in multifocal TB occurs more infrequently, and its association with multifocal TB is scarcely reported. The aim of this case report was to show a rare case of lupus vulgaris accompanied by multifocal skeletal TB (vertebrae and knee joint) in a 15-year-old girl. There were kyphosis and deformities seen on physical examination. Dermatological status showed an erythematous plaque on the cheek and an erythematous nodule on the index finger of the left hand. The additional examinations such as bacteriological, histopathological, and polymerase chain reaction (PCR) examinations supported the diagnosis of cutaneous TB. Radiographic and PCR examinations confirmed the diagnosis of multiple skeletal TB. Mycobacterium tuberculosis was obtained from GeneXpert® examination of the skin lesion on the right cheek and synovial fluid of the knee. Therefore, multifocal TB could be confirmed in this patient. The uncommonness of the skin involvement in TB infection should warn the clinicians to commit every possible examination to detect the TB involvement in other organs, especially in immunocompromised children with suspected skin lesions.

Tuberculous gummas: Epidemiological, clinical, bacteriological, immunological, and therapeutic features.

Tuberculous gummas are an unusual form of tuberculosis (TB) accounting for 1%-2% of all cutaneous TB cases. The aim of this article was to describe the epidemiological, clinical, bacteriological, immunological, and therapeutic features of this form upon a case report and a literature review. Forty-eight case reports were identified through a PubMed and Google Scholar search using the following keywords: "tuberculous gumma" and "metastatic tuberculous abscesse." Tuberculous gumma can occur at any age. Immunodepression is not a sine qua non condition to the development of the disease. Limbs are the most frequent site for gummas. Tuberculous gummas are associated to another location in only 73% of cases. The most frequent associated locations are lung, nodes, and musculoskeletal apparatus. Mantoux test is negative in 38% of cases. Skin stain is positive in 45% of cases and culture in 85% of cases. Giant epithelioid cell granuloma is present in 82.4% of cases. There is no universally accepted chemotherapy regimen for metastatic tuberculous abscesses. The classic 2RHZE/4RH is highly effective.

Multifocal tuberculosis revealed by spinal tuberculosis in an eleven-year-old Guianese child.

Multifocal tuberculosis in a child is rare event. Here we report a case of multifocal tuberculosis revealed by spinal tuberculosis in an eleven-year-old French Guianese girl. This observation underlines the difficulties, the consequences of delay, and the necessity of an early diagnosis of this disease for children.

[Multifocal tuberculosis in immunocompetent patients]. / Tuberculose multifocale chez les immunocompétents.

Multifocal tuberculosis is defined as the presence of lesions affecting at least two extrapulmonary sites, with or without pulmonary involvement. This retrospective study of 10 cases aims to investigate the clinical and evolutionary characteristics of multifocal tuberculosis. It included 41 cases with tuberculosis collected between 1999 and 2013. Ten patients had multifocal tuberculosis (24%): 9 women and 1 man, the average age was 50 years (30-68 years). Our patients were correctly BCG vaccinated. The evaluation of immunodepression was negative in all patients. 7 cases had lymph node tuberculosis, 3 cases digestive tuberculosis, 2 cases pericardial tuberculosis, 2 cases osteoarticular tuberculosis, 1 case brain tuberculosis, 2 cases urinary tuberculosis, 4 cases urogenital tuberculosis, 1 case adrenal tuberculosis, 1 case cutaneous and 1 case muscle tuberculosis. All patients received anti-tuberculosis treatment for a mean duration of 10 months, with good evolution. Multifocal tuberculosis is difficult to diagnose. It can affect immunocompetent patients but often has good prognosis. Anti-tuberculosis therapy must be initiated as soon as possible to avoid sequelae.

[Multiple meningeal and cerebral involvement revealing multifocal tuberculosis in an immunocompetent patient]. / Atteinte cérébro-méningée multiple révélant une Tuberculose multifocale chez un immunocompétent.

Tuberculosis is a public health problem in Morocco. Central nervous system involvement is nevertheless rare, occurring in the context of multifocal or miliary tuberculosis. However, it may be a mode of revelation even in an immunocompetent subject. We report the case of a 30-year old man with language disorder accompanied by significant impairment of general condition. Clinical examination showed Broca's motor aphasia, right-sided pyramidal syndrome and latero-cervical adenopathies. HIV serologic test was negative. Brain MRI showed lesions associating multiple intracranial tuberculomas and meningoencephalitis. Thoracic CT scan showed multiple pulmonary micronodules, cavity wall thickening and bronchiectasia of the right fowler and culmen. Lymph node biopsy revealed typical architecture of a TB granuloma. The diagnosis of multifocal tuberculosis was retained and the patient received anti-bacillary therapy associated with corticosteroid therapy with good clinico-radiological evolution. This study is peculiar due to the appearance and the seat of tuberculous lesions on brain imaging, the absence of immunodeficiency, a good evolution under treatment. It highlights the role of active and exhaustive assessment of associated extracerebral tuberculous infection in the case of cerebromeningeal lesion suggestive of tuberculosis.

Cutaneous tuberculosis revealing multifocal tuberculosis in immunocompetent patients.

Multifocal tuberculosis (TB) is rare. It occurs especially in immunocompromised patients. Association with skin involvement is rarer, and few cases are reported in the literature. The present study reports 7 cases of multifocal TB with cutaneous localization in immunocompetent patients. Cutaneous forms of TB included in this series are: gummas, scrofuloderma, vasculitis TB and lupus TB. The patients had at least two extra skin locations, namely: osteoarticular, lung, pleural, scrotal, muscular, digestive, laryngeal, nodal and splenic locations. These patients had no context of immunosuppression which is uncommon, but should be kept in mind, especially in endemic countries.