Obstructed ileocaecal tuberculosis with splenic tuberculosis and solid pseudopapillary tumour of tail of pancreas in an immunocompetent woman.

A 22-year-old young woman presented with fever, lower abdominal pain and vomiting for 20 days. She had persistent fever and abdominal pain. Fever panel was negative. Clinical features were suggestive of subacute small bowel obstruction. Contrast-enhanced CT abdomen showed thickening of distal ileum, ileocaecal junction and caecum with conglomerate necrotic nodal mass in the ileocolic mesentry along with a lesion in the tail of pancreas. Patient was discussed with multidisciplinary team and decided to undergo a single-stage procedure after adequate nutritional optimisation. During optimisation, she underwent acute obstruction and hence taken up for emergency laparotomy proceeded to right haemicolectomy with distal pancreatectomy and splenectomy 4 weeks after the time of admission. Histopathology showed ileocaecal tuberculosis and solid pseudopapillary tumour with margins free of tumour. Approach of obstructed ileocaecal tuberculosis in the setting of incidental diagnosis of solid pseudopapillary tumour of pancreas in a moribund patient was challenging.

Diagnostic Utility and Impact on Clinical Decision Making of Focused Assessment With Sonography for HIV-Associated Tuberculosis in Malawi: A Prospective Cohort Study.

BACKGROUND: The focused assessment with sonography for HIV-associated tuberculosis (TB) (FASH) ultrasound protocol has been increasingly used to help clinicians diagnose TB. We sought to quantify the diagnostic utility of FASH for TB among individuals with HIV in Malawi. METHODS: Between March 2016 and August 2017, 210 adults with HIV who had 2 or more signs and symptoms that were concerning for TB (fever, cough, night sweats, weight loss) were enrolled from a public HIV clinic in Lilongwe, Malawi. The treating clinicians conducted a history, physical exam, FASH protocol, and additional TB evaluation (laboratory diagnostics and chest radiography) on all participants. The clinician made a final treatment decision based on all available information. At the 6-month follow-up visit, we categorized participants based on clinical outcomes and diagnostic tests as having probable/confirmed TB or unlikely TB; association of FASH with probable/confirmed TB was calculated using Fisher's exact tests. The impact of FASH on empiric TB treatment was determined by asking the clinicians prospectively about whether they would start treatment at 2 time points in the baseline visit: (1) after the initial history and physical exam; and (2) after history, physical exam, and FASH protocol. RESULTS: A total of 181 participants underwent final analysis, of whom 56 were categorized as probable/confirmed TB and 125 were categorized as unlikely TB. The FASH protocol was positive in 71% (40/56) of participants with probable/confirmed TB compared to 24% (30/125) of participants with unlikely TB (odds ratio=7.9, 95% confidence interval=3.9,16.1; P<.001). Among those classified as confirmed/probable TB, FASH increased the likelihood of empiric TB treatment before obtaining any other diagnostic studies from 9% (5/56) to 46% (26/56) at the point-of-care. For those classified as unlikely TB, FASH increased the likelihood of empiric treatment from 2% to 4%. CONCLUSION: In the setting of HIV coinfection in Malawi, FASH can be a helpful tool that augments the clinician's ability to make a timely diagnosis of TB.

Splenic tuberculosis and multifocal serpiginoid choroiditis.

Serpiginoid multifocal choroiditis is a distinct morphological identity with a reported causal association with Mycobacterium tuberculosis. We report a case of serpiginoid multifocal choroiditis in a 17-year-old boy who was suffering from isolated splenic tuberculosis. He was treated with systemic steroids along with anti-tubercular treatment with good visual recovery. This case was unique as no other organs except spleen and choroid showed tubercular involvement. We hereby emphasize association of extrapulmonary sites with multifocal serpiginoid choroiditis and propose a thorough investigation for primary to be included in routine protocol of choroiditis workup.

Genomic diversity in autopsy samples reveals within-host dissemination of HIV-associated Mycobacterium tuberculosis.

Mycobacterium tuberculosis remains a leading cause of death worldwide, especially among individuals infected with HIV. Whereas phylogenetic analysis has revealed M. tuberculosis spread throughout history and in local outbreaks, much less is understood about its dissemination within the body. Here we report genomic analysis of 2,693 samples collected post mortem from lung and extrapulmonary biopsies of 44 subjects in KwaZulu-Natal, South Africa, who received minimal antitubercular treatment and most of whom were HIV seropositive. We found that purifying selection occurred within individual patients, without the need for patient-to-patient transmission. Despite negative selection, mycobacteria diversified within individuals to form sublineages that co-existed for years. These sublineages, as well as distinct strains from mixed infections, were differentially distributed throughout the lung, suggesting temporary barriers to pathogen migration. As a consequence, samples taken from the upper airway often captured only a fraction of the population diversity, challenging current methods of outbreak tracing and resistance diagnostics. Phylogenetic analysis indicated that dissemination from the lungs to extrapulmonary sites was as frequent as between lung sites, supporting the idea of similar migration routes within and between organs, at least in subjects with HIV. Genomic diversity therefore provides a record of pathogen diversification and repeated dissemination across the body.

Splenic Tuberculosis--Case Report.

The authors advance the case of a patient aged 42, with cardiovascular disorders who is hospitalized for non-specific, but persistent symptomatology: asthenia, fatigability, dyspnoea, night sweats. The clinical (splenomegaly), abdominal ultrasonographic (splenic hypo-echogenic lesions) and computed tomographic (splenic hypo-dense lesions) elements lead to a splenic disorder, but the association of intra-thoracic and intra-abdominal adenopathies(CT revealed) raises suspicion of a chronic lymphoproliferative syndrome. Splenectomy by open approach is performed and the surprise comes from histopathology: splenic tuberculosis. Clinical, diagnostic and therapeutic aspects of tuberculosis with splenic localization are presented.

Rotura esplénica como complicación de una tuberculosis miliar / Spontaneous splenic rupture as a complication of extrapulmonary tuberculosis

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Isolated hepatosplenic tuberculosis: a rare presentation.

Tuberculosis caused by Mycobacterium tuberculosis presents a major health challenge in endemic countries and spares no organ in the human body. This infection is a mimicker of various disease processes such as metastasis, lymphoproliferative diseases, and other granulomatous conditions such as sarcoidosis and fungal infections. The most challenging and important differential is metastasis, especially in the disseminated form of tuberculosis. We present a histopathologically proven case of isolated hepatosplenic tuberculosis that was provisionally diagnosed as lymphoma due to its unusual, restricted involvement of the liver and spleen.

18F-FDG PET and PET/CT in diagnosis and treatment monitoring of pyrexia of unknown origin due to tuberculosis with prominent hepatosplenic involvement.

The potential of (18)F-FDG PET/CT in the diagnosis and treatment response monitoring of fever of unknown origin (resulting from hepatosplenic tuberculosis) is demonstrated in this report. The patient was a 32-y-old woman who had presented to us with a history of pyrexia of unknown origin for the past 2 mo. On investigation, she was found to have hepatic and splenic granulomas, with whole-body (18)F-FDG PET demonstrating abnormal (18)F-FDG-avid foci in the liver and spleen. Ultrasonography-guided liver biopsy was suggestive of granulomatous hepatitis. The patient was clinically nonresponsive to first-line antitubercular drugs, and second-line antitubercular medications were added subsequently in view of clinical nonresponse. The patient responded well to the treatment. The repeated CT scan at 11 mo demonstrated persistence of the splenic granulomas; however, follow-up (18)F-FDG PET/CT at the same time showed resolution of (18)F-FDG-concentrating active disease foci with suggestion of complete metabolic response, commensurate with the patient's clinical improvement.

Deep vein thrombosis and tuberculosis: a causative link?

Pulmonary tuberculosis is very devastating in developing countries and its thrombogenic potential is a disturbing new entity. We report an 18-year-old woman who presented with a first episode of deep vein thrombosis. Pulmonary, hepatic and splenic tuberculosis was diagnosed while looking for secondary causes. The patient was treated with rifampicin, isoniazid, pyrazinamide and ethambutol along with low-molecular-weight heparin and antivitamin K. Tuberculosis has several mechanisms that induce a hypercoagulable state and can lead to thromboembolic complications.

PUO--a rare (and forgotten) cause!

Splenic tuberculosis is an extremely rare clinical entity and a frequently forgotten cause of pyrexia of unknown origin (PUO). We present the case of a 42 year old man who presented with fever of unknown origin. Ultrasonography revealed multiple hypoechoic areas within the spleen. As the abscesses did not respond to broad spectrum antibiotics splenectomy was done. The excised organ showed multiple cysts filled with pultaceous material. Histopathological examination revealed areas of granular caseating necrosis surrounded by epitheloid cells and Langhan's type giant cells consistent with splenic tuberculosis.There was no evidence of a primary focus in the lungs or in any other organ.The presence of isolated tubercular foci in the spleen without any evidence of tuberculosis in lung or other extra-pulmonary site prompted us to report this case.

Splenic tuberculosis presenting as fever of unknown origin with severe neutropenia.

Fever of undetermined origin always poses a challenging problem to the physician. Tuberculosis is an important health problem in developing countries. It is mostly seen in immune-compromised patients. And it is one of the common causes of fever of unknown origin. I am reporting a case of a splenic tuberculosis in 48 years old male who is not known of any immune deficiency state, he was presented with 3 weeks history of fever and found to have severe neutropenia and with negative work up for all hematological, rheumatological and malignant causes. A computerized tomography scan of the abdomen confirmed splenic enlargement with multiples hypo dense lesions consist with either splenic infection or splenic lymphoma so exploratory splenectomy was performed. Histological examination revealed granulomatouse inflammation with numerous acid fast bacilli consist with tuberculosis. He was started on four anti-tuberculouse drugs. in less than one week his fever subside with normalization of his neutrophilic count.

Idiopathic thrombocytopenic purpura associated with splenic tuberculosis: case report.

Tuberculosis is still one of the most prevalent and fatal infectious diseases in spite of considerable improvements in medical science. Splenic tuberculosis is a rare form of extrapulmonary tuberculosis. There are limited numbers of cases in which immune thrombocytopenia is associated with splenic tuberculosis. We report a case of immune thrombocytopenic purpura due to splenic tuberculosis. Our case was a 58-year-old female with headache, gum bleeding, redness in legs, and ecchymoses on the arms for 10 days. On admission to hospital, laboratory tests were as follows: platelet count 6.000/mmc (150 000-450 000), haemoglobin: 12 g/dl, WBC: 8000/mm3, erythrocyte sedimentation rate: 58 mm/h and C-reactive protein was in normal ranges. After standard laboratory tests, the patient was diagnosed with idiopathic thrombocytopenic purpura. The patient presented abdominal lymphadenopathies and spleen in normal size in radiological examinations. Diagnostic laparotomy and splenectomy and lymph node excision was performed and splenic tuberculosis was detected in pathologic and microbiologic examination. The patient was successfully treated with apheresis platelets suspension, intravenous immunoglobulin and antituberculous therapy. In conclusion, splenic tuberculosis should be suspected in patients who have fever, abdominal lymphadenopathies and immune thrombocytopenic purpura. Histopathological examination is still an ideal method to confirm the diagnosis, suitably aided by microbiological examination.

[Symptomatic hypercalcemia presenting as a case of isolated splenic tuberculosis]. / Hipercalcemia sintomática como forma de presentación de un caso de tuberculosis esplénica aislada.

BACKGROUND AND OBJECTIVE: To describe an unusual clinical presentation as isolated splenic tuberculosis. PATIENT AND METHODS: We report a case of isolated splenic tuberculosis, a rare form of extrapulmonary tuberculosis in an immunocompetent patient, and, as a peculiarity, debuts in the form of symptomatic hypercalcemia. RESULTS: We deeply report the clinical case and the procedures performed to exclude other diseases. We emphasize the usefulness of fine needle aspiration of the spleen to obtain microbiological samples, and the use of specific polymerase chain reaction for mycobacterias to establish the definitive diagnosis of this entity. In agreement with other authors, we chose initial medical treatment with antituberculous drugs, reserving surgery for refractory cases or in case of spontaneous splenic rupture. CONCLUSION: Hypercalcemia can be a presentation of granulomatous diseases. The isolated involvement of the spleen by mycobacterias is a rare form of extrapulmonary tuberculosis and more so in immunocompetent patients.