Hyperthyroidism due to involvement of thyroid gland in disseminated tuberculosis: A rare entity.

Involvement of the thyroid gland with tuberculosis (TB) is unusual and is commonly associated with hypothyroidism. Involvement of the thyroid as a part of disseminated TB is even rarer. Dissemination is an indication of immunosuppression. We present a 16-year-old immunocompetent girl with disseminated TB involving the thyroid gland and the right radius bone with features of hyperthyroidism. The patient responded well to anti-TB treatment.

Pituitary tuberculosis presented with pituitary coma.

BACKGROUND: Pituitary tuberculosis is very rare. Its diagnosis is difficult unless a bacteriological or histological evidence of tuberculosis. OBSERVATION: We report the case of a 54 years old woman who presented with a pituitary coma that occurred two weeks after the initiation of antituberculous therapy for cervical lymph node tuberculosis. Resonance magnetic imaging showed a pseudotumoral aspect of the pituitary gland. She had hormonal replacement and anti-tuberculous therapy. Outcome was favourable with the normalization of both the pituitary function and the pituitary volume. However, an acute hypopituitarism happened eight months after the withdrawal of antituberculous, which were taken during 12 months. The re initiation of anti tuberculous therapy and its extension to two years leaded to a prolonged remission. CONCLUSION: the three-phase outcome confirms the tuberculous origin of the hypophysitis in our patient.

Synchronous presentation of two rare forms of extrapulmonary tuberculosis.

Tuberculosis (TB) remains one of the leading infectious causes of death throughout the world. Extrapulmonary forms, namely adrenalitis and prostatitis, are rare presentations of TB and pose a difficult diagnostic challenge, given their non-specific manifestations. The authors present a case of a 42-year-old man with long-standing symptoms of fatigue, anorexia, weight loss, nightly fever and sudoresis. He also suffered from sporadic vomiting and episodic hypotension, and had skin hyperpigmentation, as well as frequent urination, perineal discomfort and pain at ejaculation. Laboratory investigation confirmed primary adrenal failure. On CT scan there were two hypodense right adrenal nodules and bilateral lung condensations with a tree-in-bud pattern. Another hypodense nodule was seen in the prostate. TB was diagnosed by isolatingMycobacterium tuberculosisfollowing cultures of bronchoalveolar lavage, bronchial secretions, urine and ejaculate. Antibacillary treatment resolved the infectious lesions but the patient remained on corticosteroid replacement therapy for ongoing adrenal failure.

Primary tuberculosis of the thyroid gland: an unexpected cause of thyrotoxicosis.

We describe a 38-year-old Indian man who presented with a 2-week history of fever, night sweats and neck swelling who was found to be clinically thyrotoxic with a nodular goitre, tachycardia and high fever. Biochemical investigation revealed hyperthyroidism in association with deranged liver function tests and raised inflammatory markers. Ultrasound and CT scans of the neck revealed multinodular thyroid enlargement. He was considered most likely to have an acute infectious thyroiditis with a differential diagnosis of a toxic multinodular goitre and was started on carbimazole and antibiotics. He underwent fine needle aspiration of the thyroid which revealed necrotic cells and acid-fast bacilli, confirming a diagnosis of primary tuberculosis (TB) of the thyroid gland with no evidence of any other organ involvement on systemic imaging. He was started on TB therapy for 6 months and discharged with outpatient follow-up. Symptoms and biochemical markers subsequently resolved.

Extrapulmonary disseminated tuberculosis with tuberculous adrenalitis: a stitch in time saves nine.

A 40-year-old manual labourer presented with easy fatiguability, recurrent vomiting and loss of weight of 3 months, duration. Upon examination, there was significant axillary and cervical lymphadenopathy. No pallor, icterus or clubbing was evident. There was generalised hyperpigmentation and multiple oral ulcers. The blood pressure 90/60 mm Hg in the right upper limb in the supine position. Investigations showed a low serum cortisol. Mantoux test was strongly positive (20 mm).A fine needle aspiration biopsy of the cervical lymph node revealed reactive changes. Bone marrow aspiration and biopsy were normal. Cervical lymph node biopsy showed caseating granulomas suggestive of tuberculous lymphadenitis. A CT scan of the abdomen showed bilaterally enlarged adrenal glands with hypodense areas suggestive of necrosis. He was diagnosed with extrapulmonary disseminated tuberculosis with tuberculous adrenalitis. He was started on directly observed therapy (DOTS) for disseminated tuberculosis and 40 mg of prednisolone. He is improving with treatment.

Addison's disease presenting with muscle spasm.

Primary hypoadrenalism has various causes and protean manifestation. We report a young female patient who presented with severe muscle spasm as her primary complaint. On evaluation she was found to be a case of Addison's disease secondary to adrenal tuberculosis. Her muscle spasm disappeared rapidly with replacement dose of glucocorticoid.

[Tuberculosis of the pancreas: an unsuspected cause of abdominal pain and fever]. / Tuberculosis pancreática: una causa insospechada de dolor abdominal y fiebre.

BACKGROUND: Tuberculosis is frequently the form of presentation of human immunodeficiency virus (HIV) infection even in patients who have not developed acquired immune deficiency syndrome (AIDS). Nevertheless, pancreatic affection is uncommon. Tuberculosis of the pancreas (TBP) is a clinical rarity and mimics pancreatic carcinoma both clinically and radiologically. CLINICAL CASE: We present the case of a 42-year-old man with a 5-day evolution of moderate abdominal pain in the right lower quadrant and fever and vomiting without diarrhea. The patient had no history of abdominal surgery. CT scan revealed a heterogeneously enhancing, multicystic structure in the pancreatic head. Due to suspicion of malignancy, a pancreatoduodenectomy was performed with pathological result of pancreatic tuberculosis. The patient was discharged on the 10th postoperative day without surgical complications. He died 10 months later of Pneumocystis jirovecii pneumonia. By that time he had a positive serum HIV antibodies test. CONCLUSIONS: TBP diagnosis can be missed or significantly delayed because it is often not suspected prior to laparotomy unless there is evidence of pulmonary tuberculosis. TBP should be considered in the differential diagnosis of a mass in the head of the pancreas. The response to early antituberculosis treatment is very effective.

Central diabetes insipidus induced by tuberculosis in a rheumatoid arthritis patient.

Tuberculosis, a polymorphic disease, is a diagnostic challenge, particularly when arises concomitantly to an autoimmune disease such as rheumatoid arthritis (RA). Herein, the authors describe a 33-year-old woman with nodular RA who was being treated with methotrexate, sulfasalazine and corticosteroids and presented with subcutaneous nodules simultaneously with aseptic meningitis. Mycobacterium tuberculosis was identified in cultures from a biopsy of an axillary nodule. The patient also developed polyuria and polydipsia with normal glycemia; antidiuretic hormone (ADH) treatment before and after a 3% saline infusion test was performed and diabetes insipidus was diagnosed. An encephalic MRI showed sellar and suprasellar masses, suggesting central diabetes insipidus (CDI). The patient received standard tuberculosis (TB) treatment for 6 months and also DDAVP (desmopressin acetate) during this period. Control of CDI was observed. A pre-surgical magnetic resonance imaging (MRI) showed no pituitary mass. It is known that intrasellar tuberculoma occurs in only 1% of TB patients. TB should be considered in the differential diagnosis of CDI, especially in immunosupressed patients and in countries where this infection is a serious public health problem.

Primary thyroid tuberculosis: a rare etiology of hypothyroidism and anterior cervical mass mimicking carcinoma.

OBJECTIVE: The involvement of the thyroid by tuberculosis (TB) is rare. Hypothyroidism caused by tissue destruction is an extremely rare report. Our aim was to report a patient with primary thyroid TB emphasizing the importance of diagnosis, despite the rarity of the occurrence. CASE REPORT: Women, 62 years old, showing extensive cervical mass since four months, referring lack of appetite, weight loss, dysphagia and dysphonia. Laboratorial investigation revealed primary hypothyroidism. Cervical ultrasound: expansive lesion in left thyroid lobe, involving adjacent muscle. Computed tomography scan: 13 cm diameter cervical mass with central necrosis. Fine needle biopsy: hemorrhagic material. SURGERY: total thyroidectomy, left radical neck dissection and protective tracheotomy. The pathological examination showed chronic granulomatous inflammatory process with areas of caseous necrosis and lymph node involvement. The thyroid baciloscopy was positive. Pulmonary disease was absent. The patient was treated with antituberculosis drugs. CONCLUSIONS: Thyroid TB is not frequent, and should be considered as differential diagnosis of hypothyroidism and anterior cervical mass.

Addison's disease induced by miliary tuberculosis and the administration of rifampicin.

We herein report a rare occurrence of Addison's disease caused by acute adrenal gland tuberculosis occurring in association with miliary tuberculosis and the administration of rifampicin. An 82-year-old woman with miliary tuberculosis was treated with antituberculous chemotherapeutic agents including rifampicin (RFP), but she still demonstrated general malaise in addition to hyponatremia. Abdominal CT showed an enlargement of the right adrenal gland. However, after discontinuing RFP, the patient's symptoms improved. We carefully reinitiated the administration of RFP. The patient's condition thereafter did not worsen, and the treatment could thus be maintained. It is extremely important to immediately recognize adrenal crisis precipitated by the administration of RFP.

Primary thyroid tuberculosis: a rare etiology of hypothyroidism and anterior cervical mass mimicking carcinoma / Tuberculose tireoidiana primária: rara etiologia de hipotireoidismo e massa cervical anterior mimetizando carcinoma

OBJECTIVE: The involvement of the thyroid by tuberculosis (TB) is rare. Hypothyroidism caused by tissue destruction is an extremely rare report. Our aim was to report a patient with primary thyroid TB emphasizing the importance of diagnosis, despite the rarity of the occurrence. CASE REPORT: Women, 62 years old, showing extensive cervical mass since four months, referring lack of appetite, weight loss, dysphagia and dysphonia. Laboratorial investigation revealed primary hypothyroidism. Cervical ultrasound: expansive lesion in left thyroid lobe, involving adjacent muscle. Computed tomography scan: 13 cm diameter cervical mass with central necrosis. Fine needle biopsy: hemorrhagic material. Surgery: total thyroidectomy, left radical neck dissection and protective tracheotomy. The pathological examination showed chronic granulomatous inflammatory process with areas of caseous necrosis and lymph node involvement. The thyroid baciloscopy was positive. Pulmonary disease was absent. The patient was treated with antituberculosis drugs. CONCLUSIONS: Thyroid TB is not frequent, and should be considered as differential diagnosis of hypothyroidism and anterior cervical mass.

OBJETIVO: A tuberculose tiroidiana ocorre raramente. O hipotireoidismo decorrente da destruição tiroidiana é um relato raríssimo. Nosso objetivo foi descrever o caso de paciente com tuberculose tiroidiana primária e ressaltar a raridade e a importância da doença. RELATO DO CASO: Mulher, 62 anos, apresentando massa cervical extensa há quatro meses, associada à inapetência, à perda de peso, à disfonia e à disfagia. A investigação laboratorial mostrou hipotireoidismo primário. Ultrassonografia: lesão expansiva em lobo esquerdo, envolvendo musculatura subjacente. Tomografia computadorizada: massa heterogênea com centro necrótico, 13 cm de diâmetro. Biópsia por agulha fina: material serossanguinolento. Cirurgia: tireoidectomia, dissecção radical à esquerda e traqueostomia protetora. Exame anatomopatológico: processo inflamatório crônico granulomatoso com áreas de necrose caseosa e comprometimento linfonodal. Baciloscopia tiroidiana positiva. Ausência de comprometimento pulmonar. A paciente foi tratada com drogas antituberculosas. CONCLUSÕES: Tuberculose tireoidiana não é frequente, mas deve ser considerada como diagnóstico diferencial de hipotireoidismo e massa cervical anterior.

Tuberculosis complicating tertiary hyperparathyroidism in a patient with end-stage renal disease: a case report.

A 36-year-old Nigerian woman on thrice-weekly dialysis presented with symptoms and signs of hypercalcaemia. Laboratory findings were consistent with tertiary hyperparathyroidism. Parathyroid hormone levels remained elevated and she underwent elective parathyroidectomy. Intra-operatively all 4 parathyroid glands and local lymph nodes showed necrotising granulomas with occasional acid-fast bacilli, pathognomonic of tuberculosis (TB). Post-operatively she completed a full course of anti-TB therapy and at 9 months she experienced complete resolution in her plasma biochemistry and was essentially symptom-free. This is a rare yet fascinating cause of hypercalcaemia in a dialysis patient and is the first recorded case of tubercular involvement of parathyroid tissue in a case of tertiary hyperparathyroidism. This report demonstrates the coexistence of 2 diseases that simultaneously worsened hypercalcaemia and thus emphasises the importance of the differential diagnosis and of careful histological examination post-operation.

[A case of adrenal tuberculosis complicated with acute exacerbation of adrenal insufficiency during the initial phase of anti-tuberculosis therapy for pulmonary tuberculosis].

A 36-year-old male was admitted to our hospital because of adrenal insufficiency. About one month before admission, he was diagnosed as pulmonary tuberculosis and started anti-tuberculosis therapy with isoniazid, rifampicin, ethambutol, and pyrazinamide. On the tenth day, general fatigue, abdominal pain, nausea and diarrhea developed, and laboratory examination showed hyponatremia [126 mEq/l]. Enhanced CT on admission revealed bilateral adrenal mass-like enlargement, and further examination showed high level of plasma ACTH, and low level of cortisol. These findings led to a diagnosis of adrenal insufficiency caused by adrenal tuberculosis. He was treated with hydrocortisone and his signs and symptoms rapidly improved. We suppose adrenal insufficiency became clinically apparent because rifampicin reduced half-life of serum cortisol. Interestingly we observed rapid increase and decrease in size of bilateral adrenal glands on CT scan during the course.

Addison's disease due to adrenal tuberculosis: MRI features.

BACKGROUND: Findings of adrenal tuberculosis with MR scanning have never been reported in the literature. The aim of this study was to determine MR characteristics for tuberculous Addison's disease, and evaluate the utility of MR imaging as a useful diagnosis tool of the entity. PATIENTS AND METHODS: Eighteen patients with proven adrenal tuberculosis were included. All patients had conventional T(1)- and T(2)-weighted image. Among the 18 patients, contrast-enhanced T(1)WI had been done in 10. MR manifestations were retrospectively evaluated blindly for the location, contour, signal intensity, and enhancement patterns. RESULTS: All patients clinically exhibited hyperpigmentation and lethargy. Physical examination revealed weight loss, signs of dehydration, and hypotension. Biochemical investigation confirmed adrenal insufficiency. The adrenal glands were affected bilaterally in 16 patients (89%) and unilaterally in 2 patients (11%). Thirty-three glands were enlarged (97%), while one was atrophic (3%). Of the 33 enlarged glands, 20 (61%) were mass-like and 13 (39%) had preserved contours. The central region of the enlarged glands demonstrated T(2) hypo- or iso-SI in 21 (62%) and T(2) hyper-SI in 12 (38%). Among the 18 enlarged glands that had contrast MR, 15 (83%) had peripheral rim enhancement, 1 (6%) had homogeneous enhancement, and the last two (11%) had heterogeneous enhancement. CONCLUSION: MR characteristics can reveal certain pathological changes of adrenal tuberculosis, and MR imaging could be recommended as the imaging modality for the diagnosis of the entity.