Unusual case of cerebral demyelination and bilateral optic neuritis in an infant with suppurative BCG lymphadenitis.

Cerebral demyelination and optic neuritis are often seen in children with acute disseminated encephalomyelitis following various infections and immunisations. An eight month old girl presented with a left axillary lymph node swelling and an erythematous lace-like rash over her cheeks and trunk. She then developed acute encephalopathy, bilateral nystagmus, right hemiparesis and left facial nerve palsy. Her electroencephalogram showed an encephalopathic process and visual evoked response study were grossly abnormal. Her MRI brain showed hyperintensities in the midbrain, pons and bilateral cerebellar peduncles. She was treated as postinfectious cerebral demyelination with intravenous antibiotics, methylprednisolone and immunoglobulin. Left axillary lymph node excision biopsy and GeneXpert test detected Mycobacterium tuberculosis complex that prompted initiation of antituberculous therapy. Her chest X-ray and cerebrospinal fluid examinations for tuberculosis were normal. She showed significant recovery after 2 weeks. This case illustrates a rare presentation of cerebral demyelination and bilateral optic neuritis following suppurative BCG lymphadenitis.

Tuberculosis reactivation related with ruxolitinib in a patient with primary myelofibrosis.

Primary myelofibrosis (PMF) is a clonal stem cell disease, characterized by bone marrow fibrosis. Ruxolitinib is a selective inhibitor of JAK-1 and JAK-2 used to treat PMF. Its mechanism of action is based on the reduction of signal transduction and cytokine levels; including IL-6 and tumor necrosis factor alpha. Increased infection risk related to Ruxolutinib is rarely reported. Here we describe a case of tuberculosis infection ractivation in a female patient treated with Ruxolitinib. During the treatment, she complained of night sweats, weight loss and enlarged mass in the neck. Excisional mass biopsy revealed a necrotizing granulomatous lymphadenitis. QuantiFERON-TB and PPD tests were not able to diagnose the tuberculosis infection. Therapy with Ruxolitinib was interrupted due to possible immunsuppressive effects and the patient was treated with the standard antituberculosis regimen. After six months, the patient's symptoms had resolved and there was no lymphoadenopathy. In conclusion, it is important to assess the risk of tuberculosis activation before Ruxolitinib treatment. In addition, the diagnosis of tuberculosis using QuantiFERON-TB and PPD may be misleading in patients treated with Ruxolutinib.

[Paradoxical reaction following antituberculosis therapy in immunocompetent patient]. / Réaction paradoxale à la fin du traitement antituberculeux chez le sujet immunocompétent.

INTRODUCTION: The features of paradoxical reactions (PR) that occurred in non-HIV infected patients are rare and not well known. CASE REPORT: The authors reported the case of a 21years old, non-immunocompromised, and HIV negative patient treated for disseminated tuberculosis. PR occurred after 8months after initiation of antituberculous treatment. PR presented as left cervical lymphadenopathy, pulmonary, pleural, costal and spinal location of the tuberculosis. The antituberculous drugs were prolonged. Patient's clinical symptoms improved initially. However, left inguinal lymphadenopathy appeared after 20months of antituberculous therapy. Inguinal lymph node biopsy revealed tuberculous lymphadenitis. The patient has a good compliance to the treatment. The patient was continued on same antituberculous treatment for a total of 28months. The cervical and inguinal lymphadenopathy disappeared and CT scan showed regression of thoracic, abdominal, costal and spinal lesions. CONCLUSION: PR during antituberculous treatment must be considered after exclusion of other causes. No consensus on the therapeutic management of this entity has been developed to date.

Bcgitis and vaccine-derived poliovirus infection in a patient with a novel deletion in RAG1 binding site.

A girl who developed severe BCGitis and vaccine-derived poliovirus infection was discovered to have a novel deletion of RAG1. A neonatal screening program for SCID would identify affected infants at birth, before live vaccines are administered.

Tuberculosis complicating treatment of hepatitis C in an HIV-infected haemophilia A patient.

Pegylated interferon (pegIFN)/ribavirin has been established as the treatment of choice for chronic hepatitis C in HIV co-infected individuals [1-3]. We report the case of an individual who was well prior to treatment, but was diagnosed with tuberculous adenitis after receiving 12 weeks of pegIFN/ribavirin therapy. The association of pegIFN and ribavirin therapy with tuberculosis (TB) has not been described previously.

Immune reconstitution syndrome due to bacillus Calmette-Guérin after initiation of antiretroviral therapy in children with HIV infection.

The immune reconstitution syndrome caused by bacillus Calmette-Guerin (BCG) was found in 4 HIV-infected children who were immunized with BCG at birth. The localized, suppurative, BCG-related complications developed within 10 weeks after initiation of antiretroviral therapy. The incidence rate was 2.7 cases per 100 persons (95% confidence interval, 0.7-6.7). Patients responded well to treatment with isoniazid and rifampicin.

Focal mycobacterial lymphadenitis following initiation of protease-inhibitor therapy in patients with advanced HIV-1 disease.

BACKGROUND: Inhibitors of HIV-1 protease produce a rapid decrease in plasma HIV-1 RNA, with concomitant increases in CD4 T-helper lymphocyte counts. The main side-effects of the protease inhibitors currently in use include gastrointestinal disturbances, paraesthesias, hyperbilirubinaemia, and nephrolithiasis. The increasing use of these agents in patients with advanced HIV-1 infection and CD4 counts of less than 50 cells/microL may be associated with unforeseen adverse effects not observed in earlier studies of patients with higher CD4 counts. METHODS: Five HIV-infected patients with baseline CD4 lymphocyte counts of less than 50 cells/mL were admitted to the Beth Israel Deaconess Medical Center (Boston, MA, USA) with high fever (> 39 degrees C), leucocytosis, and evidence of lymph-node enlargement within 1-3 weeks of starting indinavir therapy. Informed consent was obtained for studies that entailed CD4 lymphocyte counts, immunophenotyping, isolator blood cultures, and radiological scans. Biopsy samples of cervical, paratracheal, or mesenteric lymph nodes were taken for culture and pathology in four patients. FINDINGS: Lymph-node biopsy samples showed that focal lymphadenitis after initiation of indinavir resulted from unsuspected local or disseminated Mycobacterium avium complex (MAC) infection. The prominent inflammatory response to previously subclinical MAC infection was associated with leucocytosis in all patients and with an increase in the absolute lymphocyte counts in four patients. Three patients with follow-up CD4 counts showed two-fold to 19-fold increases after 1-3 weeks of indinavir therapy. Immunophenotyping after therapy in two patients showed that more than 90% of the CD4 cells were of the memory phenotype. INTERPRETATION: The initiation of indinavir therapy in patients with CD4 counts of less than 50 cells/mL and subclinical MAC infection may be associated with a severe illness, consisting of fever (> 39 degrees C), leucocytosis, and lymphadenitis (cervical, thoracic, or abdominal). The intense inflammatory reactions that make admission to hospital necessary may be secondary to significant numbers of functionally competent immune cells becoming available to respond to a heavy mycobacterial burden. Prophylaxis or screening for subclinical MAC infection, or both, should therefore be done before the beginning of protease-inhibitor therapy in patients with advanced HIV infection.

Is BCG vaccine innocent?

Four patients admitted to the Hacettepe University Department of Pediatric Surgery between 1987 and 1995, two with Bacille Calmette-Guérin (BCG) lymphadenitis and two with multisystem postvaccination tuberculosis (MPT), are presented. The hospital records and records of the Ministery of Health Tuberculosis Control Department were evaluated to determine the complications of BCG vaccine. The most common complication was lymphadenitis with or without suppuration (0.3 per thousand - 3 per thousand). Surgical intervention was required in two BCG lymphadenitis cases and two cases of MPT. Involved lymph nodes were excised in two lymphadenitis cases. Colostomy and percutaneous nephrostomy was performed in the first case of MPT in addition to triple antituberculous drug therapy. Although BCG lymphadenitis is self limited, chronically discharging nodes and tumor-like lymphadenopathy masses need to be excised. On the other hand, MPT has a silent nature with resistance to antituberculous drug therapy. Surgical intervention may be required, directed to the involved systems.

[Morphological features of tissue reactions in combined treatment of experimental tuberculosis induced by xenobiotics]. / Morfologicheskie osobennosti tkanevykh reaktsii pri kompleksnoi terapii éksperimental'nogo tuberkuleza, razvivshegosia na fone predvaritel'nogo vozdeistviia ksenobiotikov.

The trend to aggravated running and contribution of air pollution of large industrial centers with polycyclic aromatic hydrocarbons (PAH) to tuberculosis onset and progress dictate the necessity of the search for new treatment methods. The authors made an attempt to treat experimental tuberculosis with sodium glutamate and isoniazide under chronic exposure to PAH dust. Sodium glutamate especially in combination with isoniazide produces a good effect enhancing granulomatous reactions fibroplastic processes in the foci of specific inflammation. Sodium glutamate is thought an effective pathogenetic treatment of tuberculosis.

Practical use of polymerase chain reaction for the diagnosis of steroid induced tuberculous lymphadenitis.

Tuberculous lymphadenitis that had developed after treatment with systemic prednisolone was diagnosed using the polymerase chain reaction (PCR) combined with dot-blot hybridization. Although the patient had no history of tuberculosis or suggestive radiological findings, a DNA fragment specific for Mycobacterium tuberculosis complex strains was amplified from a paraffin-embedded biopsy specimen of a cervical swelling, which was compatible with tuberculous lymphadenitis on haematoxylin-eosin (HE) and Ziehl-Neelsen staining. This report demonstrates the practical use of PCR for diagnosis of extra-pulmonary tuberculosis in a case difficult to diagnose conventionally.