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A 45-year-old man visited our clinic with a painless swelling of the left scrotum and an ulcer as chief complaints. A hard and indurated mass was palpable with ulcerating foci that were proximal and distal, measuring 3 × 2 cm and 2 × 1 cm respectively and about 2 cm apart. Laboratory data were normal except for an elevated erythrocyte sedimentation rate (ESR), and white blood cell (WBC) differential showed neutropenia and lymphocytosis. A diagnosis of left testicular tumor was made and the patient had a left orchidectomy with fistulectomy. Histopathology results showed a stratified squamous epithelium with tuberculous granuloma and necrotic caseation. Patient is currently on anti-tubercular medication. The rarity of this condition makes these findings important to report.

Tuberculosis of parotid is a rare clinical entity, and cases of bilateral tubercular parotitis are even rarer. We present a case of bilateral primary parotid tuberculosis in a 49-year-old female. The patient received anti-tuberculosis treatment for six months, resulting in complete resolution of the disease. We also review the theories related to the pathogenesis of tubercular parotitis, and propose a novel hypothesis about greater involvement of parotid gland as compared to other salivary glands in primary tuberculosis.

Diabetic mastopathy is an uncommon, benign disease of the breast that can occur in women with diabetes and clinically mimic breast cancer. We describe a patient with long-standing type 1 diabetes who presented with a palpable breast mass with negative imaging findings on mammography, ultrasonography, and breast MRI. Surgical biopsy and histopathology confirmed diabetic mastopathy. We use this case to highlight the recognition, radiographic features, pathology, and management of this benign breast condition and emphasize that, in diabetic patients, the differential diagnosis of a new breast mass should include diabetic mastopathy.

Introduction

Spontaneous pathological fractures of the cervical spine due to tuberculosis are rare. But with escalating incidences of atypical presentations of tubercular disease, clinicians should exercise a high index of suspicion for early diagnosis of such cases.

Case presentation

We present a case of a 50-year-old Hindu man from northern India, who complained of pain and stiffness in his neck. His radiographs showed a fracture in his second cervical vertebral body. But further investigations raised the suspicion of an infective pathology, which was corroborated by magnetic resonance imaging and fine needle aspiration cytology. His symptoms improved and the fracture healed following antitubercular chemotherapy and immobilization.

Conclusion

In endemic regions like India, clinicians should be on the lookout for atypical presentations of tuberculosis. Any suspicious lesion should be evaluated with care for clinical, radiological and laboratory evidences of the infection. The affected spine should be protected and appropriate chemotherapy should be instituted at the earliest opportunity.

Spinal deformity and paraplegia/quadriplegia are the most common complications of tuberculosis (TB) of spine. TB of dorsal spine almost always produces kyphosis while cervical and lumbar spine shows reversal of lordosis to begin with followed by kyphosis. kyphosis continues to increase in adults when patients are treated nonoperatively or by surgical decompression. In children, kyphosis continues to increase even after healing of the tubercular disease. The residual, healed kyphosis on a long follow-up produces painful costopelvic impingement, reduced vital capacity and eventually respiratory complications; spinal canal stenosis proximal to the kyphosis and paraplegia with healed disease, thus affecting the quality and span of life. These complications can be avoided by early diagnosis of tubercular spine lesion to heal with minimal or no kyphosis. When tubercular lesion reports with kyphosis of more than 50° or is likely to progress further, they should be undertaken for kyphus correction. The sequential steps of kyphosis correction include anterior decompression and corpectomy, posterior column shortening, posterior instrumentation, anterior bone grafting and posterior fusion. During the procedure, the spinal cord should be kept under vision so that it should not elongate. Internal kyphectomy (gibbectomy) is a preferred treatment for late onset paraplegia with severe healed kyphosis.

Lymphocytic mastopathy or diabetic mastopathy is a benign breast disease characterized by dense fibrosis, lobular atrophy, and aggregates of lymphocytes in a periductal and perilobular distribution. The condition usually affects women with a long history of diabetes mellitus (DM) and also those with autoimmune disorders. While the pathogenesis is unknown, a particular type of class II human leukocyte antigen has been associated with this disease. Herein, we report a case of diabetic mastopathy which clinically and radiologically mimicked primary breast neoplasms. The patient was a 74-year-old woman with a 31-year history of DM type II who presented with multiple firm lumps in bilateral breasts. Findings from mammography, ultrasonography, and magnetic resonance imaging of the breasts revealed an abnormal appearance which suspiciously resembled malignancy. An aspiration cytology specimen showed atypical accumulation of lymphoid cells, leading us to suspect lymphoma. Histology of an excisional biopsy showed the characteristic appearance of lymphocytic mastopathy, which predominantly consisted of B-lymphocytes. Autoantibodies in her serum reacted positively against her ductal epithelium as well as other diabetic and nondiabetic breast ductal cells. An antigen absorption test with insulin revealed attenuating intensity according to insulin concentration. These anti-insulin antibodies produced in the DM patient may cause ductitis because of antigen cross-reactivity.

AIM: To highlight various patterns of nodal involvement and post treatment changes in pediatric chest tuberculosis based on contrast enhanced computed tomography (CECT) scans of chest.

METHODS: This was a retrospective study consisting of 91 patients aged less than 17 years, who attended Paediatrics OPD of All India Institute of Medical Sciences with clinically diagnosed tuberculosis or with chest radiographs suggestive of chest tuberculosis. These patients had an initial chest radiograph as well as CECT of the chest and follow up imaging after 6 mo, and in some cases 9 mo, of completion of anti-tubercular treatment (ATT). CECT of these patients was reviewed for the location and extent of nodal involvement along with determination of site, size, enhancement pattern and calcification.

RESULTS: Enlargement of mediastinal or hilar lymph nodes was found in 88/91 patients (96.7%), with the most common locations being paratracheal (84.1%), and subcarinal (76.1%). The most common pattern of enhancement was found to be inhomogenous. The nodes were conglomerate in 56.8% and discrete in 43.2%. In addition, perinodal fat was obscured in 84.1% of patients. In the post-treatment scan, there was 87.4% reduction in the size of the nodes. All nodes post-treatment were discrete and homogenous with perinodal fat present. Calcification was found both pre- and post-treatment, but there was an increase in incidence after treatment (41.7%). There was hence a reduction in size, change in enhancement pattern, and appearance of perinodal fat with treatment.

CONCLUSION: Tubercular nodes have varied appearance and enhancement pattern. Conglomeration and obscuration of perinodal fat suggest activity. In residual nodes decision to continue ATT requires clinical correlation.

INTRODUCTION

Tubercular infection of prosthetic joint arthroplasty is sporadically described, but its incidence is rising. Misdiagnosis is common because of disparate clinical presentation.

PRESENTATION OF CASE

We describe 1 hand, 2 hip and 2 knee prosthetic-joint infections due to Mycobacterium tuberculosis in patients without a previous history of tuberculosis. All of them were initially misdiagnosed as bacterial infections and unsuccessfully treated with antibiotic for a long period of time. Diagnosis was made by means of culture of periprosthetic tissues and histolopathological examination. Tuberculosis was cured in all patients, but two of them have had a permanent functional damage (one arthrodesis of the knee and one loss of hand function).

DISCUSSION

An aggressive diagnostic approach is required to make diagnosis of periprosthetic tubercular infection. The identification of the pathogen is advisable to test drug susceptibility.

CONCLUSION

The low index of suspicion of periprosthetic tubercular infection could delay a correct diagnosis with risk of permanent damage due to a late treatment. During any surgical revision of prosthetic joints with suspect infection culture for tuberculosis should be taken into consideration.

Thyroid nodules are a common, yet challenging clinical problem. The vast majority of these nodules are benign; however, deciding which nodule should undergo biopsy is difficult because the imaging appearance of benign and malignant thyroid nodules overlap. High resolution ultrasound is the primary imaging modality for evaluating thyroid nodules. Many sonographic features have been studied individually as predictors for thyroid malignancy. There has been little work to create predictive models that combine multiple predictors, both imaging features and demographic factors. We have created a Bayesian classifier to predict whether a thyroid nodule is benign or malignant using sonographic and demographic findings. Our classifier performed similar to or slightly better than experienced radiologists when evaluated using 41 thyroid nodules with known pathologic diagnosis. This classifier could be helpful in providing practitioners an objective basis for deciding whether to biopsy suspicious thyroid nodules.

A patient with cervical lymph node tuberculosis developed a tubercular ulcer in the oesophagus eight weeks after starting treatment. This was probably due to a drug related hypersensitivity reaction in an adjacent mediastinal lymph node and subsided with continued treatment.

Images

Tuberculosis remains a major public health problem globally, with India being one of the high burden countries. The common causative agent is Mycobacterium tuberculosis but in developing countries M. bovis is reported as a potential human pathogen. Almost 20% of all reported cases of tuberculosis are of extra pulmonary form of disease. Diagnosis of extra pulmonary tuberculosis (EPTB) is not always possible with conventional methods, due to the long time required and the paucibacillary nature of samples; hence the need of rapid molecular methods. A prospective study was conducted on 300 patients of EPTB over a period of 5 years. These patients were suspected cases of tubercular meningitis, tubercular ascites and tubercular lymphadenitis. Samples analyzed were cerebrospinal fluid, ascitic fluid and lymph node fine needle aspirate. A two step PCR targeting hup B gene was used. Clinical response to anti tubercular therapy (ATT) was taken as positive (gold standard). PCR for hup B gene was positive in 147 samples out of 155 ATT responders. Of these 85.71% were infected with M. tuberculosis, 9.52% with M. bovis alone and 4.76% showed co infection with both M.tb and M. bovis. The sensitivity and specificity of PCR was 90.32 and 94.48% respectively.

Introduction

Isolated primary tubercular abscess is one of the rare forms of extrapulmonary tuberculosis. A greater awareness of this rare clinical entity may help in commencing specific evidence-based therapy quickly and preventing undue morbidity and mortality.

Case presentation

A 30-year-old man, of Asian origin, developed a hepatic tubercular abscess which was not associated with any pulmonary or gastrointestinal tract foci of tuberculosis. An ultrasonogram of the abdomen showed an abscess in the right lobe of his liver which was initially diagnosed as an amoebic liver abscess. Subsequently, the pus from the lesion yielded Mycobacterium tuberculosis using the BACTEC TB 460 instrument and Mycobacterium tuberculosis deoxyribonucleic acid by polymerase chain reaction. The patient was started on systemic antitubercular therapy to which he responded favorably.

Conclusion

This report emphasizes the fact that, although a tuberculous liver abscess is a very rare entity, it should be included in the differential diagnosis of unknown hepatic mass lesions.

Although hepatic tuberculosis is not a rare disease entity, tubercular liver abscess (TLA) is extremely rare. It is usually associated with foci of infection either in the lung and/or gastrointestinal tract or with an immunocompromised state. An isolated or primary TLA with no evidence of tuberculosis elsewhere is even rarer. We report on a 28 year old man who developed an isolated tuberculous liver abscess not associated with lung involvement. Ultrasonography and computed tomography of the abdomen showed the abscess lesions in the liver but the diagnosis of tuberculosis was confirmed by histological examination of the wall of the abscess after surgical drainage. Although tuberculous liver abscess is very rare, it should be included in the differential diagnosis of abscess and unknown hepatic mass lesions.

Diabetic mastopathy is an unusual fibroinflammatory breast lesion that characteristically presents in premenopausal women with long-standing type 1 diabetes mellitus.

Patients present with clinically suspicious breast masses or axillary lymph nodes with imaging characteristics indistinguishable from malignancy. Fine needle aspiration is often inadequate and a core biopsy should be performed. Excisional biopsy is not necessary, and annual follow-up is recommended. Recognition of diabetic mastopathy should lead to better care of patients with breast nodules or axillary masses who are diabetic, avoiding surgery for this benign condition.

Orbital tuberculosis is an extremely rare, potentially devastating state, when not effectively treated, can lead to grave sequelae. Proptosis can be the result of primary orbital pathology or systemic disease processes. (1, 2) Thyroid ophthalmopathy being commonest cause of proptosis .It can also be a manifestation of, diseases involving various structures of orbit and of superior orbital fissure or cavernous sinus. A case of orbital tubercular abscess presenting with proptosis and blindness in a young male 27 years is reported. Clinicians should suspect rare causes in an immuno- compromised host .(2, 3) The failure to diagnose these conditions can lead to unintended sequelae.

Key Message: The patient who presents with proptosis must be evaluated to ascertain the causation. Preservation of vision is of paramount importance. On follow-up patients should be monitored for complications and remedied.

Aims: To study the prevalence of tuberculosis infection among children in household contact with adults having pulmonary tuberculosis, and identify the possible risk factors.

Methods: Children under the age of 5 years who were in household contact with 200 consecutive adults with pulmonary tuberculosis underwent tuberculin skin testing. Transverse induration of greater than 10 mm was defined as positive tuberculin test suggestive of tubercular infection. Infected children underwent chest radiography and analysis of gastric lavage fluid or induced sputum for detection of acid fast bacilli.

Results: Tuberculin test was positive in 95 of 281 contacts (33.8%), of which 65 were contacts of sputum positive patients, while 30 were contacts of sputum negative patients. Nine of these children were diagnosed as having tuberculosis based on clinical features and/or recovery of acid fast bacilli; seven were in contact with sputum positive adults. The important risk factors for transmission of infection were younger age, severe malnutrition, absence of BCG vaccination, contact with an adult who was sputum positive, and exposure to environmental tobacco smoke.

Conclusion: The prevalence of tuberculosis infection and clinical disease among children in household contact with adult patients is higher than in the general population, and risk is significantly increased by contact with sputum positive adults.

The treatment of tuberculosis is becoming more difficult due to the ever increasing prevalence of drug resistance. Thus, it is imperative that novel anti-tuberculosis agents, with unique mechanisms of action, be discovered and developed. The direct anti-tubercular testing of a small compound library led to discovery of adamantyl urea hit compound 1. In this study, the hit was followed up through the synthesis of an optimization library. This library was generated by systematically replacing each section of the molecule with a similar moiety until a clear structure activity relationship was obtained with respect to anti-tubercular activity. The best compounds in this series contained a 1-adamantyl-3-phenyl urea core and had potent activity against Mycobacterium tuberculosis plus an acceptable therapeutic index. It was noted that the compounds identified and the pharmacophore developed is consistent with inhibitors of epoxide hydrolase family of enzymes. Consequently, the compounds were tested for inhibition of representative epoxide hydrolases: M. tuberculosis EphB and EphE; and human soluble epoxide hydrolase. Many of the optimized inhibitors showed both potent EphB and EphE inhibition suggesting the antitubercular activity is through inhibition of multiple epoxide hydrolyase enzymes. The inhibitors also showed potent inhibition of humans soluble expoxide hydrolyase, but limited cytotoxicity suggesting that future studies must be towards increasing the selectivity of epoxide hydrolyase inhibition towards the M. tuberculosis enzymes.

Tubercular parotitis is an extremely rare clinical condition which is difficult to diagnose. The rarity of this condition can be seen from the evidence of only a few reported cases in the litera-ture. Tubercular infection is quiet common in this part of the world, but Tubercular Parotitis is still a rarity. A case of Bilateral tubercular parotitis diagnosed by FNAC, showing tubercular involvement of the intra parotid lymph node is presented due to its rarity.

Splenic cysts can be primary or secondary, depending upon the aetiology and pathology. Secondary cysts can be of inflammatory, infective, degenerative or traumatic aetiology. Splenic cysts can be true (lined by epithelium) or secondary (pseudocyst, not lined by epithelium). True splenic cysts are mainly congenital and pseudocysts are mainly traumatic in origin. Pseudocyst of the spleen due to tuberculosis is extremely rare .We report one such case of pseudocyst of the spleen caused by tuberculosis together with a relevant review of literature. Our case probably represents the first reported case of tubercular pseudocyst of the spleen.

Primary breast tuberculosis manifested as abscess is a rare entity. We are reporting a case of primary breast tuberculosis, which presented as breast abscess. Abscess was drained and tissue sent for histopathology. To our surprise, diagnosis came as breast tuberculosis. Aspiration cytology was not done, as it is not a routine test for abscess cases. Patient was put on anti- tubercular drugs. In the follow-up of 6 months, she was asymptomatic and advised to continue medicine.

Tuberculous brain abscess and subdural empyema are extremely rare manifestations of central nervous system tuberculosis. Here, we report a case of an 11-year-old immunocompetent child who developed temporal lobe abscess and subdural empyema following chronic otitis media. A right temporal craniotomy was performed and the abscess was excised. The Ziehl Nielsen staining of the aspirated pus from the temporal lobe abscess yielded acid fast bacilli. Prompt administration of antituberculous treatment resulted in complete recovery of the child. Even though the subdural abscess was not drained, we presume that to be of tubercular aetiology. Ours is probably the first case of brain abscess and subdural empyema due to Mycobacterium tuberculosis reported in the same child. This case is being reported because of its rarity and to stress the importance of routine staining for tubercle bacilli in all cases of brain abscess, especially in endemic areas, as it is difficult to differentiate tuberculous from pyogenic abscess clinically as well as histopathologically.

Objectives

To determine the value of breast imaging in patients with localised or diffuse pain in the breast in whom physical examination shows no abnormalities.

Design

Observational follow up study.

Setting

Radiology department of a teaching hospital in the Netherlands.

Subjects

Altogether 987 women referred for radiological breast imaging because of pain alone and a control group of 987 asymptomatic women referred for a screening mammogram.

Main outcome measures

Correlation of the radiological findings with clinical and pathological findings over two years of follow up.

Results

Radiological examination of the painful breast(s) showed the following: normal findings in 854 (86.5%) women, benign abnormalities in 85 (8.6%; mainly small cysts or mastopathy), abnormalities that were probably benign in 36 (3.6%), suspicious findings in 8 (0.8%), and malignancy in 4 (0.4%). Biopsy of the painful area was performed in 10 of the 939 women with normal findings or benign abnormalities, in two of 36 women with radiological abnormalities that were probably benign, and in all women with suspicious or malignant findings. Only the four lesions that had been classified radiologically as malignant were found to be malignant at surgery. The prevalence of breast cancer was similar in symptomatic and control women.

Conclusions

Breast imaging in women who present with pain alone is of value only in providing reassurance—no abnormalities are usually found in the painful area, radiological abnormalities classified as benign do not generally have any clinical consequences, and the prevalence of cancer is low in these women. Biopsy of the painful area should be performed only where radiological findings are suspicious.

Key messagesGeneral practitioners and hospital specialists often request a mammogram for women with localised or diffuse pain in the breast but no palpable abnormalitiesThe particular value of breast imaging in patients with breast pain alone is reassuranceBiopsy of the painful area is unnecessary where the radiological findings are not suspicious

Spinal tuberculosis (TB) produces neurological complications and grotesque spinal deformity, which in children increases even with treatment and after achieving healing. Long-standing, severe deformity leads to painful costo-pelvic impingement, respiratory distress, risk of developing late-onset paraplegia and consequent reduction in quality and longevity of life. The treatment objective is to avoid the sequelae of neural complications and achieve the healed status with a near-normal spine. In TB, the spine may become unstable if all three columns are diseased. Pathological fracture/dislocation of a diseased vertebral body may occur secondary to mechanical insult. Surgical decompression adds further instability, as part of the diseased vertebral body is excised. The insertion of a metallic implant is to provide mechanical stability and the use of an implant in tubercular infection is safe. Indications for instrumented stabilisation can be categorised as: (a) pan vertebral disease, in which all three columns are diseased; (b) long-segment disease, in which after surgical decompression a bone graft >5 cm is inserted with instrumentation to prevent graft-related complications and consequent progression of kyphosis and neural complications and (c) when surgical correction of a kyphosis is performed when both anterior decompression and posterior column shortening is required. The implant choice should be individualised according to the case. Pedicle screw fixation in kyphus correction in healed disease is a most suitable implant. Hartshill sublaminar wiring stabilisation in active disease is a suitable implant to stabilise the spine, taking purchase against healthy posterior complex of the vertebral body to save a segment.

Delirium is a clinical entity with a variety of possible etiological conditions. Clinicians must be vigilant for the possibility of additional etiological factors. Secondly, catatonic patients should be carefully looked for general medical conditions. This case report depicts a chronic alcoholic who presented with withdrawal delirium, later on developed catatonia and then was diagnosed to have tubercular meningoencephalitis, a rare clinical sequence.

The rise of multi-drug resistant (MDR) and extensively drug resistant (XDR) tuberculosis around the world, including in industrialized nations, poses a great threat to human health and defines a need to develop new, effective and inexpensive anti-tubercular agents. Previously we developed a chemical systems biology approach to identify off-targets of major pharmaceuticals on a proteome-wide scale. In this paper we further demonstrate the value of this approach through the discovery that existing commercially available drugs, prescribed for the treatment of Parkinson's disease, have the potential to treat MDR and XDR tuberculosis. These drugs, entacapone and tolcapone, are predicted to bind to the enzyme InhA and directly inhibit substrate binding. The prediction is validated by in vitro and InhA kinetic assays using tablets of Comtan, whose active component is entacapone. The minimal inhibition concentration (MIC99) of entacapone for Mycobacterium tuberculosis (M.tuberculosis) is approximately 260.0 µM, well below the toxicity concentration determined by an in vitro cytotoxicity model using a human neuroblastoma cell line. Moreover, kinetic assays indicate that Comtan inhibits InhA activity by 47.0% at an entacapone concentration of approximately 80 µM. Thus the active component in Comtan represents a promising lead compound for developing a new class of anti-tubercular therapeutics with excellent safety profiles. More generally, the protocol described in this paper can be included in a drug discovery pipeline in an effort to discover novel drug leads with desired safety profiles, and therefore accelerate the development of new drugs.

Author Summary

The rise of multi-drug resistant (MDR) and extensively drug resistant (XDR) tuberculosis around the world, including in industrialized nations, poses a great threat to human health. This resistance highlights the need to develop new, effective and inexpensive anti-tubercular agents. Unfortunately, conventional approaches have yielded very few successes in the field of anti-infective drug discovery. It is a challenge to design drugs with both efficacy and safety. These challenges are reflected in the high costs involved in bringing new drugs to market. It has been estimated that the cost to launch a successful new drug is in excess of US$800 million. We have developed a novel computational strategy to systematically identify cross-reactivity between different drug target families. In this paper we demonstrate the strength of this approach through the discovery that existing commercially available drugs prescribed for the treatment of Parkinson's disease have the potential to treat MDR and XDR tuberculosis. The protocol described herein can be included in a drug discovery pipeline in an effort to accelerate the development of new drugs with reduced side effects.