The authors report a case of iliopsoas tuberculous abscess without obvious spinal column involvement. Cervical and axillary tuberculous lymphadenopathy were also presented. Despite appropriate antituberculous treatment, patient required percutaneous drainage with CT-guided catheter insertion.
Cough dry • fever • subcutaneous mass • weight loss
Unusual clinical course
Enlargement of lymph nodes during treatment of Tuberculous lymphadenitis is well recognized phenomenon in HIV infected patient with ample literature to help guide management. On the contrary, it poses a clinical challenge to distinguish between paradoxical reaction and treatment failure in HIV-seronegative patients and require high index of suspicion.
We report a case of 21 year old female of Bangladeshi origin with tuberculous lymphadenitis diagnosed on the basis of strong clinical history and radiologic findings. Patient’s clinical symptoms and lymphadenopathy initially improved but worsened after three months of RIPE therapy. This prompted re imaging and excision biopsy of enlarging lymph node to exclude other masqueraders. Patient was continued on same antituberculous treatment. Oral prednisone was added with subsequent clinical improvement and decrease in the size of lymphadenopathy.
Paradoxical reaction during anti tuberculous treatment must be considered after careful exclusion of medication non adherence, development of resistance and other similar conditions.
paradoxical reaction (PR); highly active anti-retroviral therapy (HAART); rifampin; isoniazid; pyrazinamide and ethambutol (RIPE); tuberculosis (TB); Kikuchi’s disease (KD); tuberculosis lymphadenitis (TL)
Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has emerged as an important tool for the diagnosis and staging of lung cancer but its role in the diagnosis of tuberculous intrathoracic lymphadenopathy has not been established. The aim of this study was to describe the diagnostic utility of EBUS-TBNA in patients with intrathoracic lymphadenopathy due to tuberculosis (TB).
156 consecutive patients with isolated intrathoracic TB lymphadenitis were studied across four centres over a 2-year period. Only patients with a confirmed diagnosis or unequivocal clinical and radiological response to antituberculous treatment during follow-up for a minimum of 6 months were included. All patients underwent routine clinical assessment and a CT scan prior to EBUS-TBNA. Demographic data, HIV status, pathological findings and microbiological results were recorded.
EBUS-TBNA was diagnostic of TB in 146 patients (94%; 95% CI 88% to 97%). Pathological findings were consistent with TB in 134 patients (86%). Microbiological investigations yielded a positive culture of TB in 74 patients (47%) with a median time to positive culture of 16 days (range 3–84) and identified eight drug-resistant cases (5%). Ten patients (6%) did not have a specific diagnosis following EBUS; four underwent mediastinoscopy which confirmed the diagnosis of TB while six responded to empirical antituberculous therapy. There was one complication requiring an inpatient admission.
EBUS-TBNA is a safe and effective first-line investigation in patients with tuberculous intrathoracic lymphadenopathy.
Primary intrahepatic malignant mesothelioma (PIHMM) is an extremely rare tumor with clinicopathological characteristics that remain to be elucidated. The current study presents the case of a 68-year-old female with PIHMM and multiple lymphadenopathies due to non-tuberculous mycobacteria. The patient presented with an intrahepatic tumor, 70 mm in diameter, in the right lobe of the liver. An ultrasound-guided fine-needle aspiration biopsy of the liver tumor revealed findings that were consistent with an intrahepatic malignant mesothelioma. The systemic lymph node swellings were due to epithelioid granulomas that were caused by non-tuberculous mycobacteria. However, a hepatic rupture occurred due to the rapid growth of the liver tumor and consequently, a surgical resection was not performed. A review of the literature revealed that the clinicopathological characteristics of PIHMM are similar to those of non-occupational mesothelioma. However, PIHMM is usually a solitary tumor and is rarely associated with cavity effusion in contrast with conventional mesothelioma. Therefore, surgical resection with curative intent is often recommended for patients with PIHMM.
malignant mesothelioma; primary hepatic tumor; mycobacteria; literature review
The prevalence of infections by Mycobacterium tuberculosis and non-tuberculous Mycobacterium species in the HIV-infected patient population in Colombia was uncertain despite some pilot studies. We determined the frequency of isolation of Mycobacterium tuberculosis and of non-tuberculous Mycobacterium species in diverse body fluids of HIV-infected patients in Bogota, Colombia.
Patients who attended the three major HIV/AIDS healthcare centres in Bogota were prospectively studied over a six month period. A total of 286 patients were enrolled, 20% of them were hospitalized at some point during the study. Sixty four percent (64%) were classified as stage C, 25% as stage B, and 11% as stage A (CDC staging system, 1993). A total of 1,622 clinical samples (mostly paired samples of blood, sputum, stool, and urine) were processed for acid-fast bacilli (AFB) stain and culture.
Overall 43 of 1,622 cultures (2.6%) were positive for mycobacteria. Twenty-two sputum samples were positive. Four patients were diagnosed with M. tuberculosis (1.4%). All isolates of M. tuberculosis were sensitive to common anti-tuberculous drugs. M. avium was isolated in thirteen patients (4.5%), but only in three of them the cultures originated from blood. The other isolates were obtained from stool, urine or sputum samples. In three cases, direct AFB smears of blood were positive. Two patients presented simultaneously with M. tuberculosis and M. avium.
Non-tuberculous Mycobacterium infections are frequent in HIV infected patients in Bogota. The diagnostic sensitivity for infection with tuberculous and non-tuberculous mycobacteria can be increased when diverse body fluids are processed from each patient.
In some particular endemic area, it is not uncommon to see patients with tuberculosis pericarditis. However, it takes a period of time from tuberculous pericarditis to constrictive pericarditis. There is still no report of tuberculous constrictive pericarditis concurrent with active pulmonary TB infection in a patient without previous pulmonary TB infection history. Therefore, we reported a TB constrictive pericarditis with rare disease progress.
We report the case of a 63-year-old Taiwanese man with tuberculous constrictive pericarditis concurrent with active pulmonary tuberculous infection presenting with progressive extremities edema, puffy face, abdominal distension and dyspnea on exertion found to be caused by right heart failure. The patient was cured by pericardial stripping and anti-tuberculosis chemotherapy. We reviewed other cases of tuberculous constrictive pericarditis from the literature and described the peculiarities of this case.
Rapid diagnosis and treatment of constrictive pericarditis are crucial to reduce mortality. In some endemic areas, Mycobacterium tuberculosis infection should be taken into consideration during diagnostic evaluations for constrictive pericarditis. Surgical intervention is still the treatment of choice when the patient has the symptoms or signs of pericardial constriction and right heart failure. Our case is a constant reminder that active Mycobacterium tuberculosis infection does present itself with uncommon presentations.
We report a rare case of oculomotor nerve palsy and choroidal tuberculous granuloma associated with tuberculous meningoencephalitis. A 15-year-old male visited our hospital for an acute drop of the left eyelid and diplopia. He has been on anti-tuberculous drugs (isoniazid, rifampin) for 1 year for his tuberculous encephalitis. A neurological examination revealed a conscious clear patient with isolated left oculomotor nerve palsy, which manifested as ptosis, and a fundus examination revealed choroidal tuberculoma. Other anti-tuberculous drugs (pyrazinamide, ethambutol) and a steroid (dexamethasone) were added. After 3 months on this medication, ptosis of the left upper eyelid improved and the choroidal tuberculoma decreasedin size, but a right homonymous visual field defect remained. When a patient with tuberculous meningitis presents with abrupt onset oculomotor nerve palsy, rapid re-diagnosis should be undertaken and proper treatment initiated, because the prognosis is critically dependent on the timing of adequate treatment.
Choroidal tuberculous granuloma; Oculomotor nerve palsy; Ptosis; Tuberculous meningoencephalitis
Tuberculosis kills five lakh patients every year in India, commonest being pulmonary tuberculosis and is often associated with effusion. Delay in diagnosis and treatment results in poor prognosis. Several studies have suggested the role of adenosine deaminase (ADA) in the diagnosis of tuberculous pleural effusions, but false-positive results from lymphocytic effusions have also been reported. The purpose of this study is to find out the role of ADA levels in differentiation of tuberculous and non-tuberculous exudative pleural effusions of different etiologies.
Ninety-six lymphocytic pleural fluid samples were consecutively selected and divided into two groups: tuberculous (n = 56) and non-tuberculous (n = 40), depending upon the etiology [Malignancy (n = 16), Infectious diseases (n = 18), Pulmonary embolism (n = 1), Collagen vascular diseases (n = 3) and Sarcoidosis (n = 2)]. ADA was estimated in pleural fluid in all the cases.
In all 56 samples, ADA level of tuberculous group was above diagnostic cut-off (40 U/L), while only one sample was above cut-off in non-tuberculous group (2.5%). The negative predictive value of ADA for the diagnosis of non-tuberculous etiology was 97.5% (39 of 40) lymphocytic pleural effusion patients.
In this study, ADA levels in nontuberculous exudative pleural effusions rarely exceeded the cut-off; set for tuberculous disease. The pleural fluid ADA levels were significantly higher in tuberculous exudative pleural effusions when compared with non-tuberculous exudative pleural effusions.
Adenosine deaminase; Tuberculous effusion; Pleural fluid; Exudative pleural effusions
The interaction of Matrix metalloproteinases (MMPs), its tissue inhibitors (TIMPs) and pro-inflammatory cytokines in response to Mycobacterium tuberculosis (MTB) infection is important to understand the immune response at the site of infection. We compared the levels of MMPs, TIMPs and cytokines in plasma (BL) and pleural fluid (PF) of tuberculosis (TB) and non tuberculosis (NTB) patients. Comparison between BL and PF showed significantly higher levels of MMP-1, TIMP-1 and -3 in TB PF; of MMP-7, -8, -9 in BL of both groups. Also, levels of MMP-1,-8,-9 and TIMP-3 were significantly higher in TB PF compared to NTB. Cytokines INF-γ, TNF-α, and IL-6 significantly increased in PF of both groups. A positive correlation of MMPs with TIMPs in TB, MMP-1 and -9 with IL-6 in TB PF and MMP-9 with IFN-γ in NTB PF was observed. This study implicates the possible usage of MMPs as bio-markers aiding diagnosis in TB pleuritis.
In this manuscript we apply stochastic modeling to investigate the risk of reactivation of latent mycobacterial infections in patients undergoing treatment with tumor necrosis factor inhibitors. First, we review the perspective proposed by one of the authors in a previous work and which consists in predicting the occurrence of reactivation of latent tuberculosis infection or newly acquired tuberculosis during treatment; this is based on variational procedures on a simple set of parameters (e.g. rate of reactivation of a latent infection). Then, we develop a full analytical study of this approach through a Markov chain analysis and we find an exact solution for the temporal evolution of the number of cases of tuberculosis infection (re)activation. The analytical solution is compared with Monte Carlo simulations and with experimental data, showing overall excellent agreement. The generality of this theoretical framework allows to investigate also the case of non-tuberculous mycobacteria infections; in particular, we show that reactivation in that context plays a minor role. This may suggest that, while the screening for tuberculous is necessary prior to initiating biologics, when considering non-tuberculous mycobacteria only a watchful monitoring during the treatment is recommended. The framework outlined in this paper is quite general and could be extremely promising in further researches on drug-related adverse events.
Imatinib mesylate (IM) is the standard treatment for BCR-ABL-positive chronic myelogenous leukemia (CML) and is the first-line adjuvant and palliative treatment for metastatic and inoperable gastrointestinal stromal tumor (GIST). IM is not known to be associated with an increased risk for development of granulomatous diseases.
We describe our experience with 2 patients (42 and 62 years of age) who developed granulomatous disease during IM treatment for metastatic GIST.
Mean duration of IM treatment was 12 (range 8–16) months. Enlarged lymph nodes with increased metabolism on FDG-PET-CT examination were detected and resected. Affected sites were supraclavicular (1) and subcarinal/mediastinal (1) lymph nodes. Histological examination revealed caseating and non-caseating granulomas suggestive of tuberculosis and sarcoidosis, respectively. Mycobacterium tuberculosis was detected by PCR in lymph nodes of 1 patient who was then successfully treated by anti-tuberculous agents. The other patient had negative sputum test for acid-fast bacilli and PCR-DNA-analysis was negative for M. tuberculosis and other mycobacteria. He received no anti-tuberculous therapy and had no evidence of progressive lymphadenopathy or new lung lesions during follow-up.
Our observations underline the necessity to obtain biopsy material from enlarged or metabolically active lymph nodes developing during IM treatment for timely diagnosis and appropriate treatment of these rare complications. Follow-up without treatment is safe for patients without detectable microorganisms by sputum examination and PCR.
Gastrointestinal stromal tumor; Imatinib mesylate; Glivec; Tuberculosis; Granuloma; PET-CT
Paraplegia occurred in eight of 17 patients with central nervous system tuberculosis. In six of these paraplegia was the presenting feature. Paraplegia may complicate tuberculous meningitis, or vertebral tuberculosis, but it may also occur, as in three of our cases, as a primary localised spinal tuberculous radiculomyelitis. These cases are presented in relation to the concept that paraplegia complicating these forms of tuberculosis is caused by radiculomyelitis.
Intra-abdominal tuberculous lymphadenitis can mimic a variety of other abdominal disorders such as pancreatic cancer, metastatic lymph nodes, or lymphoma, which can make a proper diagnosis difficult. A correct diagnosis of intra-abdominal tuberculous lymphadenitis can lead to appropriate management. Endoscopic ultrasonography (EUS)-guided needle biopsy may be the procedure of choice for tissue acquisition when onsite cytopathology examination is unavailable because it is essential to obtain sufficient material suitable for the examination using an ancillary method, such as flow cytometry, molecular diagnosis, cytogenetics, or microbiological culture. We report a case of intra-abdominal tuberculous lymphadenitis diagnosed using an EUS-guided, 22-gauge histology new needle biopsy without an onsite cytopathology examination.
Endosonography; Fine needle biopsy; Tuberculosis
A collective review of tuberculous lymphadenopathy is presented with respect to incidence, pathogenesis, clinical manifestations, diagnosis, differential diagnosis, and treatment. A typical case report is also presented. A thorough history and physical examination, a purified protein derivative (PPD) skin test and acid-fast bacillus (AFB) stains, and histopathology of the node may provide useful information. Positive culture results are the only means of confirming the diagnosis and for distinguishing between tuberculous and non-tuberculous mycobacteria. Treatment, at least initially, must be guided by the physician's clinical suspicions.
Although there remains debate as to what is the best method of treating mycobacterial lymphadenopathy, chemotherapy is essential. Excisional biopsy is recommended when feasible. The possible exception is when the diagnosis of mycobacterium tuberculosis is suggested by constitutional symptoms, characteristic chest x-ray findings, a positive PPD skin test, and positive culture of mycobacterium tuberculosis from another source such as sputum or gastric washings. This needle aspiration for diagnosis is applicable as done in the case report patient. Surgery is, therefore, reserved for excisional biopsy to establish the diagnosis if systemic disease is not suspected, and also for removal of grossly enlarged nodes. Incisional biopsy should be avoided if possible, as it can result in the formation of fistulous tracts.
Tuberculous psoas abscess was usually associated to complicate Pott's disease, but it can also be secondary to direct extension from other adjacent structures or haematogenous spread from an occult source. However, the occurrence of this entity as the presenting manifestation of tuberculosis, without evidence of active infection elsewhere, has been seldom reported.
We report a clinical case of a 64-year-old immunocompetent female that presented with left lower abdominal pain and a soft tissue mass over the left iliac fossa and inguinal regions due to a primary tuberculous psoas abscess. Early diagnosis and prompt treatment with percutaneous drainage guided by ultrasound along with antituberculous drugs, lead to a satisfactory outcome.
The purpose of this case report is to point out attention to the diagnostic challenge of tuberculous psoas abscess in the absence of tuberculosis in other organs or a predisposing condition. A brief review of the literature about its epidemiology, etiology, clinical features and management is discussed over the text.
Abscess of the spleen is an uncommon clinical entity and a tuberculous abscess is particularly rare. Although image-guided aspiration has been reported, splenectomy is the preferred modality of treatment. We report a 32-year-old female diagnosed to have a large, multilocular splenic abscess during investigation of a pyrexial illness. Her haemoglobin was 9.8 gm%, ESR 100 mm/1st hour and she was HIV negative. She had been on anti-tubercular chemotherapy (started elsewhere) for 2 months but had shown poor response. A laparoscopic splenectomy undertaken using four-ports was challenging due to the presence of perisplenitis and adhesions in the splenic hilum. Also, fundus of stomach densely adherent to the upper pole of the spleen required stapled resection. Postoperatively, she developed a low-output pancreatic fistula that resolved with conservative treatment within a week. Histopathology of the spleen confirmed tuberculosis. She responded well to anti-tubercular chemotherapy and remains well 3 years later.
Abscess; laparoscopy; spleen; splenectomy; tuberculosis
Tuberculous mastitis is a rare clinical entity and usually affects women from the Indian sub-continent and Africa. It often mimics breast carcinoma and pyogenic breast abscess clinically and radiologically, may both co-exist. Routine laboratory investigations are not helpful in its diagnosis. Fine needle aspiration cytology (FNAC) / biopsy are essential for diagnosis and tuberculosis culture when positive may be very useful to guide antimicrobial therapy. Antitubercular drugs in combination with aspiration or surgical drainage are usually associated with an excellent outcome.
Tuberculosis; Breast; Tuberculous mastitis; Granulomatous mastitis
The incidence of pancreatic tuberculosis is extremely rare, and it frequently misdiagnosed as pancreatic neoplasms. The nonsurgical diagnosis of this entity continues to be a challenge.
A 33 year old male with six-month history of intermittent right epigastric vague pain and weight lost had found a solitary pancreatic cystic mass and diagnosed as pancreatic cystadenocarcinoma. The chest X-ray film and physical examination revealed no abnormalities. Abdominal ultrasound (US) examination showed an irregular hypoechoic lesion of 6.6 cm × 4.4 cm in the head of pancreas, and color Doppler flow imaging did not demonstrate blood stream in the mass. The attempts to obtain pathological evidence of the lesion by US-guided percutaneous fine needle aspiration failed, an exploratory laparotomy and incisional biopsy revealed a caseous abscess of the head of pancreas without typical changes of tuberculous granuloma, but acid-fast stain was positive.
Pancreatic tuberculosis should be considered in the differential diagnosis of focal pancreatic lesions, especially for young people in developing countries.
Between 1969 and 1979, 20 patients under-went pneumonectomy for tuberculous destroyed lungs (TDL) at the University College Hospital (UCH), Ibadan, Nigeria. Their ages ranged from 9 to 57 years, with an average age of 24 years. The left lung was involved in 16 patients (80 percent) and the right lung in four patients (20 percent). All patients had received treatment for pulmonary tuberculosis (PTB) for over three years, and all patients had negative cultures of acid-fast bacilli (AFB) at the time of operation. Pulmonary function studies were performed in 15 patients, bronchography in 18, and pulmonary angiography in four. Ninteen patients had elective resection because of mild to moderate hemoptysis without mortality. The only death occurred in a 37-year-old man who had emergency resection because of massive hemoptysis. He died intraoperatively of cardiac arrest. One patient developed bronchopleural fistula (BPF), empyema, and wound infection. The fistula closed spontaneously following prolonged chest drainage and pleural irrigation with antibiotics and antituberculous drugs. As a result of our experience with pulmonary tuberculosis in our environment, the authors now recommend elective resection for patients with TDL in order to prevent massive hemoptysis which may prove fatal.
AIM: To assess the diagnostic value of computed tomography (CT) imaging in screening for abdominal nonhematogenous disseminated tuberculous lymphadenopathy (TL).
METHODS: The CT scans of 12 patients with abdominal nonhematogenous disseminated TL suggestive of neoplasm were retrospectively analyzed in this review. The final diagnoses were confirmed by lymph node pathology for seven patients and by laparoscopic surgery for five patients. All of the patients were treated at our institution between April 1995 and August 2009.
RESULTS: The sites of involvement were the periportal (n = 6), peripancreatic (n = 3), periaortic (n = 3), and mesenteric (n = 2) regions. On the plain CT scan, the lymphadenopathy showed a heterogeneous isodensity or hypodensity in 11 patients and a low density in one patient. Peripheral enhancement was observed on the dynamic contrast-enhanced CT scans for all patients. In two cases, scans were more revealing during the portal venous and delayed phases.
CONCLUSION: Abdominal lymphadenopathy with predominant peripheral rim-like enhancement on the dynamic contrast-enhanced CT scan may suggest a diagnosis of TL.
Abdomen; Lymph node; Tuberculosis; Tomography; X-ray computed
Thirty two poor grade patients (grade 3, 20 patients and grade
4, 12 patients) with tuberculous meningitis and hydrocephalus were
prospectively studied to evaluate the response to external ventricular
drainage in predicting outcome after shunt surgery. All grade 3 patients underwent a shunt procedure irrespective of their response to
external ventricular drainage, and an attempt was made to correlate the
immediate response to external ventricular drainage to their long term
outcome. Patients in grade 4 underwent shunt surgery only if there was
clinical improvement by at least one grade after external ventricular
drainage. Follow up (mean 23.1 months) was available for 30 patients
(93%). Of the 20 patients in grade 3, seven underwent shunt surgery
directly, 13 after an external ventricular drainage. In the group which
underwent drainage, the immediate clinical response was improvement in
six, no change in six, and death in one. Long term improvement or death
occurred almost equally in all the subgroups. The immediate response to external ventricular drainage was not predictive of the long term outcome in grade 3 patients. All 12 patients in grade 4 underwent an
external ventricular drainage and only one improved. The rest continued
to deteriorate and succumbed to the disease. Grade at admission was the
single most important predictor of good outcome (p=0.002) and severity
of hydrocephalus had an adverse impact on outcome (p= 0.04). The rest
of the variables studied (age, duration of illness, duration of altered
sensorium, CSF cell count, and CSF protein concentrations) had no
effect on long term outcome. All patients in grade 3 should be given
the benefit of shunt surgery without a trial of external ventricular
drainage. However, patients in grade 4 should undergo an external
ventricular drainage in view of the high mortality in this group.
AIM: To present our experience with tuberculous peritonitis treated in our hospital from 2002-2007.
METHODS: We reviewed the medical records of 9 children with tuberculous peritonitis.
RESULTS: Nine patients (5 boys, 4 girls) of mean age 14.2 years were diagnosed with peritoneal tuberculosis. All patients presented with abdominal distention. Abdominal pain was seen in 55.5% and fever in 44.4% of the patients. Four cases had coexisting pleural effusion and two had pulmonary tuberculosis with parenchymal consolidation. Ultrasonography found ascites with septation in 7 patients. Two patients had only ascites without septation. Ascitic fluid analysis of 8 patients yielded serum-ascite albumin gradients of less than 1.1 gr/dL. Laparoscopy and laparotomy showed that whitish tuberculi were the most common appearance. Adhesions were also seen in three cases. The diagnosis of peritoneal tuberculosis was confirmed histo-pathologically in 7 patients and microbiologically in two. Two patients had been diagnosed by ascitic fluid diagnostic features and a positive response to antituberculous treatment. All patients completed the antituberculous therapy without any complications.
CONCLUSION: Tuberculous peritonitis has to be clinically suspected in all patients with slowly progressive abdominal distension, particularly when it is accompanied by fever and pain. Laparoscopy and peritoneal biopsy are still the most reliable, quick and safe methods for the diagnosis of tuberculous peritonitis.
Child; Clinical presentation; Diagnosis; Tuberculous peritonitis
Tuberculous colitis is a rare form of tuberculosis and is found in immunosuppressed patients, usually with the clinical appearance of Crohn's disease. The purpose of this article is to report a rare case of tuberculous colitis in a transplant patient, presenting in the form of bowel obstruction and acute abdomen.
A male patient, 51 years old, with a history of kidney transplant in a foreign country 19 months before, presented at the emergency department, after being referred by a primary care center, with obstipation during the previous week and acute abdominal pain. The patient had the clinical appearance of acute abdomen. Five days before the patient underwent colonoscopy, which revealed an intraluminal mass that partially occluded the lumen of the ascending colon. Blood tests revealed a mildly elevated WBC count and anaemia. Imaging studies revealed air in the peritoneal cavity and free fluid in the pelvis. The patient was diagnosed with perforation of a hollow viscus and was admitted for surgery
During laparotomy the findings were a perforation of the cecum, a fragile mass (pseudopolyp), which occluded the lumen approximately in the middle of the ascending colon, diffuse erosions of the mucosa and pseudomembranes. A bezoar was found impacted at the level of the occlusion. There was also marked lymph node enlargement in the mesentery and ischaemia of the cecum. A typical right hemicolectomy was performed and special care was taken so, as not to damage the renal transplant. The pathological and microbiological (from free peritoneal fluid) investigation suggested the diagnosis of tuberculous colitis. Further blood tests and respiratory investigation confirmed the diagnosis of active tuberculosis, with the colon as a primary site. The patient received the appropriate antituberculous treatment.
Tuberculous colitis is a rare form of tuberculosis and is found in immunosuppressed patients. Deferential diagnosis from other forms of colitis is usually problematic. Tuberculous colitis rarely manifests itself in the form of acute surgical abdomen. The possible diagnosis of tuberculous colitis must be always in mind when treating transplant patients.
Diagnosis of tuberculous meningitis (TBM) is a challenge because of the manifold clinical presentation, and diagnosis is often delayed.
We wanted to share our experience of directly observed treatment short course (DOTS) in TBM. We did a retrospective analysis to look at the presentation, management and outcome of TBM patients from November 2006 to April 2008.
Materials and Methods:
TBM was diagnosed based on clinical criteria. We excluded patients with HIV.
We had 11 patients on DOTS regime. One died following hepatitis and another patient died of unrelated gastroenteritis. The only patient on daily regime died. Our patients generally presented late, at a median duration 20 days from onset of symptoms, and 50% had stage 3 disease at presentation. The median delay in diagnosis was 4.5 days.
We found DOTS to be effective in TBM but not without side effects.
Cerebrospinal fluid; diagnosis; imaging; treatment; tuberculous meningitis
Tuberculous meningitis is the most severe manifestation of extrapulmonary tuberculosis with a high mortality rate and a high rate of sequelae among survivors. The aim of this study is to assess the current epidemiology, clinical features, diagnostic procedures, treatment and outcome in patients with tuberculous meningitis in Denmark, a country with a low tuberculosis incidence.
A nationwide retrospective study was conducted, comprising all patients notified with tuberculous meningitis (TBM) in Denmark from 2000-2008. Medical records were reviewed using a standardised protocol.
Fifty patients, including 12 paediatric patients, were identified. 78% of the patients were immigrants from countries of high tuberculosis endemicity. 64% of all patients had a pre-existing immunosuppressive condition; 10% were HIV positive, 48% were HIV seronegative and 42% had an unknown HIV status. Median symptom duration before admission was 14 days in the Danish patient population and 20 days in the immigrant group. Biochemical analysis of cerebrospinal fluid (CSF) samples revealed pleocytosis in 90% with lymphocyte predominance in 66%. Protein levels were elevated in 86%. The most common findings on neuro-radiological imaging were basal meningeal enhancement, tuberculomas and hydrocephalus. Lumbar puncture was performed on 42 patients; 31 of these specimens (74%) had a positive CSF culture for mycobacteria and 9.5% were smear positive for acid-fast bacilli. The overall mortality rate was 19% and 48% of the remaining patients had neurological sequelae of varying degree.
TBM is a rare but severe manifestation of extrapulmonary TB in Denmark. The clinician must be prepared to treat empirically if the suspicion of TBM has arisen to improve treatment outcome.