Diagnosis by needle biopsy of tuberculoma that mimics lung cancer

Two patients with subacute symptoms and signs compatible with lung cancer presented with focal opacities on chest radiographs. In both patients, tissue examinations showed typical histological changes associated with pulmonary tuberculosis. Antituberculosis therapy led to clinical and radiological resolution. Tuberculosis should be considered in the differential diagnosis of patients presenting with clinical and radiological features of lung cancer.

[Tuberculosis: pathogenesis, immune responses and genetics of the host]

Tuberculosis is a chronic infectious disease predominantly affecting the lung. The hallmark of tuberculosis infection is the formation of granulomata in the vicinity of infectious foci. The tuberculous granuloma is a complex, cellulary and biochemically well-orchestrated structure, which development plays a dual role. Restricting dissemination of infection and forming a battlefield for protective immunity, granulomatous process may compromise lung function, threatinig the host health. Both the susceptibility to infection per se and the degree of lung failure and disease severity are under genetic control. Tuberculosis genetics is complex and far from being resolved, but the information available clearly indicates that the control of intracellular infections depends upon biochemical networks, which have not been appreciated with this regard until recently.

Intradural extramedullary tuberculoma of the thoracic spine: paradoxical response to antituberculous therapy

Intradural extramedullary tuberculoma of the spinal cord (IETSC) is a rare complication of tuberculosis, which can occur as a paradoxical response to antituberculous therapy. A 46-year-old woman with tuberculosis meningitis developed an acute sensory disturbance and paraplegia eight weeks after the antituberculous treatment was started. MRI revealed a cystic lesion at the Th 2 and 3 vertebrae levels, and continuous dural thickening. Laminectomy was performed; soft granulomas were unexpectedly observed inside the dura matter. After the operation, the patient experienced progressive improvement in motor strength. IETSC should be known as rare but possible complication of tuberculous meningitis.

The aerosol rabbit model of TB latency, reactivation and immune reconstitution inflammatory syndrome

The large reservoir of human latent tuberculosis (TB) contributes to the global success of the pathogen, Mycobacterium tuberculosis (Mtb). We sought to test whether aerosol infection of rabbits with Mtb H37Rv could model paucibacillary human latent TB. The lung burden of infection peaked at 5 weeks after aerosol infection followed by host containment of infection that was achieved in all rabbits. One-third of rabbits had at least one caseous granuloma with culturable bacilli at 36 weeks after infection suggesting persistent paucibacillary infection. Corticosteroid-induced immunosuppression initiated after disease containment resulted in reactivation of disease. Seventy-two percent of rabbits had culturable bacilli in the right upper lung lobe homogenates compared to none of the untreated controls. Discontinuation of dexamethasone led to predictable lymphoid recovery, with a proportion of rabbits developing multicentric large caseous granuloma. The development and severity of the immune reconstitution inflammatory syndrome (IRIS) was dependent on the antigen load at the time of immunosuppression and subsequent bacillary replication during corticosteroid-induced immunosuppression. Clinically, many aspects were similar to IRIS in severely immunosuppressed HIV-infected patients who have functional restoration of T cells in response to effective (highly active) antiretroviral therapy. This corticosteroid model is the only animal model of the IRIS. Further study of the rabbit model of TB latency, reactivation and IRIS may be important in understanding the immunopathogenesis of these poorly modeled states as well as for improved diagnostics for specific stages of disease.

IL-17-mediated regulation of innate and acquired immune response against pulmonary Mycobacterium bovis bacille Calmette-Guerin infection

IL-17 is a cytokine that induces neutrophil-mediated inflammation, but its role in protective immunity against intracellular bacterial infection remains unclear. In the present study, we demonstrate that IL-17 is an important cytokine not only in the early neutrophil-mediated inflammatory response, but also in T cell-mediated IFN-gamma production and granuloma formation in response to pulmonary infection by Mycobacterium bovis bacille Calmette-Guérin (BCG). IL-17 expression in the BCG-infected lung was detected from the first day after infection and the expression depended on IL-23. Our observations indicated that gammadelta T cells are a primary source of IL-17. Lung-infiltrating T cells of IL-17-deficient mice produced less IFN-gamma in comparison to those from wild-type mice 4 wk after BCG infection. Impaired granuloma formation was also observed in the infected lungs of IL-17-deficient mice, which is consistent with the decreased delayed-type hypersensitivity response of the infected mice against mycobacterial Ag. These data suggest that IL-17 is an important cytokine in the induction of optimal Th1 response and protective immunity against mycobacterial infection.

Unilateral asymptomatic adrenal tuberculoma: the role of percutaneous biopsy

We report the case of a 55-year-old male with a large left adrenal mass that conformed to the normal shape of the adrenal gland. Percutaneous biopsy revealed tuberculosis and, following anti-tuberculosis therapy, there was a >75% decrease in the size of the mass. In large tumefactions of the adrenal glands in which a normal adrenal contour is maintained, a percutaneous biopsy may obviate the need for major intervention.

Isolated intrasellar tuberculoma mimicking pituitary adenoma

A 37-year-old woman presenting with galactorrhea and menstrual irregularity due to an intrasellar lesion of the pituitary gland underwent transsphenoidal surgery for histopathological diagnosis and removal of the lesion. Histological findings were consistent with a tuberculoma. The post-operative course was satisfactory with resolution of galactorrhea and improved ovulatory cycle. The patient was successfully treated with a combination of surgical resection and anti-tuberculous therapy for one year, which resulted in hormonal and tuberculosis control. This patient appears unique regarding the location of the lesion and the dramatic response to surgical treatment. Although differential diagnosis of inflammatory pathologies of the intrasellar region presents difficulties, this patient demonstrates that tuberculoma should be considered.

Quantification of physiological and hemodynamic indices usingT1 dynamic contrast-enhanced MRI in intracranial mass lesions

PURPOSE

To estimate precontrast tissue parameter (T(10)) using fast spin echo (FSE) and to quantify physiological and hemodynamic parameters with leakage correction using T(1)-weighted dynamic contrast-enhanced (DCE) perfusion imaging.

MATERIALS AND METHODS

Voxel-wise T(10) computation was performed followed by the analysis of T(1)-weighted DCE perfusion data for the conversion of signal intensity time curve to concentration time curve, estimation of hemodynamic and physiological perfusion indices, and a method for leakage correction. Validations of accuracy of the computations have also been carried out.

RESULTS

The computed T(10) and hemodynamic perfusion indices in normal white and gray matter were in good agreement with the literature values. Physiological perfusion indices in these regions were found negligible, validating computations. Cerebral blood volume (CBV) values change negligibly over the length of concentration time curve in white matter, gray matter, and lesion (CBV(corrected)), while CBV(uncorrected) (lesion) shows linear increase over time.

CONCLUSION

T(1)-weighted DCE perfusion data along with FSE-based T(1) estimation can be used for an accurate estimation of hemodynamic and physiological perfusion indices.

Expression of mycobacterial cell division protein, FtsZ, and dormancy proteins, DevR and Acr, within lung granulomas throughout guinea pig infection

The ability of Mycobacterium tuberculosis to persist in a dormant state is a hallmark of tuberculosis. An insight into the expression of mycobacterial proteins will contribute to our understanding of bacterial physiology in vivo. To this end, the expression of FtsZ, Acr and DevR was assessed in the lung granulomas of guinea pigs infected with M. tuberculosis. Antigen immunostaining was then compared with the detection of acid-fast bacilli (AFB) and mycobacterial DNA. Surprisingly, immunostaining for all three antigens was observed throughout the course of infection; maximum expression of all antigens was noted at 20 weeks of infection. The intensity of immunostaining correlated well with the presence of intact bacteria, suggesting that mycobacterial antigens in the extracellular fraction have a short half-life; in contrast to protein, extracellular bacterial DNA was found to be more stable. Immunostaining for bacterial division and dormancy markers could not clearly distinguish between replicating and non-replicating organisms during the course of infection. The detection of Acr and DevR from 4 weeks onwards indicates that the dormancy proteins are expressed from early on in infection. Both antigen staining and DNA detection from intact bacilli were useful for detecting intact mycobacteria in the absence of AFB.

Primary tuberculosis clinically presenting as gingival enlargement: a case report

Tuberculosis is a chronic systemic granulomatous disease which rarely affects the oral cavity. Oral lesions can be either primary or secondary to systemic tuberculosis, the former being rare. This is a never-before reported case of primary tuberculosis presenting as a localized diffuse gingival enlargement in an 11-year-old Indian female patient. The diagnosis was reached through identification of positive histopathological features, Tuberculin test results, presence of anti-tubercular antibodies confirmed by a polymerase chain reaction. In view of the recent increase in the incidence of tuberculosis and the prevalence of the same, it is reasonable to include tuberculosis in the differential diagnosis of gingival enlargements. This is essential to avoid any serious complications for both the clinician and patient due to a delay in the diagnosis of such a rare but plausible oral condition.

Intramedullary tuberculoma of the conus

We present a conus medullaris tuberculoma in a 12-year-old girl. She presented with low backache, weakness of both lower limbs and urinary disturbance. Magnetic resonance imaging revealed a D10-L1 intramedullary mass. The tumour was excised and the biopsy was suggestive of tuberculoma. The patient received antituberculous therapy postoperatively and improved. The relevant literature is discussed briefly.

Determination of the optimal MRI sequence for the detection of malignant lung nodules

OBJECTIVE

For staging, follow-up and even screening (www.screening.info) an "all-in-one" imaging examination is desirable. In the concept of whole body MRI, lung imaging prevails as the weakest link. The purpose of our study was to determine the optimal MRI sequences for the detection of malignant lung nodules.

PATIENTS AND METHODS

On the basis of 6 lung cancer, 46 metastases and one tuberculoma in 13 patients eight MRI sequences--HASTE, IR-HASTE, fat saturated TrueFISP, STIR, VIBEipat = 2, and contrast-enhanced (CE) VIBE (with ipat = 2, 0, 4) performed with parallel imaging and 12 matrix coil elements--were compared in terms of contrast-to-noise ratio (CNR) and quality in the visualization of the lung nodules using multidetector CT as standard of reference. The parameters of the sequences were pragmatically selected to minimize the imaging time to allow for imaging the entire lung within one breathold interval.

RESULTS

The STIR sequence was found to be the best for detecting malignant lung nodules (p<0.01) followed by the FS TrueFISP, CE VIBE subsetipat = 0, CE VIBE subsetipat = 2, IR-HASTE, HASTE, CE VIBE subsetipat = 4, and VIBE. The STIR sequence visualized malignant nodules down to 2 mm in size and did not display the 19 mm tuberculoma.

CONCLUSION

The STIR sequence should be included in future studies investigating if MRI can compete with CT in the early identification (detection and classification) of malignant lung nodules.

Massive primary hepatic tuberculoma mimicking hepatocellular carcinoma in an immunocompetent host

Tuberculoma of the liver is rare in an immunocompetent individual. We report a 26-year-old man with upper abdominal pain, abnormal liver function, and raised inflammatory markers. Abdominal computed tomography (CT) scan revealed a mixed attenuation lesion measuring 6 x 5 cm occupying most of the left lobe of the liver. Subsequent histology and culture confirmed tuberculous abscess. Following antituberculous therapy, repeat CT scan revealed complete resolution of the initial findings. This case illustrates the diagnostic difficulties of hepatic tuberculosis (TB) and the importance of considering TB in patients with hepatic lesions.

Orbital tuberculoma extending into the cranium

Orbital tuberculoma is not uncommon in the developing countries, but intracranial extension of orbital tuberculoma is extremely rare. Our case, a 14-year-old girl, presented with proptosis and progressive painless diminution of vision eventually leading to loss of vision. MRI showed a mass with peripheral enhancement of contrast, separate from the optic nerve and extending into the cranium through the optic foramen. Early decompression and chemotherapy resulted in marked visual recovery. Histopathology of the excised lesion confirmed tuberculosis. The case is reported to highlight both the rare presentation as well as remarkable visual recovery in a patient with orbital tuberculosis.

[Empirical treatment of granulomatous hepatitis of unknown origin: practice investigation in the French National Society of Internal Medicine]

PURPOSES

Ten to fifteen percent of granulomatous hepatitis are idiopathic. If symptoms like prolonged fever are present, empirical treatment is discussed. The goal of this study is to describe the empirical treatment proposed in this situation by French specialists of internal medicine.

METHODS

We conducted a practice investigation among the French national society of internal medicine (SNFMI), using an anonymous questionnaire that related a case of idiopathic granulomatous hepatitis. This questionnaire was proposed to all French internists present at the SNFMI congress in June and December 2004. French specialists of internal medicine had to answer if they would prescribe an empirical treatment and if so, to specify this treatment.

RESULTS

Thirty-six French specialists of internal medicine answered to the questionnaire. In the proposed situation, 89% of them initiate an empirical treatment. In 18/36 cases (50%), a first-line anti-tuberculosis empirical treatment is proposed (quadritherapy in 11 cases). In 7 cases (19%), an empirical treatment with prednisone, 0.4 mg/kg/d (N=1) and 1 mg/kg/d (N=6), would be prescribed. Seven internists (19%) would prescribe an empirical treatment with cyclins at the dose of 100 to 400 mg/d. Median duration of the empirical treatment would be 28 days (range: 8-252d). The evaluation parameters mentionned are: fever (69%), weight (59%), seric level of C-reactive protein (59%), and liver biology (53%). In case of failure of first-line empirical treatments, 69% of all questionned internists prescribe a second-line treatments: prednisone at the dose of 0.4 to 2 mg/kg/d (72%), anti-tuberculosis treatments (16%), cyclins 200 mg/d (12%), with a median duration of 28 days. Seven internists (19%) propose to combine two empirical treatments.

DISCUSSION

Faced with a problem of idiopathic granulomatous hepatitis, French internists questionned propose four therapeutics options: no treatment, anti-tuberculosis treatment, cyclins or steroids treatment. First-line anti-tuberculosis treatment is a coherent proposition regarding to the high prevalence of tuberculosis. There are only few data available concerning empirical treatment with steroids or cyclins. Specific proposition of such empirical treatments should be defined.

CONCLUSIONS

The management of idiopathic granulomatous hepatitis is difficult. Our study shows that therapeutics practices of French internists are heterogenous. The main proposition consists in a first-line anti-tuberculosis empirical treatment, that has to be evaluated after four weeks, and switched with steroids (prednisone, 1 mg/Kg/d) in case of failure. This study is not an expert proposition but contributes to suggest clinical practice guidelines for a rare, complex, heterogenous, and typically internist situation.

Intramedullary spinal tuberculoma: report of three cases

BACKGROUND

Intramedullary spinal tuberculoma is a rare form of central nervous system tuberculosis. This article describes the successful management of intramedullary spinal tuberculoma in 3 patients who received treatment between 2000 and 2003.

CASE DESCRIPTION

The character of 3 cases was analyzed retrospectively, including clinical manifestation and magnetic resonance imaging findings. All masses were excised totally under microscope. Histopathologic examination revealed tuberculoma. Postoperatively, all patients received a 6 to 9 month course of ATT. The outcome was favorable.

CONCLUSIONS

The intramedullary spinal tuberculoma must be considered in the differential diagnosis of the spinal cord compression in patients with a history of tuberculosis. When confronted with a progressing neurologic deficit and poor response to ATT, surgical intervention should be considered. The optimal treatment is a combination of microsurgical resection and ATT.

Brainstem tuberculoma presenting as eight-and-a-half syndrome

We present a case of a young child who developed eight-and-a-half syndrome following a pontine tuberculoma, an unusual complication of central nervous system tuberculosis not previously described in an immunocompetent child. The combination of clinical findings allowed for precise localization of the lesion whilst magnetic resonance T1 weighted imaging with contrast provided valuable etiological information. We also discuss the management and outcome of the case.

The Supraorbital Approach: An Alternative to Traditional Exposure for the Surgical Management of Anterior Fossa and Parasellar Pathology

OBJECT

The use of a supraorbital craniotomy as a minimally invasive neurosurgical technique to treat pathology located in the anterior cranial fossa and parasellar region is reported.

MATERIALS AND METHODS

25 patients were operated upon using the supraorbital keyhole technique to expose various lesions located in the anterior skull base. Included were benign and malignant tumors, AVM, tuberculoma and trauma.

DISCUSSION AND CONCLUSION

Utilizing small eyebrow incisions, a small supraorbital ("keyhole") craniotomy, and microneurosurgical and/or endoscopically assisted access, allowed us to gain excellent optimal and safe exposure to a number of different pathologies of the anterior base and parasellar regions. The lesions were resected under complete control and with full preservation of surrounding neurovascular structures.

[Microvessel density and expressions of survivin and vascular endothelial growth factor in non-small cell lung cancer and their correlations to clinicopathologic features]

BACKGROUND & OBJECTIVE

Survivin, an anti-apoptosis gene, expresses in most tumors, and takes part in tumor angiogenesis. This study was to investigate microvessel density (MVD) and expressions of Survivin and vascular endothelial growth factor (VEGF) in non-small cell lung cancer (NSCLC), and explore their correlations to clinicopathologic features of NSCLC.

METHODS

MVD and expressions of Survivin and VEGF in 96 specimens of NSCLC tissues, 31 specimens of tumor adjacent tissues, and 20 specimens of benign lesions were detected by SP immunohistochemistry; their interrelations and correlations to clinicopathologic features of NSCLC were analyzed.

RESULTS

Positive rate of Survivin was significantly higher in NSCLC than in adjacent tissues and benign lesions (69.8% vs. 16.1% and 0, P<0.05); its expression was related with differentiation and TNM stage of NSCLC. Positive rate of VEGF was significantly higher in NSCLC than in adjacent tissues and benign lesions (72.9% vs. 45.2% and 25.0%, P<0.05); its expression was related with lymph node metastasis and TNM stage of NSCLC. MVD was significantly higher in NSCLC than in adjacent tissues and benign lesions (24.44+/-7.79 vs. 19.37+/-5.26 and 11.83+/-6.25, P<0.05), and was related with lymph node metastasis and TNM stage of NSCLC. Survivin expression was positively correlated with VEGF expression and MVD.

CONCLUSION

Survivin is overexpressed in NSCLC, which relates with differentiation and TNM stage of NSCLC and takes part in angiogenesis.

Hepatic tuberculomas. A case report

BACKGROUND

The liver is often involved secondarily by sytemic/extrahepatic vascular, metabolic, infectious, granulomatous, and malignant processes.

CASE REPORT

A 57-year old woman was admitted because of fatigue, malaise, night sweating and right upper abdominal quadrant pain. Physical findings revealed pale skin and mucosae, and hepatomegaly. Laboratory data showed normocytic, normochromic anemia and marked inflammatory syndrome. Real-time ultrasonography revealed one hypo-echogenic nodule, 25 mm in size, in the segment II of the liver, and three hypoechogenic nodules, 11-25 mm in diameter, in segments III and IV. Enlarged lymph nodes, 20-50 mm, were observed in the region of the pancreatic head. Histo-pathological examination of the liver and peritoneum biopsies evidenced granulomas with caseous necrosis and multinuclear Langhans' giant cells, indicating hepatic and peritoneal tuberculosis. The tuberculostatic chemotherapy (isoniazid 300 mg/24h; rifampycin 600 mg/24h and pyrazinamid 2000 mg/24h) was applied for 12 months. The patient responded well to the treatment, followed-up for 6-12 months.

CONCLUSION

In the differential diagnosis of focal liver lesions, pseudotumoral hepatic tuberculomas must be considered.

The infected liver: radiologic-pathologic correlation

Recent technologic advances have significantly enhanced the role of imaging in the detection, characterization, and management of infectious diseases involving the liver. In addition, imaging-guided percutaneous drainage has greatly improved the clinical treatment of patients with focal liver abscess. Infectious liver diseases can be accurately evaluated with ultrasonography (US), computed tomography (CT), and magnetic resonance (MR) imaging. Characteristic changes in US echogenicity, CT attenuation, or MR imaging signal intensity and typical enhancement patterns can contribute to the diagnosis of specific infectious diseases, including abscesses, parasitic diseases, fungal diseases, granulomatous diseases, viral hepatitis, and other less common infections. CT is particularly helpful in revealing the presence of calcifications and gas and in detailing the enhancement pattern. The multiplanar capability of MR imaging and its sensitivity to small differences in tissue composition increase its specificity for certain hepatic infections, including hydatid cyst and candidiasis. Radiologic findings may be sufficient to obviate aspiration or histologic examination, although in most instances they are less specific. Nevertheless, imaging findings taken together with appropriate clinical information may provide the most likely diagnosis, even if biopsy is sometimes required for confirmation.