Sites of tuberculous involvement in patients with AIDS. Autopsy findings and evaluation of gallium imaging

The purpose of this study was to review autopsy and gallium scan findings in two different acquired immune deficiency syndrome (AIDS) patient populations who had a confirmed diagnosis of tuberculosis (TB) to identify organs involved and accuracy of clinical diagnosis. The first group was comprised of 29 autopsies between January 1982 and December 1994, including only 18 patients who were diagnosed before death. Organs most commonly involved were the lymph nodes (59%), lungs (56%), spleen (53%), liver (45%), and kidneys (37%). Other opportunistic infections were present in 18 (59%) of autopsies, with more than one opportunistic infection present in 11 (37%) of the autopsies. Lungs were involved in 79% of all autopsies. The second population group included 94 patients with AIDS with a proven diagnosis of TB, only 24 of whom had gallium scans in the period between January 1992 and December 1994. Chest x-ray results were negative in 4 patients (17%); gallium scan results were positive in 16 patients (66%). The reasons for false-negative gallium scan results were due to anti-tuberculous treatment for periods varying from 2-21 months in 7 patients or the presence of extra pulmonary tuberculosis. The sites of TB involvement in the chest were: lung parenchyma in 5 patients (19%, 4 in mid and lower lung, and 1 in upper fields). There was lymph node involvement in all 16 patients (24 locations with mediastinal involvement in 23%, supraclavicular 23%, axillary 11%, retroperitoneal 11%, and inguinal region in 4%. We conclude that (1) tuberculosis in patients with AIDS behaves similar to primary tuberculosis; (2) the combination of chest x-ray and gallium imaging is sensitive for the diagnosis of pulmonary tuberculosis in patients with AIDS; (3) the involvement of mediastinal lymph nodes in gallium scans in the presence or absence of chest x-ray abnormalities should raise the possibility of TB involvement in patients with human immunodeficiency virus; (4) anti-TB treatment decreases the sensitivity of gallium scan.

[A case of tubercular liver and splenic abscesses]

A 34-years male was admitted to our hospital with a hypochondria pain and low grade fever. Abdominal CT revealed an encapsulated 8 x 3 cm low density lesion on the surface of the liver (S5, S8) and multiple low density lesions of the spleen. The patient had already been treated with anti-tuberculous drugs for the past 7 months after being diagnosed as tuberculous pleuritis. Although echo-guided percutaneous needle biopsy was tried for the hepatic lesion, no special finding was obtained. Therefore a diagnostic laparotomy was performed and the hepatic lesion was resected. Abscess formation of the resected lesion was noted. Histopathology of the lesion revealed epithelioid granuloma, but microscopy, culture and PCR for tuberculosis revealed negative results. Abdominal CT, 3 weeks after surgery, revealed enlargement of the splenic lesion. Splenectomy was carried out to avoid splenic rupture. Multiple abscess of the resected spleen was noted. Pathological finding, Ziehl-Neelsen stain and PCR for tuberculosis confirmed the diagnosis of tubercular splenic and liver abscess. Although tubercular liver and splenic abscess are very rare recently, it should be included in the differential diagnosis of unknown hepatic and splenic lesions.

Microabscesses of the liver and spleen in AIDS: detection with 5-MHz sonography

PURPOSE

To determine whether sonograms of the liver and spleen, obtained with 5-MHz linear-array transducers, aid in detection of hepatosplenic microabscesses in patients with acquired immunodeficiency syndrome (AIDS).

MATERIALS AND METHODS

Abdominal sonographic examinations (n = 111) were performed in 102 consecutive patients with AIDS. A 3.5-MHz sector transducer was used in each study, with additional images of the hepatic and splenic parenchyma obtained with a 5-MHz linear-array transducer. Each study was reviewed without benefit of the 5-MHz images, and categories of the hepatic and splenic parenchyma were as follows: 1, lesions definitely present; 2, lesions possibly present; and 3, lesions absent. The 5-MHz images were subsequently reviewed, and studies were recategorized. Findings were correlated with results of pathologic examination.

RESULTS

The 5-MHz scans enabled identification of focal hepatic or splenic lesions in 14 of 96 studies placed in category 2 or 3 on the basis of the 3.5-MHz sector scans.

CONCLUSION

In patients with AIDS, 5-MHz sonograms of the liver and spleen enable detection of microabscesses not confidently identified on 3.5-MHz scans.

Tuberculosis presenting as a solitary splenic tumour

A 48-year-old male had suffered from body weight loss and general malaise for 2 months. Abdominal computed tomography showed a dilated intrahepatic duct with stones and a hypodense nodular mass in the spleen. A splenectomy and distal pancreatectomy were performed under the preoperative impression of a malignancy. Histological examination of the specimens revealed tuberculosis.

CT appearances in macronodular hepatosplenic tuberculosis: a review with five additional new cases

Pseudotumoral or macronodular hepatosplenic tuberculosis (HSTB) is rare. Only 31 cases have been documented in imaging literature so far. Presented is the clinico-imaging review with five additional new cases of this uncommon variety. Due to nonspecific wide spectrum of imaging appearances, biopsy is mandatory in almost all cases. Clinical recovery and resolution of lesions on imaging may not be directly proportional.

Ultrasound detection of tuberculomas of the spleen

A case of multiple tuberculomas of the spleen, detected as hypoechoic masses on ultrasound and subsequently proved at operation and histopathology, is presented. This was the only manifestation of the disease.

[Tuberculosis of the lymph nodes and spleen preceding Hodgkin's disease]

Tuberculosis of the lymph nodes is not rare today. However tuberculosis of the spleen has been very rare even in the past when many patients had suffered from tuberculosis. The appearance of Hodgkin's disease following tuberculosis is an extremely rare condition. It has thought that deficiency of cellular immunity was responsible for both tuberculosis and malignancy. We present a 44-year-old man in whom lymph node and spleen tuberculosis antedated the clinical onset of Hodgkin's disease for three years. The patient was successfully treated with tuberculostatics until he developed Hodgkin's disease; he was treated according to MOPP protocol. Six years after the onset of disease nodular lesion of the spleen was detected and splenectomy was carried out. The enlarged spleen, g in weight, was removed with tuberculoma in the lower pole, 4 cm in diameter. The tuberculostatic therapy for a year followed splenectomy. The patient stayed symptom-free, with no sign of tuberculosis. He is in the remission stage of Hodgkin's disease with normal clinical and laboratory data.

[Rare abdominal manifestations of tuberculosis: isolated splenic tuberculosis and peritoneal tuberculosis]

Two patients with rare localizations of extrapulmonary tuberculosis are presented. In a 55-year-old man admitted with septic fever and a low neutrophil count, ultrasonography of the spleen revealed splenomegaly with numerous hypodense foci. Fine needle biopsy of one of the foci disclosed tuberculosis. Persistent splenogenic neutropenia and thrombocytopenia, despite tuberculostatic therapy, required splenectomy which confirmed the initial diagnosis. At laparotomy no other abdominal foci of tuberculosis were found. In a second 57-year-old man admitted for ascites and weight loss, a biopsy specimen of the liver showed normal liver parenchyma but, by chance, peritoneal tuberculosis. Tuberculostatic therapy brought about cure.

[Anergic miliary tuberculosis, with principally splenic localization simulating hemolymphopathy. Report of 4 cases]

Four cases of disseminated tuberculosis with prevailing spleen involvement and lack of tuberculin reactivity are described. The atypical clinical picture justified, at the beginning of the disease, the suspect of a lymphoreticular disorder (malignant lymphoma in 3 cases) or of a pulmonary hemosiderosis (in 1 case). The splenectomy and the following anti-tubercular chemotherapy were fully successful in all 4 patients and the skin reactivity was restored. The Authors discuss the pathogenesis of the observed features and the differential diagnosis of the cases of tuberculosis with only extrapulmonary involvement. These cases represent today about 1/6 of the patients with postprimary tuberculosis.

[Isolated hepatosplenic tuberculosis: 1 case]

A 27-year-old woman presented with high spiking fevers, progressive malaise, weight loss, and marked hepatosplenomegaly. The clinical picture and laboratory findings (including hepatic scintiscan, coeliac arteriography and abdominal lymphangiography) prompted surgical exploration of hypochondriac organs. On laparotomy, both liver and spleen surface exhibited extensive inflammatory lesions. Histopathologic investigations on hepatic tissue showed microscopic caseating granulomata. Specific stains and cultures for mycobacterium, fungi etc. were negative in tissue preparations. Antituberculous and steroid therapy elicited a rapid response. Follow-up observations indicated the resolution of specific hepatic lesions.

[Bone marrow's histopathology in tuberculosis of the hematopoietic organs (author's transl)]

Through the reports of the literature, the histopathologic lesions of the bone marrow in tuberculosis of the hematopoietic organs are analysed. Whether the lesions are typical or not, it is necessary to have a bacteriologic proof of tuberculosis. Near these lesions, bone marrow's cellularity is often greater or lower, reticular fibers are often increased and sometimes reticulin fibrosis is marked. Other necrosis and granulomatous inflammation are discussed. Contribution of macrophage is described. The relationships between tuberculosis and hematologic diseases are reported.