[Manifestations, diagnosis and treatment of non-tuberculous mycobacterial infections in non-immunodepressed patients]

Non-tuberculous mycobacteria (NTM) can be the etiologic agents of chronic pulmonary disease, lymphadenitis, skin and soft-tissue infection and disseminated disease in non-immunocompromised patients. The recognition of disease needs repeated isolation of the NTM from bronchopulmonary secretions or from tissue biopsies, and its identification by specific laboratory methods. A wide spectrum of clinical presentations and severity of disease can be found, from spontaneous healing to progressive and destructive lung disease, and death, according to predisposing conditions and mycobacterial species. The choice of surgical and drug treatment will depend on identification of specific pathogen and clinical evaluation.

[The role of surgery in tuberculosis in children]

Despite increasingly rigorous preventive measures which have limited the number of cases in France, the number of children undergoing surgery for tuberculosis has remained unchanged. Over the last ten years we operated on 40 children in our pediatric unit. In 10 cases, surgery was indicated for diagnosis, in 19 cases surgery was required in an emergency situation during treatment and in 11 the operation was performed at the stage of sequellae. The type of surgery depended on the clinical situation. Thoracoscopy was used for surgical diagnosis and to empty caseous nodes in the lateral tracheal chain but was generally impossible at the sequellae stage.

[Surgery of thoracic and pulmonary tuberculosis and the sequelae of its treatment in adults]

Surgery for tuberculosis was the starting point for thoracic and cardiovascular surgery in the modern day, but its place was more and more restricted to the treatment of the disease. Excisions (lobectomies, pneumonectomies, segmentestomies) currently represent the majority of operations, after this come operations on the pleura (decortication) and rarely those on the thoracic wall (thoracoplasty, parietectomy). The indications for excision are principally encountered with disease of the parenchyma itself: progressive disease under treatment or with resistant tubercle bacilli, sequelae of parenchymal complications (infections, aspergilloma or haemoptysis) and certain forms of atypical mycobacteria, and also a small but significant group in which excisions are aimed at diagnosis. Sometimes excisions are associated by necessity with decortication for pleural disease which may or may not have originally been intended for the underlying parenchyma or the lesions may be the sequelae of previous complications of treatment such as collapse therapy. Occasionally surgery is indicated in the treatment of lymph node masses in the mediastinum which have not responded to antituberculous therapy and during the treatment bronchial complications have evolved or there have been other sequelae. As for the indications for surgery of the thoracic wall such as thoracoplasty, they appear more than ever obsolete and even if they are still used in certain complications of surgery, they have apart from a few exceptions, lost their original therapeutic role in tuberculosis. However, currently there is a recrudescence of tuberculosis favoured by certain socio-economic situations and strengthened by the appearance of TB cultures which are more and more resistant. The surgery of tuberculosis in its oldest forms (thoracoplasty and removal of cavities) can no longer be said to be the surgery of the past. They proved in the old days that they could cure. Surgery has once more its place in the therapeutic arsenal of new forms of the disease and indirectly in limiting the risk of spread it has a role to play in prevention.

[Surgical aspects of mycobacterioses. Evolution during the last 20 years]

INTRODUCTION

Tuberculosis remains one of the major infectious diseases. Its incidence has grown in immigrants and in immunosuppressed patients, and, moreover, cases of drug resistance are on the increase. The goal of this study was to analyze the implications of these new developments and surgical experience in our patients.

METHODS

The cases of 104 patients with tuberculosis hospitalized between 1975 and 1995 were reviewed retrospectively.

RESULTS

22% of the patients (23/104) were immigrants. No HIV-positive patients were described but association with debilitating diseases was frequent. Diagnosis was chiefly by histology. The culture was positive in only 30/104 patients (29%). Drug resistance was seen in only one patient (1%). 72/104 patients (69.2%) presented with an infection of the pulmonary parenchyma, 21/104 (20.2%) with pleural tuberculosis including tuberculous empyema, 3/104 (2.9%) with tuberculosis of the chest wall and 8/104 (7.7%) with mediastinal tuberculosis. Surgery was performed in 84/104 patients (80.8%). The chief indications were suspected carcinoma in 39/84 cases (46.4%), destroyed lung in 11/84 (13.1%), empyema combined with bronchopleural fistula in 10/84 (11.9%), enlarged mediastinal lymph-nodes of unknown dignity in 7/84 (8.3%), recurrent pleural effusion in 5/84 (5.9%) and bronchial stenosis in 4/84 (4.8%).

CONCLUSION

The number of surgical patients with tuberculosis has remained fairly stable over the last 20 years, but the proportion of immigrants has grown since 1990. Thoracoscopy is playing an increasingly important role in the diagnosis and surgical treatment of tuberculosis (recurrent pleural effusion, resection of peripheral pulmonary nodules turning out to be tuberculoma).

[Tuberculous lesions of the cervico-facial area. A case load of 20 years]

BACKGROUND

Tuberculosis is a granulomatous inflammatory process consequent to infection by Mycobacterium tuberculosis (human or bovine type). In the maxillofacial district easily the most frequent localisation is the laterocervical and submandibular lymph nodes.

MATERIALS AND METHODS

The series presented here includes cases of specific tubercular infection of the maxillo-facial district observed by the Division of Maxillo-Facial Surgery of the University of Turin during the period 1975 and 1995.

RESULTS

121 surgically-treated benign cervical lesions were examined of which 25 cases were found to be specifically tubercular, representing 21% of the total. In addition to the cases treated surgically during the period in question a further 12 cases of specific tubercular adenopathy were diagnosed which were treated using medical treatment alone. The clinical trend observed in these patients was variable but almost constantly characterised by scarce subjective symptomatology.

CONCLUSIONS

Diagnostic ascertainment, according to our experience, must be complete and include an accurate family and individual anamnesis, a careful objective examination, hematochemical tests (hemochrome, ESR), cervical and lung X-rays and bacterioscopic tests using fine needle aspiration. From a therapeutic point of view, in agreement with the majority of papers, the authors affirm that surgery appears to be the most indicated form of treatment.

Surgical treatment of bacillus Calmette Guérin lymphadenitis

Although its protective effect is contested and the risk of contracting tuberculosis is rather low nowadays, BCG vaccination is frequently performed. Changes of strain repeatedly led to an increased complication rate. In Austria between 1990 and 1991, of 3386 newborn babies (Strain Pasteur) 116 developed lymphadenitis 3 to 28 weeks after vaccination. The affected children received four types of treatment: nothing specific, isoniazid, or surgery with and without isoniazid. Surgical treatment was found to be necessary in 96 cases. Bacilli were successfully grown in culture in 46% of cases up to week 20 after vaccination; but later than 20 weeks no culture became positive. All cultured bacteria were isoniazid-sensitive. From our data we drew the following conclusions: isoniazid therapy did not prove successful when inflamed lymph nodes exceeded a certain size. Suppurative lymphadenitis in lymph nodes exceeding 1.0 to 1.5 cm usually led to infiltration or even perforation of the skin. Surgery prevents these complications and significantly reduces healing time. Adjuvant isoniazid therapy cannot be recommended, except for generalized BCG tuberculosis.

Mediastinal tuberculous lymphadenitis diagnosed and treated by thoracoscopy

Mediastinal tuberculous lymphadenitis is a relatively rare disorder and it is sometimes hard to identify the acid-fast bacilli involved or its specific pathological findings. We employed thoracoscopy to obtain diagnostic material from a 25-year-old woman with a newly-appearing mediastinal mass despite antituberculous therapy for cervical tuberculous lymphadenitis. Thoracoscopy also proved effective in the curative surgical procedure, i.e. resection of the abscess wall as far as possible, debridement of the remaining wall, irrigation, and instillation of streptomycin into the abscess and thoracic cavity. Postoperatively the patient has followed a favorable course for one year.

[A case of mediastinal tuberculous lymphadenitis with tracheal stenosis]

68-year-old female was introduced our hospital for productive cough and dyspnea. Chest X ray film showed right upper mediastinal mass and tracheal stenosis. Chest CT showed mediastinal mass with calcifying lesion. ESR at 1 hour was 50 mm and CRP was 1.08 micrograms/ml. Because of progressive dyspnea, the operation was performed without further assessment. We found a mass of adhesive lymph nodes by the side of trachea. We removed it and it turned out to be tuberculous lymphadenitis. Postoperative PPD skin test showed strongly positive reaction. She has taken medication by antituberculous drugs and lives well without complications.

Atypical mycobacterial infection in childhood: a "surgical disease'

Atypical mycobacterial (AMB) infection is an important cause of lymph node enlargement in children. Over the period, January 1992 to December 1993, 17 patients with lymphadenitis because of AMB infection were treated at the Royal Hospital for Sick Children in Glasgow. These case notes of the patients were reviewed. The mean age at presentation was 5.37 years (range 1.5-10.6 years). The patients had a short history (1-11 weeks) of unilateral single focus, usually cervicofacial (16/17), disease. The tuberculin skin test was not helpful in diagnosis (negative in 14/15). Primary excision was curative (11/11). Incision and drainage of an abscess or drainage with partial excision led to chronically discharging sinus in all cases (6/6). AMB were not always seen on staining (11/17) of drained or excised material and cultures were negative in eight cases. The diagnosis in the remaining patients was made on the basis of clinical features and particular histopathological patterns. We are currently assessing the use of polymerase chain reaction (PCR) techniques for making the diagnosis in non-cultured cases.

Specific and nonspecific lymphadenitis in childhood: etiology, diagnosis, and therapy

Over a period of 4 years, 39 children with lymphadenitis were treated surgically; in 31 cases cervical lymph nodes were the main location. In 9 cases the lymphadenitis was caused by mycobacterial infection. Staphylococcus aureus was the most frequent causative organism of unspecific lymphadenitis (11 cases). The therapy of choice appears to be surgical treatment and medical care after operation. Especially in mycobacterial lymphadenitis, complete surgical excision of the lymph node is decisive for definitive healing. There was only 1 case of therapy-resistant, relapsing cervical lymphadenitis that needed a second operation. Causative organisms in this case were Mycobacterium avium and Mycobacterium intracellulare. All other patients showed an uneventful postoperative clinical course. We believe that a consequent diagnostic process and cooperation between the pediatric surgeon and pediatrician are necessary for effective therapy.

Is BCG vaccine innocent?

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

[Duration of treatment and followup of patients operated for peripheral lymph nodes tuberculosis]

The paper analyzes patients with localized caseous necrotic tuberculosis of the peripheral lymph nodes, who were treated with antituberculous agents and underwent early surgical interventions. Follow-ups of the patients' status, changes in the clinical signs of the disease, hemograms, ESR, and immunological parameters revealed that the duration of the basic treatment regimen and follow-ups averaged 5 months and 4 years, respectively.

Surgery for tuberculosis before and after human immunodeficiency virus infection: a tropical perspective

AIM

To review from a tropical perspective the presentation and management of tuberculosis and how it is affected by coexistent human immunodeficiency virus (HIV) infection.

METHODS

A 20-year literature review using Medline (National Library of Medicine, Washington, DC, USA) searches of the terms tuberculosis, HIV and acquired immune deficiency syndrome (AIDS) by site, body system and geographical region was undertaken.

RESULTS

The dual epidemic of HIV and tuberculosis now afflicts well over 4 million people. In subSaharan Africa 20-50 per cent of patients with pulmonary tuberculosis and 60-90 per cent of those with extrapulmonary tuberculosis are HIV positive. Tuberculosis presents both with generalized systemic symptoms, and with symptoms and signs according to the site of involvement. Specific sites reviewed include lymph nodes, abdomen, bones and joints, pleural and pericardial spaces, and genitourinary system.

CONCLUSION

All surgeons need to be aware of the manifestations of tuberculosis at different sites and the effects of HIV infection. HIV-positive patients are more likely to present with systemic illness and multiple sites of involvement, and to respond poorly to major surgery. Surgical management is generally limited to making a diagnosis or treating life-threatening complications.

Surgical infection in art

The earliest images of medicine and surgery in Western art are from the late Middle Ages. Although often attractive, at that time they were illustrative and mirrored the text on how to diagnose or treat a specific condition. These drawings in medieval manuscripts represent management of abscesses, perianal infection and fistulas, amputation, and wound dressings. With the Renaissance, art in all its forms flourished, and surgeons were represented at work draining carbuncles, infected bursae, and mastoiditis; managing ulcers, scrofula, and skin infections; and performing amputations. Specific diagnosis can be made, such as streptococcal infection in the discarded leg of the miraculous transplantation performed by Saints Cosmas and Damian and in the works of Rembrandt van Rijn and Frederic Bazille. Evocations of cytokine activity are evident in works by Albrecht Dürer, Edvard Munch, and James Tissot. The iconography of society's view of a surgeon is apparent and often not complimentary. The surgeon's art is a visual art. Astute observation leads to early diagnosis and better results in surgical infection and the septic state. Learning to see what we look at enhances our appreciation of the world around us but, quite specifically, makes us better clinicians.

Cervical lymphadenitis in children: the role of Mycobacterium avium-intracellulare

Non-tuberculous mycobacteria are the most frequent cause of mycobacterial cervical lymphadenitis in children. Although uncommon, the incidence in recent years has shown a marked increase. Its early differentiation from tuberculous mycobacterial lymphadenitis is essential as the treatment of choice is early surgical excision rather than antituberculous chemotherapy. Three such cases are reported with emphasis on the differential diagnosis and management.

A review of 23 patients with tuberculosis of the head and neck

OBJECTIVE

to review the clinical features and management of tuberculosis of the head and neck and to identify those features which may aid diagnosis.

DESIGN

retrospective study.

SETTING

teaching hospital, England, UK.

SUBJECTS

Twenty-three patients with tuberculosis of the head and neck diagnosed by culture of specimens obtained by fine needle biopsy (n = 8) or by open biopsy of the lumps in the neck (n = 15) who presented between 1990 and 1993.

MAIN OUTCOME MEASURES

methods of diagnosis and management.

RESULTS

thirteen of the 23 patients (57%) presented with either a fluctuant mass or a discharging sinus in the neck. Nine (39%) had uncomplicated enlarged lymph nodes and 12 (55%) had systemic symptoms. The supraclavicular region was the most common site (n = 11) and 8 of these 11 had abnormalities in the chest radiograph. In 3 patients the disease was resistant to treatment with standard antituberculous treatment.

CONCLUSIONS

atypical mycobacterial lymphadenitis is usually resistant to standard antituberculous treatment, so it is essential to obtain a microbiological diagnosis. Excision is usually the treatment of choice for such patients.

[Three cases of tuberculous mediastinal lymphadenitis]

Mediastinal lymph node involvement is uncommon in intrathoracic tuberculosis. We report three cases of this disease, each of which had a different clinical course. Chest CT scans showed preferential involvement of right paratracheal nodes, central areas of relatively low density with peripheral rim enhancement after injection of contrast medium. Specimens obtained by mediastinoscopy and fiberoptic bronchoscopy revealed acid-fast bacilli in all cases. In view of its relative frequency, tuberculous mediastinal lymphadenitis in adults must be distinguished from other causes of mediastinal masses.

Non-tuberculous mycobacterial lymphadenitis

BACKGROUND

Non-tuberculous mycobacterial lymphadenitis has been recognized since medieval times by an array of names. The condition is familiar to paediatricians and paediatric surgeons but it often is not recognized in its early stages. A paediatric surgeon's experience of the condition in Newcastle over 30 years is reviewed.

METHODS

A personal series of children with non-tuberculous mycobacterial lymphadenitis treated in Newcastle from 1966 to 1994 is reviewed. Clinical diagnosis was supported by multiple Mantoux skin testing in most patients using human purified protein derivative (PPD) and avian antigens. All were treated surgically with histological confirmation of the diagnosis. A total of 89 patients were encountered. Twenty-two were seen in hospital practice between 1966 and 1976 and have already been reported. The current paper presents the results of analysis of the clinical features, diagnosis and surgical treatment of the remaining 67 patients seen in paediatric surgical practice between 1976 and 1994.

RESULTS

There was equal sex distribution. Ages ranged from 1 to 10 years, with none under 1 year, and 82% of the patients were in the pre-school age group. Cervical lymph nodes were involved in all, the majority being jugulo-digastric or submandibular. Surgical excision by limited dissection of lymph nodes was performed in 55 patients with one recurrence, and by excision and curettage in eight patients with two recurrences. Simple bacterial wound infection occurred in four patients and two had prolonged postoperative suppuration as a result of mycobacterial wound infection. Paresis of the mandibular or cervical branch of the facial nerve occurred in 50% of patients where the nerve was at risk, but the majority of these recovered although it took over 6 months in some children. Culture for mycobacterial organisms was positive in only 29 patients.

CONCLUSIONS

The diagnosis of non-tuberculous mycobacterial lymphadenitis is clinical and its early recognition requires an awareness of the condition. It can be confirmed by multiple Mantoux testing or fine needle aspiration biopsy. The treatment is local excision of the affected lymph nodes. Histological examination and mycobacterial culture should be performed.

Treatment of nontuberculous mycobacterial lymphadenitis with clarithromycin plus rifabutin

Treatment with clarithromycin plus rifabutin in children with nontuberculous mycobacterial lymphadenitis was associated with resolution of chronic sinus formation and discharge after incomplete excision in five of five cases, and involution of the enlarged lymph nodes in two of three cases treated without surgery.

Adverse reactions to BCG

In the post-war period the following BCG vaccines were successively in use for preventive vaccination in the Czech territory: (a) Copenhagen BCG, 1947-1950, (b) Prague BCG 725, 1951-1980, (c) Moscow BCG, 1981-1993, and (d) Behring BCG, from 1994 onwards. These BCG substrains can be now identified by modern methods of molecular genetics. Introducing the Moscow BCG brought about an elevated incidence of iatrogenic local and regional lymph node adverse reactions compared with the previous Prague BCG product and, as a new phenomenon, bone and joint involvements in children vaccinated at birth. The aim of this study was to analyze the incidence of postvaccination adverse reactions reported in the period from 1981 to 1993 as related to the Moscow BCG vaccine and, to demonstrate the effect of lower vaccination dosage on their frequency. The concentration of the Moscow BCG varied from 11 to 22.6 x 10(6) (average 16.2) CFU per 1 mg. In the period when full dose of BCG (0.05 mg per 0.1 ml) was applied to newborns 437 local and 195 regional lymph node complications were recorded, i.e. 0.08% of vaccinated were affected, demanding antituberculosis chemotherapy in 6.5% and surgical interventions in 24%. When the lowered vaccination dose (0.025 mg per 0.1 ml) was inoculated to newborns the local adverse reactions rose paradoxically affecting 0.1% of vaccinated but the regional lymph node reactions fell considerably to reach 0.01%; the demand for chemotherapy and surgery also fell down to 3.1 and 4.8% respectively. Bone and joint adverse involvements were recorded in 28 cases, i.e. in 3.7 per 10(5) of those vaccinated with the full dose.(ABSTRACT TRUNCATED AT 250 WORDS)

[Diagnosis and surgical treatment of tuberculous lymphadenopathy of hilar and mediastinal lymph nodes]

Fifty-eight patients with hilar and mediastinal tuberculous lymphadenopathy treated with surgical operation were reported. The authors presented their preliminary experience in diagnosis, surgical technique and satisfactory outcome. The concluded that in certain situation, thoractomy is indicated for both acquiring objective, accurate diagnosis and definitive, effective treatment.

Tuberculosis of the breast masquerading as carcinoma: a study of 100 patients

One hundred patients with tuberculous mastitis were referred to the Tata Memorial Hospital, a cancer center, with a clinical diagnosis of malignancy. This study identifies the possible causes of misdiagnosis and reviews the management of these patients. A lump in the breast with or without ulceration was the commonest presentation, the others being diffuse nodularity and multiple sinuses. Concomitant axillary lymph nodes were found in one-third of the patients. Tuberculosis lesions such as nodular mastitis, disseminated mastitis, and sclerosing lesions clinically mimicked a fibroadenoma, carcinoma, and fibrocystic mastitis depending on the mode of presentation. A young, multiparous, lactating woman with a lesion should arouse the suspicion of tuberculous mastitis, although pretherapeutic pathologic confirmation of a benign disease is mandatory. Mammography, fine-needle aspiration cytology, and excision biopsy for this purpose are successful in 14%, 12%, and 60% of cases, respectively. Acid-fast bacilli were identified in 12% patients. All patients received antituberculous chemotherapy, and 14% patients required simple mastectomy, due to either lack of response to chemotherapy (10%) or large painful, ulcerative lesions involving the entire breast (4%). Axillary dissection was performed in only 8% patients with large ulcerated axillary nodes. All patients, followed for a minimum of 2 years, were free of disease after therapy.

[Bronchoesophageal fistula and broncholithiasis]

Bronchoesophageal fistulas (BEF) in an adult, whether acquired or congenital, are uncommon but bronchoesophageal perforation secondary to broncholithiasis caused by calcified mediastinal adenopathy and leading to the formation of a fistulous tract is extremely rare. We present a case of acquired BEF in a 57-years-old women who presented cough with expectoration of broncholiths, hemoptysis and cough after swallowing liquid or solid hemoptysis and cough after swallowing liquid or solid foods. The chest film and computed tomographic scan showed calcified mediastinal adenopathy. Endoscopic examination of the esophagus revealed no mucosal abnormality. A bronchial esophageal fistula was identified at the level of the 1/3 midesophagus just below the carina in the esophagogram. The bronchoscopy showed a polypoid area located in the medial side of the right main bronchus. There was no evidence of neoplasm. The patient underwent excision of fistula and interposition of pleural bundle after completing a right posterolateral thoracotomy. The postoperative course was uneventful and the patient has been doing well on follow-up.

Intra-abdominal tuberculosis in acquired immunodeficiency syndrome. Diagnosis and management

Tuberculosis (TB) in human immunodeficiency virus (HIV) immunosuppressed patients is characterized by extra-pulmonary disease in as many of 70% of them. If intestinal or lymph node involvement occurs, the differential diagnosis between an acute abdomen and other non surgical conditions may be a challenging problem. The authors analyzed eight double infected patients (TB and acquired immunodeficiency syndrome AIDS), who were admitted to the University Hospital (HUCFF) of the Federal University of Rio de Janeiro. This association should be considered when abdominal pain, anemia, fever, weight loss and abdominal lymph node enlargement are present. Bacteriology of body fluids, abdominal ultrasound (US) and computed tomography scans (CT) combined with guided needle aspiration biopsies, barium examination, colonoscopy and laparoscopy, can not only elucidate the diagnosis but also be helpful in assessing an appropriate management. Thus a systematic evaluation often yields an etiology and a correct therapeutic indication reducing the high mortality rate.

Surgical treatment of childhood mediastinal tuberculous lymphadenitis

Between 1985 and 1991, we treated 6 children, aged 2 months to 3 years, who required an invasive procedure for the management of complications caused by enlarged mediastinal lymph nodes secondary to tuberculosis. Radiologic and endoscopic studies revealed bronchial involvement by lymph nodes, with endobronchial granulomas and lobar or pulmonary obstruction in 4 patients and marked tracheal and esophageal stenosis produced by extrinsic compression in the remaining 2. Pathologic study of the lymph node or bronchial samples from the 6 patients disclosed granulomas with caseous necrosis and Langhans' giant cells. All the children were treated with a standard 6-month drug regimen consisting of isoniazid, rifampicin, and pyrazinamide. Five of the patients underwent thoracotomy for the purpose of nodal curettage or excision. In 1, upper right lobectomy and bronchoplasty were necessary. The sixth patient was treated by endoscopic resection of the granulomas. There was no postoperative morbidity, and radiologic and endoscopic evidence of resolution of the lesions was observed in all the patients. In our experience, surgical treatment, when performed as a coadjuvant treatment for tracheobronchial complications stemming from mediastinal tuberculous lymphadenitis, results in the resolution of the lesions and has no related morbidity.