[A case of hemophagocytic syndrome associated with miliary tuberculosis]

We reported a case of a 76-year-female with hemophagocytic syndrome caused by military tuberculosis. The patients had complained high fever over 38.0 degrees C and anorexia. Her chest X-ray and computed tomography revealed disseminated miliary shadows in both lung fields. Laboratory examinations revealed anemia, thrombocytopenia and liver dysfunction. Bonemarrow aspirate revealed tuberculous granulomas and tubercle bacilli by acid-fast stains, and hemophagocytosis by macrophages. We diagnosed as miliary tuberculosis and tuberculosis-associated hemophagocytic syndrome, and started antituberculous and steroid therapy. After these therapy, fever, laboratory examinations dramatically improved. In this case, serum IL-18, sICAM-1, sVCAM-1 were elevated. These cytokines and adhesion molecules were reported to elevate in both hemophagocytic syndrome and tuberculosis correlating with disease activity. We conclude that IL-18, sICAM-1, sVCAM-1 may play important roles in pathogenesis of tuberculosis associated hemophagocytic syndrome.

Bilateral pneumothorax complicating miliary tuberculosis in children: case report and review of the literature

An 11-year-old boy presented with a 4-week history of fever and 2 weeks later developed a cough with breathlessness. His chest X-ray showed bilateral miliary shadows with pneumothorax on the left side. While on antituberculous therapy which was started on admission, he developed right-sided pneumothorax with significant collapse of the left lung. He was managed by tube thoracotomy with underwater seal but died 4 hours after the procedure was completed.

Concomitant tuberculous and cryptococcal thyroid abscess in a human immunodeficiency virus-infected patient

Suppurative thyroiditis is a rare condition caused mostly by Staphylococcus aureus and streptococci. Both tuberculous and cryptococcal thyroid abscess are even rarer. The incidence of extrapulmonary forms of tuberculosis and cryptococcosis has increased in areas with a high prevalence of human immunodeficiency virus (HIV) infection. A case is reported of dual infection by M. tuberculosis and Cryptococcus neoformans presenting as a thyroid abscess in a 32-y-old woman with symptomatic HIV infection. Atypical presentations of both tuberculosis and cryptococcosis should be considered in areas with a high incidence of these diseases.

Tuberculous otitis media with mastoiditis and central nervous system involvement

Tuberculosis of the middle ear and mastoid is currently a rare disease in developed countries, but this disease still occurs and may cause serious consequences. We report a case of disseminated tuberculosis involving the middle ear, mastoid, lung and central nervous system. Tuberculosis should be considered in the differential diagnosis of chronic ear drainage, especially in young children.

Hemophagocytic syndrome as an initial presentation of miliary tuberculosis without pulmonary findings

A 9-y-old girl was admitted with fever, weakness and weight loss. She had pancytopenia in peripheral blood, hypocellularity and hemophagocytosis in bone marrow. Disseminated tuberculosis was diagnosed after a long delay, with involvement of the lungs, bone marrow, liver, spleen and central nervous system. Tuberculosis can be a cause of hemophagocytosis and should be taken into account in the differential diagnosis of fever of unknown origin associated with pancytopenia and hemophagocytosis.

[Acute tuberculous bronchiolitis in a patient with generalized miliary tuberculosis]

A case study of an acute tuberculous bronchiolitis (a rarely encountered form of generalized miliary tuberculosis), whose aggravated progressing resulted in fatal outcome 2 months after the onset of the initial disease signs, is described. The prevalence of non-specific infectious-and-allergic manifestations is a clinical-and-morphological peculiarity within the case study, which confirms a diversity of morphological changes occurring in the organism in tuberculosis infection. The etiological- and pathogenetic specific features of acute tuberculous bronchiolitis in children and in adults are under discussion; in particular, a possible role of a preceding viral infection is evaluated. It is one of the cases of hematogenic generalization in primary tuberculosis of adults, observed by the authors, when an involvement of the pulmonary and parenchymatous organs as well as of arachnoids and substances of the cerebrum was registered. The presence of generalized vasculitis with fibrinoid swelling and with necrosis of collagenous fibers of medium (and with the development of pan-vasculitis in the discussed case) is typical of all such observations.

Risk factors and clinical features for tuberculosis among patients with systemic lupus erythematosus in Hong Kong

OBJECTIVE

To determine the risk factors associated with and to describe the clinical course of tuberculosis (TB) in patients with systemic lupus erythematosus (SLE).

METHODS

Clinical features of patients with TB during the 1-year period prior to the diagnosis of TB were compared with controls.

RESULTS

Of the 526 SLE patients, 57 (11%) had TB. Extra-pulmonary or miliary TB occurred in 67%. Patients with TB were more likely to have organic brain syndrome, vasculitis, and nephritis: and they were also more likely to have received intravenous 'pulse' methylprednisolone or high cumulative dose of prednisolone. The cumulative dose of prednisolone and presence of nephritis were independent risk factors for the development of TB using multivariate regression analysis.

CONCLUSIONS

There is a high prevalence of TB, especially extra-pulmonary diseases, among SLE patients in Hong Kong. High cumulative dose of corticosteroid and lupus nephritis are important risk factors for the development of TB.

[A case of Pneumocystis carinii pneumonia during treatment for miliary tuberculosis]

A 30-year old man of Myanmar origin was admitted to our hospital because of productive cough, anorexia, weight loss and fever. Sputum smear was strongly positive for M. tuberculosis (Gaffky 6) and sputum culture proved M. tuberculosis. Caseous necrosis with Langhans giant cells was observed in the biopsied specimens of the liver and bone marrow. He was diagnosed as miliary tuberculosis. Treatment with combined use of isoniazid, rifampicin, ethambutol and streptomycin was started. After one month, his cough resolved, fever subsided and chest X-ray findings improved. Two months later, non-productive cough and fever recurred. Chest radiograph and computed tomographic scan of the chest revealed diffuse ground-glass opacity. Specimens taken by transbronchial biopsy showed pneumocystis carinii in alveoli. Pulsed use of methyprednisolone with Trimethoprim-sulfamethoxazole was started. The symptoms and chest X-ray findings disappeared and he recovered uneventfully. Tests for HIV infection were negative. Anti-HTLV antibody was negative. There were no other suggestive evidences of immune suppression. CD4+T cell count was low, when Pneumocystis carinii pneumonia occurred. The relation between miliary tuberculosis, Pneumocystis carinii pneumonia and CD4-T lymphocytopenia has remained unelucidated.

[Tuberculosis in patients with HIV infection: clinico-morphological and epidemiological aspects]

A contingent of patients with pulmonary tuberculosis concurrent with HIV infection in 1997 and 1999 is analyzed. The first analysis covers all cases of this combined pathology occurring in Russia throughout the notification of HIV infection in the country. The specific features of the course of tuberculosis have been defined in relation to the stage of HIV infection. The second analysis involved the data on such patients in 59 subjects of the Russian Federation in 1999. It has shown that there are changes in the composition of the contingent that has combined pathology, which is associated with the HIV transmission route that is new for Russia. This in turn resulted in that patients with HIV infection were much more frequently detected at the tuberculosis facilities. The altered HIV-infection epidemic situation enhances the topicality of this problem for phthiologists.

[Thymoma complicated with miliary tuberculosis]

We report a case of thymoma complicated with miliary tuberculosis. A 69-year-old woman was admitted to a hospital because of body weight loss, general fatigue, and dyspnea. Chest X-ray showed a small, diffuse granular shadows in both lungs. Biopsied-specimens from bone marrow and left pharynx revealed granuloma with both giant cells and caseous necrosis. The diagnosis of miliary tuberculosis was made. The patient was then transferred to our hospital. Both chest X-ray and computed tomography conducted on admission revealed a mass in the mediastinum as well as diffuse granular shadows in both lungs. We suspected a presence of thymoma. Anti-tuberculosis therapy was started, and extended thymectomy was performed. The diagnosis of thymoma was confirmed pathologically. Immunological analysis of peripheral blood lymphocytes was done before and after the operation. Negative conversion of PPD reaction was observed after thymectomy. Although the response of peripheral lymphocytes to phytohaemoagglutinin (PHA) and concanavalin A recovered after thymectomy, a marked decrease of the number of CD 4 T cells, a decrease of T helper 1 cells, a slight increase in the number of B cells and cells expressing natural killer cell-related surface markers were observed throughout the course of illness.

[A case of miliary tuberculosis complicated by acute respiratory failure after bronchofiberscopy]

A 79-year-old man presented with persistent nonproductive cough and high fever. The chest radiograph showed bilateral miliary shadows. We performed bronchoalveolar lavage and transbronchial lung biopsy to assist diagnosis. Severe dyspnea developed after the bronchofiberscopy, when the chest radiograph revealed bilateral ground-glass shadows and the oxygen saturation in the room air fell to 60%. It was suspected that the patient had acute respiratory distress syndrome, so that methylprednisolone was given intravenously at a dose of 250 mg daily for 3 days, which resulted in a reduction in ground glass shadows and an improvement in oxygen saturation. We diagnosed miliary tuberculosis because the transbronchial lung biopsy specimen showed caseous granuloma and the PCR test for Mycobacterium tuberculosis in the bronchoalveolar lavage fluid was positive. The patient was cured with antituberculosis chemotherapy.

Aortoesophageal fistula associated with tuberculous mediastinitis, mimicking esophageal Dieulafoy's disease

Aortoesophageal fistula is a rare and lethal disorder that may result from primary diseases of aorta or esophagus, aortic bypass graft, ingestion of foreign body, trauma, surgical procedure or instrumentation. Tuberculous fistula is extremely rare. We present a 27-yr-old female patient with aortoesophageal fistula associated with tuberculous mediastinitis. The patient experienced massive hematemesis and esophagoscopy revealed a small mucosal defect with exudate-coated blood vessel like Dieulafoy 's lesion on about 25 cm from the incisor teeth. Despite two sessions of endoscopic hemostatic procedures, active massive hemorrhage recurred and was controlled effectively with a prompt insertion of Sengstaken-Blakemore tube. The patient underwent open thoracotomy, which revealed aortoesophageal fistula. Numerous white-yellowish, millet seed-like tubercles were scattered in pleural and abdominal cavity. Division of fistular tract and esophageal resection with Ivor-Lewis anastomosis were performed. Histopathologic study confirmed tuberculous pleuritis and peritonitis. The patient died of postoperative pulmonary complication.

Miliary tuberculosis with bilateral pneumothorax: a rare complication

A 15-year-old girl presented with a history of cough, fever for five months and breathlessness of two days duration. Her chest roentgenogram showed bilateral miliary shadows with a left sided pneumothorax. Shortly afterwards, she developed a pneumothorax on the other side also. She was managed with intercostal tube drainage on both sides and antitubercular treatment. She made an uneventful recovery.

[A case of miliary tuberculosis complicated with SIADH, brain tuberculoma, and tuberculous meningitis]

A 46-year-old man complained fever, headache, and vertigo after he was given steroid for sudden deafness. He was diagnosed as miliary tuberculosis by his chest CT findings. After admission, 4 anti-tuberculous drugs (INH, RFP, SM, and PZA) were prescribed but his laboratory findings showed SIADH, which was difficult to treat, and steroid was readministered. Brain MRI, examined 2 months after admission, showed brain tuberculomas, and examination of cerebrospinal fluid revealed a diagnosis of tuberculous meningitis. Three months later, meningitis deteriorated transiently, however symptoms and findings improved by increasing steroid. Later, miliary tuberculosis and SIADH were cured, however, some tuberculomas grew larger gradually on brain MRI, and spinal MRI showed tuberculomas in the spinal cord. LVFX, high concentration in CSF, was added. At present (2 yrs after beginning the therapy), lesions in the brain and spinal cord improved but remain with the sequelae.

Persistent radiological changes following miliary tuberculosis in miners exposed to silica dust

SETTING

Silicosis leads to increased susceptibility to tuberculosis, but it has also been suggested that tuberculosis may interact with intra-pulmonary silica to exacerbate fibrotic lung disease.

OBJECTIVES

To investigate the possibility that silicosis developed due to or was exacerbated by tuberculosis.

METHODS

In a case series of 15 miners presenting with culture-positive miliary tuberculosis, serial radiographs taken premorbidly, at presentation, and after 2 and 6 months of standard anti-tuberculosis treatment were graded for nodularity using the International Labour Organization system.

RESULTS

Increased nodule profusion (compared to premorbid film) remained in 13 (87%) and eight (53%) patients after 2 and 6 months of treatment, respectively, despite clinical improvement in all and documented bacteriological cure in eight (53%). These phenomena, observed irrespective of human immunodeficiency virus (HIV) status, were most pronounced in men with minor premorbid changes. Abnormal pulmonary collagenisation related to silica particles was apparent at post-mortem in two men who died of HIV-associated cryptococcosis after completing TB treatment.

CONCLUSIONS

Previous silica exposure appears to result in delayed and potentially incomplete radiological resolution of miliary TB. We postulate that the immune response in tubercles may evoke a 'bystander' fibrotic response, as cytokines play a central role in the pathogenesis of both TB and silicosis.

A successfully treated case of disseminated tuberculosis-associated hemophagocytic syndrome and multiple organ dysfunction syndrome

We report the case of a patient who presented with disseminated tuberculosis-associated hemophagocytic syndrome (HPS). A 40-year-old man was admitted because of fatigue, fever, and renal dysfunction. Chest radiograph and computed tomography scan showed diffuse reticulonodular shadow, and Mycobacterium tuberculosis was identified. Peripheral blood counts decreased rapidly, and bone marrow aspiration revealed hemophagocytosis by macrophages. Despite antituberculous and steroid pulse therapy, multiple organ dysfunction syndrome developed. After plasma exchange and continuous hemodiafiltration were started, hypercytokinemia and vital signs improved dramatically. Although disseminated tuberculosis-associated HPS carries a poor prognosis, acute blood purification may be an effective means of treating HPS involving multiple organ dysfunction syndrome.

Pneumocystis carinii pneumonia in systemic lupus erythematosus: a report of two cases

Patients with systemic lupus erythematosus (SLE) have increased susceptibility to infection by Pneumocystis carinii, but this condition has rarely been reported in Taiwan. Here, we describe two cases of patients with SLE who developed Pneumocystis carinii pneumonia (PCP). The first patient was a 39-year-old woman presenting with fever and dyspnea that had lasted 2 weeks. Chest roentgenography disclosed bilateral interstitial and alveolar infiltrates. The second patient was a 22-year-old woman presenting with a 4-day history of malaise, cough, dyspnea, and fever. She had concomitant Mycobacterium tuberculosis infection. Both patients had been treated with varying doses of corticosteroids and/or cytotoxic drugs within 4 months before presentation. Diagnosis was established based on the findings of bronchoalveolar lavage (BAL) and transbronchial lung biopsy (TBLB). Both patients received trimethoprim-sulfamethoxazole (20 mg.kg-1.d-1 trimethoprim), but finally died of nosocomial septicemia (Acinetobacter baumanni and Pseudomonas aeruginosa bacteremia in one, P. aeruginosa bacteremia in the other). These two cases demonstrate that PCP should be included in the differential diagnosis of patients with SLE presenting with pneumonic processes. In addition, a second opportunistic pathogen should be suspected. Bronchoscopic examination should be performed if the diagnosis is not clear and should include TBLB and BAL.

Significance of haematological manifestations in patients with tuberculosis

OBJECTIVE

Tuberculosis is a major public health problem in India. Haematological changes associated with tuberculosis have been incompletely investigated. To the best of our knowledge, there is no comprehensive study assessing the haematological abnormalities in these patients from the Indian subcontinent. In the present study, we have compared peripheral blood and bone marrow findings in patients with disseminated/miliary tuberculosis (DTB/MTB) as well as pulmonary tuberculosis (PTB). An attempt has also been made to assess the effect of antituberculosis therapy on the haematologic abnormalities.

MATERIAL AND METHODS

Thirty two patients with disseminated/miliary tuberculosis and 23 patients with pulmonary tuberculosis were prospectively studied to determine the various haematological manifestations in tuberculosis and the effect of antituberculosis therapy. All patients received standard antituberculosis treatment. They were subjected to a detailed haemogram including peripheral blood examination, which was repeated on completion of antituberculosis therapy. Bone marrow aspiration and biopsy was also done in all patients before starting antituberculosis treatment.

RESULTS

Normocytic normochromic anaemia was the most common abnormality observed in all the groups and subgroups (DTB/MTB 84%, PTB 86%). Other haematological abnormalities of the white blood cells include leucopenia (DTB/MTB 25%, PTB 0%; p < 0.02), neutropenia (DTB/MTB 22%, PTB 0%; p < 0.04), lymphocytopenia, monocytopenia, leukocytosis, neutrophilia, lymphocytosis and monocytosis. Pancytopenia was observed only in patients with disseminated/miliary tuberculosis (p < 0.05). Thrombocytopenia was more common in patients with disseminated/miliary tuberculosis (p < 0.007), whereas thrombocytosis was more common in patients with pulmonary tuberculosis (p < 0.04). The patients of disseminated/miliary tuberculosis with granulomas in the bone marrow had certain significant differences as compared to patients without granulomas. These patients showed severe anaemia, peripheral monocytopenia and bone marrow histiomonocytosis. The haemogram reverted to normal with antituberculosis therapy in these patients.

CONCLUSIONS

In view of the varied haematological abnormalities observed in patients with tuberculosis in this part of the world, it is concluded that the differential diagnosis of tuberculosis should be entertained in patients with varied haematological disorders.

[Choroidal tubercles in miliary tuberculosis]

OBJECTIVE/METHOD

We present 2 cases of miliary tuberculosis with choroidal tubercles.

RESULTS/CONCLUSIONS

Miliary tuberculosis is a severe disease that may cause death in case of misdiagnosis, but might be resolved with an adequate mycobacterial therapy. The diagnosis was based on a combínation of findings and the presence of choroidal tubercles may play an important role in the final diagnosis and correct treatment.

Severe immune hemolytic anemia in disseminated tuberculosis with response to antituberculosis therapy

Severe hemolytic anemia in patients with disseminated tuberculosis is exceedingly rare. We report an episode of Coombs'-positive hemolytic anemia in a previously healthy young man with miliary tuberculosis, resulting in a hemoglobin level of 5 g/dL and an undetectable haptoglobin level. The patient responded well to treatment with antituberculosis drugs, and the results of the direct Coombs' test became negative without the need of blood transfusion or steroid therapy.

[Miliary tuberculosis associated with acute respiratory distress and pancytopenia in HIV-negative patient]

The acute respiratory distress syndrome (ARDS) is a rare but serious complication of miliary tuberculosis with a mortality rate near 100% when associated with pancytopenia. This association has been rarely reported (eleven cases in a Medline search, 1966-1999). A case is here reported of an HIV-negative patient with miliary tuberculosis which presented as ARDS associated with pancytopenia. This case prompted us to review the literature and risk factors, diagnosis and treatment issues are discussed. In patients with predisposing factors miliary tuberculosis must be considered as a possible cause of ARDS.

Spontaneous pneumothorax: a rare complication of miliary tuberculosis

Pneumothorax is a rare complication of miliary tuberculosis. In this report, a 25-year old patient developing pneumothorax while on the treatment for miliary tuberculosis treatment is presented and the related literature has been reviewed. Pneumothorax, although rare, should be considered when a patient with miliary tuberculosis develops a sudden, severe pain on either side of the chest with breathlessness. The treatment should be tailored according to the size of pneumothorax either pleural drainage through chest tube or needle aspiration. Meanwhile, antituberculous treatment should be continued without interruption.

Hypercalcaemia and elevated 1,25(OH)(2)D(3) levels associated with disseminated Mycobacterium avium infection in AIDS

Hypercalcaemia may complicate granulomatous diseases, such as tuberculosis and sarcoidosis, and various AIDS-related opportunistic infections and malignancies. We report here two patients with AIDS and disseminated Mycobacterium avium infection who developed symptomatic hypercalcaemia several weeks after commencing antimycobacterial chemotherapy, and in whom inappropriately elevated 1,25(OH)(2)D(3)levels were documented. Although vitamin D supplementation may have contributed, no other cause for the hypercalcaemia was found. The biochemical and clinical similarities between these cases and other hypercalcaemic granulomatous diseases suggest a common mechanism related to macrophage activation and dysregulated vitamin D production.

Non-atherosclerotic aorto-arterial thrombosis: A study of 30 cases at autopsy

BACKGROUND

Aorto-arterial thrombosis is very often associated with atherosclerotic and/or aneurysmal changes. Thrombosis, unrelated to these changes is infrequent.

AIMS

To evaluate the clinical presentation and aetiopathogenesis of aorto-arterial thrombosis, unrelated to atherosclerosis and aneurysms.

SUBJECTS AND METHODS

A retrospective study of 30 autopsied cases of non-atherosclerotic and non-aneurysmal aorto-arterial thrombosis collected over a period of 14 years was carried out.

RESULTS

There were 23 males and seven females and majority presented in the third to fourth decades of life with clinical features of acute abdomen or lower limb gangrene. Abdominal aorta as the site of thrombosis was observed in 46.5% cases. The causes were attributed to hypercoagulable states and changes in the aortic wall. No aetiology could be identified in 5 patients (16.6%. Associated tuberculosis was seen in six cases.

CONCLUSIONS

Non-atherosclerotic aortic thrombosis is a heterogeneous group of disorders. Young and even elderly patients with symptoms related to abdominal ischaemia or peripheral vascular disease should be investigated thoroughly for hypercoagulable states and aortic pathology.

Effect of potent antiretroviral therapy on immune responses to Mycobacterium avium in human immunodeficiency virus-infected subjects

To characterize the influence of highly active antiretroviral therapy (HAART) on cell-mediated immunity (CMI) to Mycobacterium avium complex (MAC), we measured immune responses to M. avium in human immunodeficiency virus (HIV)-infected individuals before and during HAART, in subjects with a history of disseminated MAC (DMAC), and in HIV-uninfected control subjects. Forty-seven percent of untreated HIV-infected patients and 78% of control subjects exhibited in vitro proliferative responses to M. avium (P=.03). Proliferative responses to M. avium increased after HAART for 3 months and were present in 77% of subjects after 6 months. Mean interferon-gamma production increased from 199 to 1156 pg/mL after HAART (P=.06). Proliferative responses to M. avium occurred in 76% of DMAC subjects receiving HAART. CD4 and CD8 but not gammadelta T cells expanded in response to M. avium. CMI to M. avium reconstitutes rapidly after HAART and appears sustained even with partial viral suppression.

[Diffuse infiltrative lung diseases of infectious and neoplastic origin]

Among the causes of chronic diffuse infiltrative lung diseases, infection and neoplasia have to be suspected in priority because of their frequency and their therapeutic specificities. Diffuse infiltrative lung diseases related to infection, often acute and feverish, are due to Pneumocystis carinii pneumonia, miliary tuberculosis, or virus and atypical pneumonia. Strategy for microbiological diagnosis depends on the pathogen suspected and the pulmonary disease severity. By contrast, diffuse infiltrative lung diseases due to neoplasia, mostly chronic diseases, include lymphangitic carcinomatosis and more rarely diffuse bronchoalveolar carcinoma and lymphoproliferative diseases.

Hepatic artery pseudoaneurysms in a patient treated for miliary tuberculosis

A 70-year-old woman with fever was admitted to our hospital. She was diagnosed as miliary tuberculosis and treated with antituberculous drugs. After seven weeks of therapy, she developed a sudden sharp upper abdominal pain and shock. Angiography of the celiac artery showed two hepatic artery pseudoaneurysms with extravasation. The hemorrhage was successfully stopped by microcoil embolization. The clinical course suggested that miliary tuberculosis had caused the pseudoaneurysms. Although aneurysms rarely occur as a complication of miliary tuberculosis, they should be diagnosed as early as possible because of the high rate of rupture and associated high mortality rate.

Disseminated tuberculosis causing bilateral adrenal enlargement and Addison's disease

The clinical features and computed tomography imaging of a patient with acute adrenal failure following disseminated tuberculosis is described.

Miliary sarcoidosis following miliary tuberculosis

A patient who presented with a miliary radiographic pattern due to tuberculosis and later with a similar miliary pattern due to sarcoidosis is described. The patient, a 47-year-old man, was admitted to the hospital due to coughing, weakness, weight loss and an abnormal chest radiograph with a miliary pattern. A gastric fluid culture was positive for Mycobacterium tuberculosis and he was treated appropriately. He showed complete clinical and radiological remission. One year later he presented with a dry cough and a similar miliary pattern on the chest roentgenogram. Lung biopsy taken by thoracoscopy revealed sarcoidosis. The patient had a complete remission with corticosteroids. To our knowledge, this is the first report describing a miliary pattern as presenting radiological sign in a patient with tuberculosis who subsequently developed a new miliary pattern due to sarcoidosis.

[The complication with tuberculosis of the central nervous system in patients with miliary tuberculosis]

The complication with tuberculosis of the central nervous system (CNS) were studied in 16 patients with miliary tuberculosis who were admitted to our hospital during a period of two years from April, 1997 to March, 1999, and were examined by head MRI. Twelve cases (75%) were diagnosed as having tuberculosis of CNS. Six cases had tuberculosis of CNS which was found during the screening of miliary tuberculosis cases, and all had only cerebral tuberculoma. Meningeal irritative symptoms led to the discovery of tuberculosis of CNS in the remaining six cases, in which cerebral tuberculoma was complicated with tuberculous meningitis. Of these cases of meningitis, three cases showing disturbance of consciousness died, but no cases of death was found in cases by the screening. The length of time from the onset of symptoms to the diagnosis of tuberculosis was long in many of the cases complicated with tuberculosis of CNS compared with the cases without such a complication. In the cases of miliary tuberculosis, the rate of complication with tuberculosis of CNS is high, and the possibility of patients developing serious symptoms suddenly even when they were asymptomatic at the time of diagnosis and the paradoxical expansion that becomes intensified after initiation of treatment have been reported. Therefore, it is necessary to make a close checkup of CNS when the diagnosis of miliary tuberculosis has been made.

[Three cases of tuberculosis complicating acute respiratory distress syndrome]

In this report, we describe three patients with pulmonary tuberculosis with acute respiratory failure with an extensive tuberculous consolidation in bilateral lung fields. Disseminated intravascular coagulation (DIC) was present in one patient and miliary tuberculosis in two patients. They all developed acute respiratory distress syndrome (ARDS), nessecitating management by mechanical ventilation with a combination therapy of antituberculous agents and methylprednisolone (m-PSL) pulse therapy. Only one patient survived in whom the PaO2/FiO2 ratio recovered rapidly after the initiation of therapy. Two patients whose systemic condition upon admission was critically ill eventually died of hepatic failure and bacterial pneumonia, even though ARDS and pulmonary tuberculosis were successfully treated. Prognosis of pulmonary tuberculosis complicating ARDS and DIC is poor, and these patients need systemic intensive treatment, in which m-PSL therapy may be beneficial.

[Intracranial tuberculomas developing during treatment of pulmonary tuberculosis: case report]

The classical presentation of neurotuberculosis is meningitis. Intracranial tuberculomas are a rare manifestation of neurotuberculosis and are due to hematogenous dissemination of distant focuses of Mycobacterium tuberculosis infection. Around 1% of patients with central nervous system tuberculosis develop intracranial tuberculomas some weeks or months after the beginning of the specific treatment with tuberculostatic chemotherapy. The involution of the lesions is slow and does not mean drug resistance nor lack of adequate treatment. We describe the case, diagnosed and treated at the 25th Infirmary of Santa Casa da Misericórdia do Rio de Janeiro, of an immunocompetent male patient who developed meningitis and multiple intracranial tuberculomas during the specific treatment of miliary tuberculosis. The literature is revised and the diagnosis, treatment and possible immunological mechanisms are discussed.

[Acute respiratory failure caused by tuberculosis requiring mechanical ventilation]

The patients with active tuberculosis in whom respiratory failure requiring mechanical ventilation developed were studied retrospectively. Nine patients (M 8, F 1) were identified at the National Tokyo Hospital during 5 years from January, 1993 to December, 1997. Seven of 9 patients were single men, and the duration of symptoms before admission was over 1 month in all patients, while the time from first visit to diagnosis was less than 7 days. All patients were identified as malnourished, and 7 patients suffered from another underlying diseases. The patients were classified into two groups. Six of 9 patients had pulmonary tuberculosis and the other three had miliary disease. The proportion of cases requiring mechanical ventilation was 0.3% and 8.6%, respectively, in pulmonary tuberculosis and miliary tuberculosis. At the start of mechanical ventilation, PaO2/FIO2 was lower than 200 in all 9 patients, and 6 patients were probably ARDS. Steroids (methylprednisolone 250-1000 mg/day) were used in all 9 patients. Despite the use of mechanical ventilation and antituberculous therapy, 8 out of 9 patients died. Only one patient with miliary tuberculosis survived. The establishment of the therapy for acute respiratory failure is needed so as to improve prognosis of such cases. At the same time, the delay in consulting a doctor led to acute respiratory failure in most cases, so it is also important to encourage tuberculosis patients to visit a doctor as soon as possible, after the appearance of symptoms.