[A case of tuberculous uveitis complicated by myelodysplastic syndrome]

BACKGROUND

Recently, the incidence of tuberculosis in compromised hosts has increased.

CASE

A 52-year-old man suffering from myelodysplastic syndrome (MDS) had pulmonary tuberculosis. On June 22, 1996, we found a disc-sized choroidal lesion with milky appearance on the paramacular in his right eye. After 1 month, a similar choroidal lesion was found near the disc in the same eye. In spite of chemotherapy for MDS and antituberculosis medications, those choroidal lesions gradually enlarged. In November, satellite lesions were found around them. Some retinal exudates and hemorrhage were also detected in both eyes. He died on April 6, 1997. We found Langhans' giant cells in the choroid on the specimen of his eyes. So we judged the choroidal lesions to be tuberculous uveitis.

CONCLUSION

This case showed choroidal tuberculosis and choroidal miliary tuberculosis in the same eye that were resistant to medications. We thought resistance to medication was due to destruction of the immune system by MDS.

[Intracerebral tuberculomas in a pregnant Somalian woman]

A pregnant Somalian woman aged 28 years, in the Netherlands for the last five years, suffered from a progressive hemiparesis, epilepsia, behavioural problems and low fever. Brain MRI showed multiple lesions with contrast enhancement. Extensive serologic and parasitologic tests on serum and cerebrospinal fluid did not disclose any cause. A brain biopsy revealed only necrosis, but bacterial culture and polymerase chain reaction (PCR) supplied the diagnosis of 'tuberculosis'. PCR on the cerebrospinal fluid remained negative. In the meantime the chest X-ray showed miliary tuberculosis and a spine MRI thoracic spondylodiscitis and a large paravertebral abscess. Subsequently the patient was treated successfully with tuberculostatic agents. Her healthy child which was born by caesarean section was treated with the tuberculostatic agents as well.

Diagnosis and treatment of the malignant gestational trophoblastic tumor with pulmonary metastasis complicated with pulmonary tuberculosis

OBJECTIVE

To evaluate the diagnosis and treatment for malignant gestational trophoblastic tumor (MGTT) with pulmonary metastasis complicated with pulmonary tuberculosis.

METHODS

To analyze ten cases of MGTT with pulmonary metastasis complicated with pulmonary tuberculosis in our hospital from 1980 to 1997 retrospectively.

RESULTS

From the x-ray film, there are great resemblances between MGTT with pulmonary metastasis and pulmonary tuberculosis. Of 10 patients, 7 of them were examined out pulmonary tuberculosis during the chemotherapy of MGTT. Pulmonary tuberculosis appeared six months before chemotherapy in three cases. All of the patients were treated with multiagent chemotherapy. Seven patients achiceved a complete remission, 2 patients developed drug resistance and died of cerebral haemorrhage and cerebral herniation, 1 woman who had achieved a complete remission from MGTT for 14 months died of miliary tuberculosis.

CONCLUSION

It is very important to make differential diagnosis of the MGTT with pulmonary metastasis complicated with pulmonary tuberculosis. Trying to avoid excessive anti-tumor treatment owing to mistake pulmonary tuberculosis for pulmonary metastasis, and avoiding missing an opportunity of anti-tuberculosis treatment because of missed diagnosis should be emphasized.

[Intrahepatic calcification--a differential diagnostic problem]

HISTORY AND CLINICAL FINDINGS

A 57-year-old woman was admitted for investigation of intrahepatic calcifications. Intrahepatic cholangiolithiasis was suspected. In 1993 she underwent cholecystectomy because of lithiasis. The examination with endoscopic retrograde cholangiography (ERC) was planned.

INVESTIGATIONS

The laboratory findings were normal except for a mild elevation of alkaline phosphatase and gammaglutamyl transpeptidase. The sonographic examination of the abdomen showed multiple hyperechoic calcifications along non-dilated bile ducts. In the spleen of normal size there were found a lot of intraparenchymatous calcifications. The abdominal roentgenography revealed calcifications also in the pancreas. In ERC, the intra- and extrahepatic bile ducts were normal with simultaneous proof of parenchymatous calcifications.

TREATMENT AND COURSE

Because of the medical history of the patient and the radiologic findings the multiple parenchymatous calcifications could be referred to a miliary tuberculosis during childhood. In miliary tuberculosis, the liver almost always is involved by acute granulomatous inflammation. The therapy of hepatic tuberculosis follows the guidelines of systemic tuberculostatic therapy according to other presentations of this disease. Under sufficient therapy, tuberculotic granulomas normally heal without cicatrization. Sometimes tissue reactions in form of local fibrosis and calcification lead to a mild reduction in hepatic function as seen in this case.

CONCLUSION

In the European population, intrahepatic cholangiolithiasis is a rare cause of focal hyperechoic liver lesions. In differential diagnosis, numerous diseases of possible systemic course have to be considered, which may induce calcifications of the liver or other organs. Among systemic diseases characterized by granulomatous inflammation and possible calcification tuberculosis and sarcoidosis have to be mentioned first.

Miliary tuberculosis presenting with rigors and developing unusual cutaneous manifestations

We report a case of miliary tuberculosis presenting with high fevers and rigors. While undergoing evaluation, the patient developed a diffuse, erythematous, maculopapular eruption coalescing to form erythematous plaques involving the abdomen, trunk, and proximal extremities. Biopsies of the lesions were smear- and culture-negative for Mycobacterium tuberculosis. Rigors are an unusual presenting symptom of miliary tuberculosis and have only been reported three times in the (post-antibiotic era) literature. Chills have been reported to occur 28% of the time. This symptom can be confusing to the practitioner, leading to delay in diagnosis. The skin lesions were most consistent with a lichenoid tuberculid eruption. The patient had a negative purified protein derivative and non-reactive anergy panel, and the lesions involved only the cutis and healed without scarring. The patient had a dramatic response to antituberculous therapy, with resolution of the fever within 2 days and resolution of the rash within 2 weeks.

[Recurrent orchiepididymitis, 6 months after likely miliary tuberculosis]

OBJECTIVE

To underscore the difficulty and importance of early diagnosis in tuberculous epididymo-orchitis.

METHODS

Herein we describe a male patient with a history of fever for a long period, constitutional symptoms and retinal exudates that had been diagnosed and treated as systemic candidiasis instead of miliary tuberculosis. Six years later the patient presented with acute epididymo-orchitis. One year thereafter he developed contralateral epididymo-orchitis with a more torpid course. The patient did not respond to conventional treatment. Sterile pus was detected in urine; cultures and bacilli studies were negative. Testicular US findings were compatible with the condition and disclosed an abscessed area which was functioned and the diagnosis was made.

RESULTS

The patient was treated with pirazinamide for two months and isoniacid and rifampicin for 12 months. However, the patient developed sterility.

CONCLUSIONS

Tuberculous epididymo-orchitis can present acutely and can be confused with infection from other more common pathogens, or subacutely and confused with tumors. In many cases there is no previous patient or family history and chest x-ray, bacilloscopies and cultures can be negative. Tuberculosis must be considered due to its increasing incidence. US-guided fine needle punction-aspiration biopsy is very useful for diagnosis, which has to be made as early as possible to avoid sterility.

Multiple organ failure and septic shock in disseminated tuberculosis

The diagnosis of disseminated tuberculosis should be entertained in all patients with unexplained fever associated with hepatomegaly and/or splenomegaly with or without anomalies in liver function tests and haemogram. It should be considered as a possible cause of septic shock especially in patients with typical risk factors such as advanced age, diabetes, alcoholism or immunosuppression. Prompt therapy could be life saving in an otherwise potentially fatal condition. It is therefore appropriate to initiate anti-tuberculosis treatment as soon as such a diagnosis is suspected and not await final confirmation.

Bone marrow examinations as final clue to diagnosis of hypercalcemia: report of two cases

Two young men with severe hypercalcemia in association with renal failure (one acute and one chronic) are reported in whom usual diagnostic tests failed to reveal an etiology, and the final diagnoses were given by bone marrow examinations. Early bone marrow examinations in specific patients with hypercalcemia of undetermined origin sometimes are vital as shown by our two patients.

[Mycobacterial infection in patients with hematologic disorders]

In patients with hematologic disorders, cellular immunity may be suppressed by the disease itself or by treatment with adrenal corticosteroids, immunosuppressants, or anticancer agents. Miliary tuberculosis developing in such compromised hosts is cryptic, and thus its diagnosis is difficult to make. Miliary tuberculosis will be fatal if it cannot be detected. Therefore, the possibility of mycobacterial infection should always be kept in mind when treating patients with hematologic disorders. However, such patients often have a poor prognosis, even if they have already been diagnosed with miliary tuberculosis. Prophylactic medication has been proved to be effective against mycobacterial infection with hematologic disorders. Thus, the importance of prophylactic medication should be emphasized.

[Disseminated tuberculosis in non-immunocompromised host: three case reports]

INTRODUCTION

Disseminated tuberculosis, i.e., tuberculosis involving lung, liver, spleen, bone marrow and lymph nodes is rare (2.8%), particularly when immunocompromised diathesis is lacking.

EXEGESIS

We report three cases of disseminated tuberculosis confirmed by bacteriology or histology, which occurred in non-immunocompromised patients. Disease evolution under antituberculous treatment was favorable in two cases and fatal in the third one.

CONCLUSION

Disseminated tuberculosis must be suspected when miliary pulmonary lesions are associated with hematologic abnormalities, even in non-immunocompromised host. Early treatment is mandatory to avoid fatal outcome.

Pulmonary miliary tuberculosis with multiple intracerebral tuberculous granulomas--report of two cases

Although intracerebral tuberculomas are common in countries where tuberculosis is still endemic, miliary tuberculosis with involvement of the central nervous system is exceptionally rare. We report two cases of pulmonary miliary tuberculosis with multiple intracerebral tuberculomas.

[Fulminant hepatitis in the course of antitubercular treatment (apropos of 2 cases)]

We report two cases of fulminant hepatitis induced by antitubercular drugs. The mechanism is both immunoallergic and toxic. The fatal case appears in patient with acquired immunodeficiency syndrome. Liver tests must be realized during antitubercular treatment, that is difficult in sub-Saharan Africa.

Miliary tuberculosis presenting as tenosynovitis in a case of rheumatoid arthritis

A 77-year-old woman with a seropositive nodular rheumatoid arthritis and vasculitis, who was treated with high doses of corticosteroids and intravenous cyclophosphamide, developed miliary tuberculosis that was heralded by a tenosynovitis in her right wrist. A 1-year course of anti-tuberculous therapy resulted in complete resolution of the tenosynovitis and disseminated infection.

Central nervous system tuberculoma: a case report

Pediatric cerebral tuberculoma is a disease rarely encountered in the United States. We report a case of central nervous system tuberculoma in a 6-month-old infant who presented to the emergency department with isolated right upper extremity paralysis. The discussion includes a brief review of central nervous system tuberculomas.

Massive posterior fossa tuberculous abscess developing in a young child treated for miliary tuberculosis. Possible role of very rapid acetylation of isoniazid

A 21-month-old infant presented with acute obstructive hydrocephalus due to a large tuberculous abscess in the posterior fossa 3 months after starting treatment for miliary tuberculosis. Insertion of a ventriculo-peritoneal shunt resulted in some clinical improvement but subsequent neurological deterioration occurred due to massive enlargement of the tuberculous abscess despite apparently adequate antituberculosis therapy. Repeated drainage procedures of the abscess eventually resulted in resolution and clinical improvement. As part of the workup for poor weight gain and the unusual clinical course, the patient's acetylation status for isoniazid was determined and found to be very rapid. Doubling the daily dose of isoniazid was followed by a dramatic weight increase and further clinical improvement. Decreasing the load of tuberculous antigen by draining the abscesses and increasing the pulse exposure of isoniazid is the best possible explanation for the clinical improvement finally seen in this patient.

Auditory disorder in central nervous system miliary tuberculosis: case report

We evaluated a 28-year-old female with a unilateral hearing loss of unusual pathogenesis, that of central nervous system miliary tuberculosis. Audiologic and otologic findings were consistent with left retrocochlear disorder, characterized by a profound hearing sensitivity loss, absent acoustic reflexes, normal otoacoustic emissions, and the presence of only wave I of the auditory brainstem response. Imaging studies revealed the presence of multiple punctate lesions, one of which was extra-axial and located at the left cerebellopontine angle. The pattern of audiometric test results, particularly the combination of normal otoacoustic emissions and profound hearing sensitivity loss, contributed importantly to the investigative sequence leading to the final diagnosis.

[A case of miliary tuberculosis with multiple cerebral tuberculoma and spinal tuberculosis owing to total delay]

We reported a case of miliary tuberculosis with multiple cerebral tuberculoma and spinal tuberculosis. The case was a 37 year old man. In the last sixteen months to the first visit to a hospital, he has been suffering from low grade fever, cough, and back pain, but he bared his symptoms without any therapy. At a hospital he first visited, he was told that he might have a malignant disease, which prevented him to visit the hospital because of a fear for his disease. Six months later, he was admitted to other hospital because of severe back pain. At last, he was diagnosed as tuberculosis and referred to our hospital. By the examinations on admission he was diagnosed as multiple cerebral tuberculoma and spinal tuberculosis, and anti-tuberculous therapy was started. It is thought that his severe disease status on admission is caused by the total delay, namely the delay in visiting a doctor and the doctor's delay in making diagnosis.

Disseminated miliary tuberculosis of the skin in patients with AIDS: report of four cases

We present clinical, bacteriologic, and pathological findings for four patients with AIDS and cutaneous miliary tuberculosis. All patients had generalized tuberculosis with hematogenous dissemination to multiple organs including the skin. Microscopic examination of the skin lesions revealed ill-formed or no granulomata, extensive necrosis, and numerous acid-fast bacilli. Mycobacterium tuberculosis was detected in the skin lesions by cultures for three patients and by polymerase chain reaction for one. Three of the isolates were resistant to at least isoniazid and rifampin, and one was susceptible to these drugs. The outcome was rapidly fatal for the three patients with multidrug-resistant tuberculosis. This report draws attention to the reappearance of a once-rare manifestation of disseminated tuberculosis which, in the setting of advanced human immunodeficiency virus disease, may offer the first indication of infection with multidrug-resistant M. tuberculosis and a poor prognosis.

[Acute respiratory distress syndrome and pancytopenia during miliary tuberculosis in a HIV positive patient]

Acute respiratory distress syndrome (ARDS) is a rare but severe complication of miliary tuberculosis, which may occur even under antituberculous therapy. Even with adequate treatment, its mortality is close to 70%, and if associated with pancytopenia, it may reach 100%. Underlying diseases, delayed diagnosis and additional complications are factors of poor prognosis. We report a case of a patient infected with the human immunodeficiency virus who experienced pancytopenia and ARDS associated with miliary tuberculosis. The patient recovered under antituberculous chemotherapy.

Tuberculosis of the prostate

We present five cases of tuberculous prostatitis. In all cases this was an incidental histologic finding after transurethral prostatectomy. The patients were all treated with an antituberculous drug regimen. A literature review of this rare condition is included.

[A successfully treated case of miliary tuberculosis with adult respiratory distress syndrome and tuberculous aneurysm of abdominal aorta]

A 52-year-old woman visited a physician on Oct. 17, 1995 because of dizziness, general fatigue and a slight fever. A Chest X-ray film showed micronodulous and infiltrative shadows in the bilateral upper lung fields. Liver dysfunction was also recognized. As dyspnea and hypoxemia progressed very rapidly, the patient was intubated and kept under mechanical ventilation. A diagnosis of miliary tuberculosis with adult respiratory distress syndrome (ARDS) was made based on the detection of acid-fast bacilli from sputum obtained from the endotracheal tube. She was admitted to our hospital on Oct. 24, 1995 receiving anti-tuberculous drugs combined with high-dose methylprednisolone. As disseminated intravascular coagulation (DIC) and acute pancreatitis also developed, gabexate mesilate was added to the preceding therapy. This combination therapy was effective and the patient gradually improved. Two months after the admission, aneurysms of the abdominal aorta and left renal artery were discovered. As the size of the aneurysms had been increasing along with abdominal and low back pain, the patient was transferred to an other hospital for surgical treatment. She underwent a successful operation for pseudoaneurysms, the etiology of which was tuberculosis according to pathological findings and detection of acid-fast bacilli from the resected specimens. This is the 10th case of tuberculous aneurysm of the aorta which was successfully operated on in Japan. ARDS, DIC and aneurysm occur rarely as complications of miliary tuberculosis, but they are life-threatening, and lead to a serious prognosis if untreated. Early diagnosis of miliary tuberculosis and tuberculous aneurysm is very important for a good outcome.

[Focal dystonia and tremor secondary to brain stem tuberculoma]

Brainstem tuberculoma is exceptionally observed. We report a 44 year-old immunocompetent man with proven diagnosis of miliary tuberculosis (TBC) who developed a complex neurological syndrome characterized by right ophtalmoplegia, left-sided hemiparesis and hemihypoesthesia and a gross ipsilateral postural and action tremor with hand dystonia. A ponto-mesencephalic mass was detected by CT and MRI studies of the brain. Clinical, bacteriological and neuroimaging studies allowed to suspect a ponto-mesencephalic tuberculoma. Long-term therapy with anti-TBC drugs and steroids was started, achieving clinical and imaging improvement which retrospectively confirmed the diagnosis. Although with less amplitude, tremor persisted but a complete disappearance of focal dystonia was observed. The pathogenesis of both abnormal movements is particularly discussed since hand dystonia has never been mentioned in the literature as a consequence of brainstem damage.

[Hemophagocytic syndrome due to miliary tuberculosis in the course of aplastic anemia]

We report a 63 year-old female with aplastic anemia (AA) who was complicated with hemophagocytic syndrome induced by systemic miliary tuberculosis. Two years before admission to our hospital, she was diagnosed as AA and had been treated with granulocyte colony-stimulating factor, erythropoietin and methenolone acetate. In May, 1996, She was transferred to our hospital because of high fever and exacervation of pancytopenia. She showed severe pancytopenia, and an increase in macrophages showing remarkable erythrophagocytosis and decrease in hemopoietic cells in the bone marrow. In initial examination, high titer of IgM antibody to herpes simplex virus type I was identified and methylprednisolone pulse therapy was started under the diagnosis of virus associated hemophagocytic syndrome. Ten days later, however, she died for intestinal hemorrhage followed by multiorgan failure. In autopsy, multiple epitheloid cell granulomas with acid-fast bacilli were found in bone marrow, lungs, liver, spleen and kidneys.

Massive hepatosplenomegaly, jaundice and pancytopenia in miliary tuberculosis

A 29-year-old Caucasian woman presented to hospital with a 2-day history of diarrhoea, anorexia and rigors. Investigations showed abnormal liver function tests, hyponatremia, hypoalbuminaemia and lymphopenia. The initial chest radiograph was normal. A bone marrow trephine biopsy showed non-caseating granulomata and she subsequently developed miliary shadowing on the chest radiograph. A transjugular liver biopsy confirmed the presence of acid-alcohol fast bacilli. Despite starting triple therapy for miliary tuberculosis she remained febrile and developed massive hepatosplenomegaly, jaundice and pancytopenia. Standard triple therapy was substituted with ethambutol, streptomycin and oral prednisolone and the patient made a dramatic recovery. The clinical symptoms of miliary tuberculosis are frequently non-specific and the onset of the illness is often insidious. The liver is involved in almost all patients with miliary tuberculosis, but massive hepatosplenomegaly and jaundice are rare. Standard triple-therapy should be discontinued when there is significant liver dysfunction, and corticosteroids should be considered for patients with miliary tuberculosis who fail to respond to conventional therapy.

Fatal hepatic failure caused by miliary tuberculosis in a hemodialysis patient: case report

A 57 year-old male dialysis patient died soon after the onset of high fever, hypoglycemia, and disturbance of consciousness. Autopsy revealed granulomatous lesions associated with caseous necrosis mainly found in the liver, despite the absence of pulmonary changes on chest radiographs performed during the patients illness. It appears that tubercle bacilli were hematogenously disseminated mainly to the liver causing miliary tuberculosis without producing typical diffuse lesions in the lungs. Since tuberculosis is a common complication in hemodialysis patients, the potential development of atypical miliary tuberculosis should always be borne in mind.

[Disseminated tuberculosis with cutaneous manifestations in AIDS patients. Presentation of 4 cases]

BACKGROUND

Acute cutaneous miliary tuberculosis is a rare form of Mycobacterium tuberculosis infection which has been described in only 25 published cases in the last 15 years. The appearance of serious disseminated forms of tuberculosis is enhanced by the severe immunodeficiency which characterizes AIDS.

METHODS

Four cases are described of disseminated tuberculosis with cutaneous localization clinically described as the acute miliary form. Patients had AIDS and CD4 lymphocyte levels of < 100 cells/mm3. Diagnosis was established in all cases by scraping of cutaneous lesions and direct examination with Ziehl-Neelsen coloration.

RESULTS

The 4 patients presented signs and symptoms of disseminated tuberculosis with cutaneous manifestations, without a definite pattern and with localization predominantly on the thorax. Three had BAAR-positive sputum. Multiresistant strains of Mycobacterium tuberculosis were confirmed by antibiogram. One patient infected by a strain sensitive to first-line drugs responded favorably to conventional treatment for disseminated tuberculosis. In the remaining three with multiresistant strains, the evolution of the disease was rapid and unfavorable.

CONCLUSIONS

Abrupt appearance of cutaneous lesions in a patient with disseminated tuberculosis and advanced HIV-disease should raise the suspicion of its etiology. Scraping and direct examination using Ziehl-Neelsen coloration is practical, economical and non-invasive diagnostic method.