[Pulmonary tuberculoma in the North: pathomorphological study]

Autoptic specimens from tuberculosis patients operated on, delivered to the Laboratory of Pathomorphology, Institute of Tuberculosis, were used to examine quantitative changes, age-sex ratio, ethnicity, and admission of patients with pulmonary tuberculoma by climatic and geographical regions of Yakutia. The morphological types of tuberculomas, their numbers, size, activation, ratios by ethnicity were identified. Their clinical and morphological features were determined both by climatic and geographical conditions and the quality and nature of treatment, the distinguishing features of a contingent of patients. The pattern of the more severe process in the indigenous population calls for close attention and further study.

Sellar tuberculoma: report of two cases

Hypophyseal tuberculomas are exceptionally rare. We report two patients with sellar tuberculoma but with no evidence of concurrent extrasellar disease. Although the lesion is often mistaken for adenoma, there are characteristic radiological features: intense enhancement on contrast CT and thickening of the pituitary stalk on MRI in 86% of cases. Accurate diagnosis is important because pituitary tuberculoma is curable.

Tuberculoma presenting as an en plaque meningioma. Case report

Intracranial tuberculomas generally present as either solitary or multiple lesions in the brain parenchyma. They are characterized by a ring-enhancing area on either computerized tomography scans or magnetic resonance images. A case is presented in which an intracranial tuberculoma was dural based and had an appearance similar to an en plaque meningioma.

Application of whole-mount section of lung specimen in study of radiologic-pathologic correlations

We evaluated the usefulness of the whole-mount section of the inflated-fixed lung specimen in the study of radiologic-pathologic correlations. Altogether, 24 resected fresh lobe specimens with 1.5- to 3.0-cm solitary pulmonary carcinomas or tuberculomas were inflated with air, intrabronchially fixed by infusing Heitzman's solution, and finally cut into 10- to 15-micron-thick whole-mount sections for the histopathological examination. All 24 inflated-fixed lobes were satisfactorily soft as sponge, sufficiently springy, and kept their original shape. All whole-mount sections clearly presented the complete morphological features of the whole lobes, and could be directly observed by the naked eye and examined under microscopy. The use of the whole-mount section of the lung specimen may facilitate precisely and effectively the studies of the radiologic-pathologic correlations.

Abdominal macronodular tuberculomas: MR findings

PURPOSE

Our goal was to determine the appearance of abdominal macronodular tuberculomas on MRI.

METHOD

MR findings of two patients with abdominal macronodular tuberculoma, one of the liver and the other in the kidney, were reviewed.

RESULTS

The two tuberculomas, histologically confirmed to have no calcification, hemorrhaging, or fibrosis, commonly showed low signal intensity on both T1- and T2-weighted images.

CONCLUSION

We report two cases of a macronodular tuberculoma in the liver and kidney, which is visualized as a region of hypointensity on T2-weighted MR images. This finding appears to be important in reaching a definitive diagnosis of an abdominal tuberculoma.

Dementia associated with dorsal midbrain lesion

Although the dorsal midbrain has been implicated in cognitive processes in animals, its role in humans is unclear. We report the neuropsychological and postmortem neuropathological findings of a 52-yr-old university professor who developed a profound dementia in association with a focal dorsal midbrain lesion. The patient's disorder appeared to result from a tuberculous granuloma based on the clinical course and autopsy results. Neuropsychologically, he exhibited a generalized impairment across most of the cognitive domains assessed. His deficits were not explained by impaired arousal, specific sensory or motor defects, depression, or hydrocephalus. Although there are inherent limitations to a single-case investigation, our observations are consistent with animal studies that have demonstrated that focal dorsal midbrain lesions may result in cognitive impairment. We propose that the dorsal midbrain is involved in cognitive processing via modulation of thalamocortical networks.

Vascular manifestations of small solitary pulmonary masses. Angiographic-pathologic correlations and clinical significance

RATIONALE AND OBJECTIVES

By performing pulmonary specimen angiographies, the authors attempted to determine the pathologic correlations of the vascular-related radiologic manifestations within, at the edge of, and adjacent to the small solitary pulmonary masses, and to evaluate their usefulness in differentiating small bronchogenic carcinomas from tuberculomas.

METHODS

A total of 29 resected lobe specimens with 1.5- to 3.5-cm solitary pulmonary masses, including 24 carcinomas and 5 tuberculomas, were studied prospectively with preoperative radiographs, postoperative specimen arteriographies (in 19 carcinomas and 5 tuberculomas), and venographies (in 5 carcinomas), 10- to 15 micrograms-thick whole-mount sections, and 5-micrograms-thick slices for the examination of angiographic-pathologic correlation. Another series of chest radiographs and conventional tomographs of 100 patients with 1- to 3-cm peripheral pulmonary masses, including 60 carcinomas and 40 tuberculomas, were reviewed retrospectively and analyzed with the chi-square test.

RESULTS

Specimen angiographies showed the intralesion avascularity, small arterial speculation, and lobulation or notch at the mass margin with arterial compression, as well as vascular convergence to the mass, in both carcinoma and tuberculoma groups. The irregular arterial wall (79.2%) and venous dilation distal to the mass (100%) were found in the carcinoma group only. Microscopically, arterial or venous fibrous hyperplasia was observed in both carcinomas and tuberculomas, whereas the arterial erosion by tumor tissue and tumor emboli within the vessels were found in carcinomas only. The retrospective review of the 100 patients showed that two radiologic signs of the vascular convergence to the mass and the vascular dilation distal to the mass occurred at similar frequencies (12%-13%) between the carcinoma and tuberculoma groups.

CONCLUSIONS

In addition to compression of vessels by tumor and vessel occlusion by tumor embolus, pulmonary vascular fibrotic hyperplasia can cause intramass avascularity. Small vessels running vertically into or from the mass margin can construct the spiculation sign of the tuberculomas. Any evidence of pulmonary vascular irregularity will indicate a bronchogenic carcinoma. The vascular convergence to the mass and the vascular dilation distal to the mass are not specific radiologic signs for small solitary bronchogenic carcinomas.

[Video-assisted thoracic surgical (VATS) biopsy as a technique for differential diagnosis of indeterminate small pulmonary nodules]

The authors experienced two cases of multiple pulmonary tuberculomas, which were suspected of metastatic lung tumors. First patient was a 63-years-old male, who was found to have multiple pulmonary nodular shadows on his check up chest X-ray film, suspected of pulmonary metastases of rectal cancer. VATS biopsy, performed for one of nodules revealed that it was caseating granuloma, suggestive of pulmonary tuberculosis. Second patient was a 55-years-old female with rheumatoid arthritis and a chest X-ray film showed multiple pulmonary nodules, which were thought to be metastatic lung tumor from unknown origin. VATS biopsy for a subpleural nodule showed epitheloid granuloma with caseous necrosis of lung, indicating pulmonary tuberculosis. VATS biopsy is, therefore, an useful technique for differential diagnosis of small pulmonary nodules of unknown origin.

Pulmonary parenchymal manifestations surrounding small peripheral masses: pathologic correlation with chest radiographs and diagnostic value

RATIONALE AND OBJECTIVES

We evaluated pathologic correlations of pulmonary parenchymal manifestations surrounding small peripheral masses and their usefulness in differentiating small peripheral bronchogenic carcinomas from tuberculomas.

METHODS

We evaluated 29 resected lobe specimens with 1.5- to 3.5-cm solitary pulmonary masses, including 24 carcinomas and five tuberculomas. These specimens were prospectively studied with preoperative chest radiographs, postoperative specimen radiographs, 10- to 15-microns-thick wholemount sections, and 5-microns-thick slices. A total of 100 chest X-rays and conventional tomography scans of 1- to 3-cm peripheral pulmonary masses, including 60 carcinomas and 40 tuberculomas, were retrospectively reviewed and analyzed.

RESULTS

The pulmonary parenchymal manifestations surrounding the masses presented as small infiltrates and nodular protrusions, thickened strands, and "double track" shadows, which extended from the proximal margin of five tuberculomas (100%, 5 of 5) and from the distal margin of 17 carcinomas (71%, 17 of 24). These pulmonary changes represented caseous material spreading from tuberculomas into the proximal bronchus and alveolar inflammatory exudation distal to the carcinomas. The proximal pulmonary manifestations were significantly more frequent in tuberculomas than in carcinomas (p < .01), whereas the distal pulmonary manifestations were more often found in carcinomas than in tuberculomas (p < .01).

CONCLUSION

The radiologic findings of the pulmonary parenchymal manifestations proximal or distal to the masses may be valuable radiologic signs for distinguishing between tuberculomas and small peripheral bronchogenic carcinomas, even though there is still considerable crossover between the two disease populations in the findings.

The human lysozyme promoter directs reporter gene expression to activated myelomonocytic cells in transgenic mice

The 5' region of the human lysozyme gene from -3500 to +25 was fused to a chloramphenicol acetyltransferase (CAT) reporter gene and three transgenic founder mice were obtained. All three transgenic lines showed the same pattern of CAT enzyme expression in adult mouse tissues that was consistent with the targeting of elicited, activated macrophages in tissues and developing and elicited granulocytes. In normal mice high CAT enzyme activity was found in the spleen, lung, and thymus, tissues rich in phagocytically active cells, but not in many other tissues, such as the gut and muscle, which contain resident macrophages. Cultured resident peritoneal macrophages and cells elicited 18 hr (granulocytes) and 4 days (macrophages) after injection of sterile thioglycollate broth expressed CAT activity. Bacillus Calmette-Guérin infection of transgenic mice resulted in CAT enzyme expression in the liver, which contained macrophage-rich granulomas, whereas the liver of uninfected mice did not have any detectable CAT enzyme activity. Although the Paneth cells of the small intestine in both human and mouse produce lysozyme, the CAT gene, under the control of the human lysozyme promoter, was not expressed in the mouse small intestine. These results indicate that the human lysozyme promoter region may be used to direct expression of genes to activated mouse myeloid cells.

Computer-aided differential diagnosis of small solitary pulmonary nodules

A new digital processing method was developed to improve the specific diagnosis of small (up to 3 cm) solitary pulmonary nodules on lung tomograms. The proposed method gives advanced imaging of diagnostically important details and structures of the nodule. It helps the physician easily identify known diagnostic features and discover some additional ones that are useful for reliable verification of cancer, tuberculoma, and hamartoma. X-Ray morphological comparison confirmed that all details, displayed on the processed tomogram, corresponded to morphological structures on postsurgical histotopograms. The method can give additional information to data from conventional and computed tomography, especially in the case of small radiographically indeterminate pulmonary opacities.

[Solitary calcaneal cyst]

Differential diagnosis of solitary calcaneal cysts extends from benign cysts to malignant tumours. In all, 10-50% of these cysts are located at the centre of the calcaneal body in the form of intraosseous lipomas. Among our patients treated over a period of more than 20 years, there were four who underwent surgery for calcaneal cysts; the respective histological findings showed three lipomas and one tuberculoma. The average age of these patients corresponded to that of Milgram's study. It should also be remarked that all four patients came from a region in which mining was of central economic importance. Our experience has shown that such cysts should be surgically removed and filled with plastic spongiosa material in order both to check whether the cysts are benign or malignant and to avoid an imminent spontaneous fracture of the heel bone.

[Cellular and subcellular morphology of the repair process in pulmonary tuberculosis]

The repair processes in pulmonary tissue and granuloma in experimental tuberculosis were studied electron-microscopically and histochemically. At the beginning of inflammation they manifest at the ultrastructural level in aerohematic barrier cells. The period of granuloma formation is characterized by cell hypertrophy, particularly of type II alveolocytes, intensive macrophagal reaction, and increased functional activity of more and more cells. Ultrastructural and functional differences in epithelioid and multinuclear giant cells are revealed. A progressive course of tuberculosis involves decompensation of the compensatory and repair processes. Contrary to this, during chemotherapy of tuberculosis repair reactions predominate, resolution of inflammatory changes is in progress, cell populations in the granuloma change, and it is separated from the adjacent pulmonary tissue.

Paradoxical response to antitubercular drugs

Seven patients with paradoxical response to antitubercular drugs are reported. In three cases of intracranial tuberculomas, newer lesions appeared and in two cases preexisting tuberculomas enlarged. In two cases of tubercular meningitis, multiple tuberculomas appeared. All these cases exhibited newer symptoms and CT/MBI revealed the paradoxical response to antitubercular drugs. All responded to continued conservative therapy, with addition of pyrazinamide.

Monocyte aggregation around agarose beads in collagen gels: a 3-dimensional model of early granuloma formation?

Granulomas consist of organised collections of macrophages showing evidence of activation in response to an agent localised within a tissue. To date, in vitro models of granuloma formation have failed to reproduce the histological appearance of a granuloma, which forms a characteristic three-dimensional structure. The use of 3-D collagen gels allows agarose beads and human mononuclear cells to be suspended together in a milieu which permit the two to interact. The interaction between agarose beads and mononuclear cells produces monocyte-macrophage aggregates within 24 h which resemble an early granuloma. The monocytes show evidence of activation by direct microscopy, electron microscopy and immunohistochemistry. This model should permit the laboratory testing of hypotheses describing granuloma formation.

Protective role of gamma/delta T cells and alpha/beta T cells in tuberculosis

Tuberculosis is a chronic infectious disease which causes major health problems globally. Although acquired resistance crucially depends on alpha/beta lymphocytes, circumstantial evidence suggests that, in addition, gamma/delta T lymphocytes contribute to protection against tuberculosis. We have studied Mycobacterium tuberculosis infection in TcR-delta-/- or TcR-beta-/- gene deletion mutants which completely lack gamma/delta T cells or alpha/beta T cells, respectively. Low inocula of M. tuberculosis led to death of TcR-beta-/- mice and transient disease exacerbation in TcR-delta-/- mutants. Infection with higher inocula caused rapid death of TcR-delta-/- mice. The development of and bacterial containment in granulomatous lesions was markedly impaired in TcR-beta-/-, and less severely affected in TcR-delta-/- mutants. Mycobacteria-induced IFN-gamma production by spleen cells in vitro was almost abolished in TcR-beta-/- and virtually unaffected in TcR-delta-/- mice. Our data confirm the crucial role of alpha/beta T cells in protection against established tuberculosis and formally prove a protective role of gamma/delta T cells in early tuberculosis.

Tuberculosis of the nasal fossa manifested by a polypoid mass

Since the introduction of effective antituberculous chemotherapy, upper respiratory tract tuberculosis is infrequent; nasal involvement is a very rare form of this disease. In this localization, tuberculosis is usually unilateral and typically discloses a definite granular mass or an ulcer. We report a case manifested by an intranasal mass on computerized tomography scans that evolved as chronic rhinitis.

Tuberculous tonsillitis

The epidemiology of tuberculosis has changed recently with an increasing incidence of unusual presentations. A case of tuberculous tonsillitis, which is a rare condition, is presented in this report. The manifestations of this entity are tonsillar hypertrophy and painful ulceration. Final diagnosis of tuberculous tonsillitis is usually made after histopathologic examination of tonsillectomy material. Cultures should be obtained from the tissue specimens, and acid-fast bacilli must be investigated to confirm the diagnosis. Systemic signs of tuberculosis may not be seen in this clinical form. These features may confuse tuberculous tonsillitis with malignancies. In this article, general information and literature about tuberculous tonsillitis are reviewed, and a case of tuberculous tonsillitis is reported to draw attention to this rare clinical form of tuberculosis.

Cutaneous tuberculosis: a clinical, histopathologic, and bacteriologic study

BACKGROUND

In recent years cutaneous infections with Mycobacterium tuberculosis with an atypical clinical appearance have become more common because of the increasing number of immunocompromised patients.

OBJECTIVE

We report the clinical, histopathologic, and bacteriologic data of 11 patients with several forms of cutaneous tuberculosis seen during the past 14 years.

METHODS

Patients from whom M. tuberculosis was isolated from culture of skin biopsy specimens, sinus drainage, or material aspirated from cutaneous abscesses were included. In all but two patients a biopsy specimen was obtained for histopathologic study. All but one patient received combined antituberculous therapy.

RESULTS

The clinical diagnoses were scrofuloderma (four cases), cutaneous miliary tuberculosis (two), lupus vulgaris (two), tuberculous gumma (two), and one unclassified. All but three patients had evidence of either previous or simultaneous tuberculous foci other than in the skin. Histopathologic findings varied according to the type of cutaneous tuberculosis.

CONCLUSION

In some patients with cutaneous tuberculosis, lesions are atypical in appearance because of immunodeficiency. Culture for M. tuberculosis should be performed in all suspected cases, even in those in whom special stains for acid-fast bacilli are negative.

Application of a new tactile sensor to thoracoscopic surgery: experimental and clinical study

BACKGROUND

We developed a new tactile sensor that could quantify the hardness of objects as changes in the resonance frequency of the sensor (delta f). We have applied it to thoracoscopic operations for the localization of small invisible nodules in the lung.

METHODS

When the sensor probe was moved over the lung surface, a delta f curve was depicted on the computer screen. When the sensor tip reached a point directly above a hard object, a sudden upward jump of the delta f curve was evoked. After experimental studies using pigs, the sensor was applied in 8 patients. More recently we produced a needle sensor to distinguish small nodules from bronchi that may evoke similar upward jumps of the delta f curve. Eight nodules and four bronchi in resected human lungs were probed directly using this sensor.

RESULTS

In all of the patients, the hardness of various thoracic structures could be quantified. A total of 10 nodules were found using the sensor and resected thoracoscopically. The needle sensor distinguished nodules from bronchi, as the mean delta f of the bronchial walls (-64 +/- 45.9 Hz) was significantly higher than that of nodules (-526 +/- 168 Hz, p < 0.001).

CONCLUSIONS

Thoracoscopic detection of small and invisible pulmonary nodules using our new tactile sensor is feasible.