Pathology and pathogenetic mechanisms in neurotuberculosis

The mechanisms and the changes described herein typically begin with a dense basal meningeal exudate often resulting from a "Rich focus" along the basal surface of the cerebrum or ventricular ependyma. In the interpeduncular fossa, when the exudate is copious, among other structures the proximal parts of the optic nerves and of the internal carotid arteries are seen surrounded and compressed by the exudate. This exudate is made up of small and large mononuclear cells, including epithelioid cells, which also act as macrophages and may fuse to form Langhans' giant cells. Further extension of this exudate along small proliferating blood vessels into the brain substance constitutes a border zone encephalitis with the development of focal and diffuse ischemic brain changes due to vasculitis. Entrapment and occasional arteritic occlusion of larger arteries, such as the middle cerebral in the Sylvian fissures, results in infarction. Blockage of the basal subarachnoid cisterns around the midbrain and pons by the dense basal exudate or narrowing of aqueduct and third ventricle by a small tuberculoma causes consequent hydrocephalus. Development of many or one large focal granuloma (i.e., tuberculoma) occurs in the cerebrum, cerebellum, and/or brain stem. Similar pathogenetic mechanisms produce tuberculous spinal meningitis myeloradiculopathy that may be secondary to or occur before cranial tuberculous meningitis. More extensive damage to the white matter may occur together with the infrequent onset of perivascular demyelination on the basis of a hypersensitivity reaction to tuberculoprotein (i.e., "allergic tuberculous encephalopathy"). Finally, there may be a part played by NO in the production of the vascular and perivascular inflammatory central nervous system changes and a role for the the potential beneficial action of corticosteroids, especially in cases of tuberculous encephalopathy.

[Ileocecal tuberculosis as rare differential diagnosis of lower abdominal tumor]

Tuberculosis is extremely rare in Germany today. Diagnosis of extrapulmonary tuberculosis has proved to be particularly difficult and a correct diagnosis can take months. The danger of fatality is high. In the case of a 29 year old male paraplegic patient suffering from enteral tuberculosis, diagnosis was possible only after several weeks of onward observation, extreme physical degeneration and finally, a laparotomy.

[The tuberculid concept from the current viewpoint]

The concept of tuberculid was introduced by Darier in 1896. In contrast to "true" cutaneous tuberculosis, properties of the tuberculids were explained by an hyperergic response to myobacteria or their fragments released from a different site of manifest or passed tuberculous infection. Key features include a strongly positive tuberculin skin test, evidence of concomitant manifest or past tuberculosis, and prompt response to antituberculous therapy. The inability to culture M. tuberculosis or to demonstrate it microscopically from lesional biopsies, together with reports on tuberculid-like eruptions after BCG vaccination, supports this concept. Clinical manifestations are lichen scrophulosorum, papulo-necrotic tuberculids and erythema induratum of Bazin. The existence of tuberculids has been questioned, however, because the clinical and histological appearances are not always specific. An increasing number of case reports on tuberculids, new immunological tests and molecular biology-based techniques for the detection of mycobacteria have shed new light on the tuberculid concept.

Tuberculous peritonitis in an adolescent male

OBJECTIVE

To report the use of a new diagnostic approach in children with tuberculous peritonitis.

PATIENT

A 14-year-old boy with tuberculous peritonitis.

RESULTS

None of the new diagnostic techniques helped us to make our diagnosis.

CONCLUSION

More experience of using the new diagnostic techniques will be necessary before they supersede invasive procedures.

Clinical and bronchoscopic features of endobronchial tuberculosis

Clinical and bronchoscopic features of endobronchial tuberculosis were retrospectively investigated in 24 patients. A barking cough was the most frequent chief complaint in 50% of patients. The typical apico-subclavian localization of pulmonary tuberculosis in adults was found in only 50% of patients; in one patient the lung fields were clear. Bronchoscopic features consisted of exudative lesions in 38% of cases, ulcerative lesions in 25%, granulomatous lesions in 25%, and ulcerative-granulomatous tumour-like lesions in 12%. In 12% of patients, a residual fibrotic stenosis was seen. It was concluded from our data that patients whose cough is barking and resistant to antitussive agents should be evaluated for endobronchial tuberculosis, and, therefore, the use of fibreoptic bronchoscopy is mandatory. We also conclude that diagnosis of endobronchial tuberculosis demands the use of corticosteroid therapy.

[The differential diagnosis of peripheral lung formations (cytological research)]

The following pulmonary lesions were studied: carcinoma, carcinoid, tuberculoma, chondromatous hamartoma, chronic non-specific inflammatory process. Material was obtained through fiber bronchoscopy and roentgeno-endoscopical examination. Pappenheim staining in the modification of Astrakhantsev-Nechaeva and Ziehl-Neelsen staining were used. 80 cases within 1993 were studied, among them 71 peripheral lung carcinomas. 3 carcinoids, 3 tuberculoses, 1 non-specific inflammation. Basic cytological criteria are summarized which will improve the quality of the presurgical diagnosis.

Intramedullary tuberculoma of the spinal cord: case report

A case report of intramedullary tuberculoma is presented. Only one other case of intramedullary tuberculoma has been reported in the North American literature in the last 30 years. It is also unique because it is the only documented case of the paradoxical enlargement of an intramedullary tuberculoma after the initiation of antituberculous chemotherapy. Excellent results were obtained with a combination of medical and surgical management.

[Clinical, radiologic and morphologic characteristics of localized forms of pulmonary tuberculosis. Tuberculosis and hypoplasia]

Clinical and x-ray examinations and study of operation material from 555 patients with local forms of tuberculosis permitted the authors to distinguish three form of the condition: tuberculoma (77% of cases), cavitary (cavernous) tuberculosis (16%), and tuberculosis of the bronchi (5%). Morphologic investigations showed the local tuberculosis develops at small sites of pulmonary tissue hypoplasia. Sites of hypoplasia are usually concentrated in the pulmonary segments which are formed in the postnatal period, thus explaining the typical localization of a postprimary tuberculous focus. Tissue decomposition with development of destruction cavities is not characteristic of local tuberculosis. Cavitary (cavernous) form is a morphologic reflection of a tuberculous inflammation in the zone of cestous hypoplasia. Morphonesis of local forms of tuberculosis reflects its social dependence.

Influence of HIV status on pathological changes in tuberculous pleuritis

SETTING

The AIDS epidemic has been associated with an increase in the incidence of tuberculosis, pulmonary or extrapulmonary.

OBJECTIVE

To compare morphological changes in tuberculous pleurisy, and response to therapy in HIV-positive and-negative patients.

DESIGN

57 consecutive patients admitted between January and August 1991 with tuberculous pleurisy who were biopsy proven were studied. 36 were HIV-positive and 21 were HIV-negative.

RESULTS

3 types of morphological changes were observed: reactive, hyporeactive and non-reactive. Hypo- and non-reactive patterns were found in 14 of 36 HIV-positive patients but in only 2 of 21 HIV-negative patients (P < 0.02). In the HIV-positive group, 10 of the 14 with hypo- or non-reactive patterns had other HIV-related complications, compared to 6 of 22 with reactive patterns (P < 0.01). When HIV-positive patients' response to therapy was investigated, 2 of 5 patients with hypo- and non-reactive patterns improved compared to all 13 with reactive patterns (P < 0.05).

CONCLUSION

A hypo- or non-reactive tissue reaction in HIV-positive patients with tuberculous pleuritis seems to indicate a less favourable prognosis.

[The clinical investigation of so-called "pleural tuberculoma" in the last 3 years]

We have investigated on the clinical features of pleural nodular lesions which have appeared during chemotherapy of tuberculous pleurisy. Such lesions were observed in more than 10% of the cases of tuberculous pleurisy. This type of lesion occurred more frequently in the pleurisy patients whose chest X-ray did not show any tuberculous lesion in lung field and whose sputum was negative of tubercle bacilli. Most of the patients with such lesion were young. From these results, it was suggested that such lesion might develop during the course of primary tuberculosis. Single nodular lesion was more common but multiple nodular lesions were not rare. They had occurred in 2-4 months after the start of anti-tuberculous chemotherapy including RFP, usually accompanied with chest pain. They had disappeared within 6-12 months without any additional therapy. In summary, pleural nodular lesions, which occurred during chemotherapy of tuberculous pleurisy, were not rare, but the clinical course and prognosis of such lesion were favourable and improved without any additional therapy. The etiology of such lesion has remained to be clarified.

The detection of Mycobacterium tuberculosis in bone marrow aspirate using the polymerase chain reaction

SETTING

Tygerberg Hospital, South Africa.

OBJECTIVE

Bone marrow aspirate and biopsy were obtained from 37 patients who were in-patients at the Tygerberg hospital. The specificity and sensitivity of the polymerase chain reaction (PCR) in the detection of Mycobacterium tuberculosis in bone marrow aspirate was evaluated.

DESIGN

The PCR was compared to standard culture as well as to clinical and bone marrow biopsy data in 24 patients with suspected tuberculosis (TB).

RESULTS

12 of the 24 patients eventually had definite or probable TB and in these 12 patients the detection incidence was 42% for PCR and 25% for culture.

CONCLUSION

This study confirms that it is possible to use PCR to detect M. tuberculosis in bone marrow aspirate material and that this technique is more sensitive than culture methods. The PCR technique has the added advantage of being a rapid test yielding results within 2 days of sampling. Overall sensitivity for the detection of M. tuberculosis in bone marrow aspirate may be improved to 58% [corrected] by using both culture and PCR techniques.

[Bone marrow granulomas]

PURPOSE

To evaluate bone marrow granulomatous lesions in order to establish their etiology.

MATERIAL AND METHODS

2,250 bone marrow biopsies were studied during the period of March 1983-March 1991. Granulomas and/or granulomatous lesions were found in 24 of them (1.06%). A correlation between histological characteristics, special stains: PAS, Ziehl Neelsen and Grocott and cultures were done. Immunohistochemistry was done to evaluate B or T cell-lineage in 4 patients.

RESULTS

The 24 patients were biopsied because of the clinical diagnosis of haematological and non-haematological neoplasias, infections, AIDS, sarcoidosis and fever of unknown origin. Bone marrow cellularity ranged from 20% to 75% (M: 49.8%). Myeloid cells were increased in 54% of the cases. The number of granulomas ranged from 1 to 19 (M: 3.9). The epithelioid cells were the predominant component in 66% of the cases. Of the 7 patients with non-Hodgkin's lymphoma, 4 had lymphomatous involvement with granulomatous pattern. These cases showed predominance of lymphoid cells and vessels in addition to epithelioid cells.

CONCLUSION

We consider that in order to establish a relationship between infection and granuloma, the identification of a microorganism through a culture is a more reliable test. We couldn't find any morphological characteristic which allowed an etiologic diagnosis of bone marrow granulomas. In case of lesions with a great lymphocytic and vascular proliferation plus the presence of epithelioid cells and fibrosis, NHL with bone marrow involvement with a granulomatous pattern should be strongly considered.

[Availability of diagnosis by percutaneous needle aspiration cytology of the lung in cases who showed a peripheral solitary tumorous shadow on chest Xp and diagnostic rate of transbronchial approach]

We report the availability of diagnosis by percutaneous needle aspiration cytology of the lung (NAC) in 526 cases who showed a peripheral solitary tumorous shadow on chest Xp. The positive rate of the transbronchial approach was 62% (147 of 238) in lung cancer cases and 43% (6 of 14) in metastatic lung tumor cases. The positive rate of NAC in relation to lung cancer increased with decrease of diameter of the tumor. The positive rate of NAC was significantly higher than the positive rate of the transbronchial approach with NAC. Complications of NAC were bloody sputum (11%), pneumothorax (8%) and subcutaneous emphysema (0.2%), which did not create therapeutic problems. Pleural dissemination (0.4%) was a serious complication of NAC.

Tuberculosis of the thyroid gland: a clinicopathological profile of four cases and review of the literature

Four cases of tuberculosis of the thyroid with different presentations including chronic sinus (following drainage of thyroid abscess), thyrotoxicosis, severe dysphagia clinically mimicking malignancy and euthyroid multinodular goitre are described. Except in the case presenting with chronic sinus (discharging acid-fast bacilli), the diagnosis was a pathological surprise (cytopathology in one and histopathology in two). Only in one case was there evidence of disease outside the cervical region. All cases showed multiple coalescing and caseating epitheloid cell granulomas along with giant cells, which are considered as diagnostic of tuberculous thyroiditis even if acid fast bacilli cannot be demonstrated. The literature is reviewed and the pathogenesis discussed.

[The appearance and enlargement of localized pulmonary granuloma with eosinophilic infiltration during tuberculosis chemotherapy]

A pulmonary tumorous shadow appeared and enlarged in a 25 years-old male patient undergoing intensive chemotherapy for tuberculosis. The chest X-rays taken on admission revealed effused pleura in the right lung and nodular shadows in the upper area of the right lung. After 40 days of using isoniazid (INH), rifampicin (RFP) and streptomycin (SM), a homogeneous opacity, not previously observed, appeared in the middle area of the right lung (S5). Microscopic examination of the tissues obtained during a transbronchial lung biopsy disclosed epithelioid cell granulomas with marked eosinophilic infiltration. The presence of eosinophilic infiltration due to the admission of antituberculosis agents was disregarded because no change was observed in the new granulomatous shadows during the drug challenge tests and the lymphocyte stimulation test to INH, RFP and SM was negative. Transient aggravation during the initial phase of chemotherapy for pulmonary tuberculosis, such as in this case, is suspected cause by some eosinophilic allergic-induced mechanisms, against bacillary components.

Mycobacterial infection of the parotid gland: an unusual cause of parotid swelling

Six cases of mycobacterial infection of the parotid gland are reviewed. All six cases presented solely with a slowly enlarging parotid swelling clinically indistinguishable from a parotid tumour. All of the swellings required surgical removal, superficial parotidectomy in four cases, and enucleation in two cases to obtain a definitive diagnosis.

[BCGitis as a cause of mediastinal tumor]

In a one year old female infant BCG-vaccinated as a neonate, a large mediastinal mass was found after routine examination. X-ray and CT scan suggested a teratoma. Histology and microbiology, however, revealed the diagnosis of an active tuberculosis. Thus, the tumor was caused by mediastinal BCGitis. To our knowledge this complication of BCG-vaccination has not yet been described.

Tuberculous otitis media: a difficult diagnosis

Two cases of tuberculous otitis media, both presenting with otorrhoea and facial paralysis, are reported. The difficulties of diagnosing this rare condition are highlighted, and a brief review of its clinical features from other series is presented.

Hepatic involvement in tuberculosis

Seventy one cases of pulmonary and extrapulmonary tuberculosis (confirmed by clinical, sputum examination, Skiagram, lymph node or other organ biopsy) and 13 cases of PUO suspected to be tubercular in origin were included in the study. Besides, thorough clinical workup, LFTs and liver biopsy were also done in all cases. LFT alterations were seen in only 5 (7%) cases of tuberculosis while in PUO group, 3 (23%) cases showed deranged LFT. In all, alteration in SGOT/SGPT was most frequent observation. In Liver biopsy, histopathological changes were seen in 63 percent (45 out of 71) of cases of tuberculosis and in 46.16 percent cases of PUO. In tubercular cases, various abnormalities observed were caseating granulomas: 18.30 percent, nonspecific inflammatory infiltration: 25.32 percent, focal Kupffer cell hyperplasia: 11.2 percent and fatty changes: 8.45 percent. Four of the PUO cases, showing Kupffer cell hyperplasia and non-specific inflammatory infiltration responded to antituberculous therapy. Thus it is surmised that though the caseating granuloma is the hallmark of tuberculosis, but nonspecific inflammatory hepatitis and retothelial tubercle nodules may be the forerunner in the evolution of granuloma.

Pulmonary tuberculoma and indications for surgery: radiographic and clinicopathological analysis

Tuberculomas of the lung are one of the more common lesions presenting a solitary pulmonary nodule, roentgenographically. We treated 36 patients with such nodules and describe here the radiologic-pathologic correlations and surgical treatment. In 21 patients, lung cancer was suspected preoperatively, based on radiographic findings of an ill-defined margin, pleural indentation and spicular radiation. Histologically, the tuberculous granuloma proliferated in the alveolar septa of the surrounding normal lung, often seen as a spicular radiation resembling lung cancer. In eight patients, tuberculoma was suspected because of radiographic findings of calcification and satellite nodules, and anti-tuberculous chemotherapy was prescribed for a few months. As this treatment was ineffective, surgical resection had to be done. Postoperative complications were nil and all of these patients are doing well at the time of preparation of this report. Anti-tuberculous chemotherapy was prescribed for 28 of 36 patients, postoperatively. We believe that surgical intervention is required for selected patients.