Disseminated mycobacterial infection in AIDS patients: abdominal US features and value of fine-needle aspiration biopsy of lymph nodes and spleen

Abdominal Involvement in Children With Bacteriologically Confirmed Tuberculosis: A Five-year Experience From Cape Town, South Africa

BACKGROUND

Abdominal tuberculosis (TB) in children is poorly described and often poses a diagnostic challenge. We evaluated abdominal involvement in children presenting with bacteriologically confirmed TB.

METHODS

We undertook a retrospective study at Tygerberg Hospital, Cape Town, from January 1, 2014, through December 31, 2018, of all children (<13 years) diagnosed with bacteriologically confirmed TB, in whom abdominal involvement was found. Demographic and clinical data were collected through folder review, laboratory records and imaging reports.

RESULTS

Of 966 children with bacteriologically confirmed TB, 111 (11.5%) had abdominal involvement; 16 (14.4%) were excluded from further analysis because of lack of clinical data. The median age of the remaining 95 children was 43 months (interquartile range 20-94); 26 (27%) were HIV positive. The main gastrointestinal symptoms/signs were weight loss (84.2%), abdominal distention (54.7%), hepatomegaly (60.0%) and abdominal pain (26.3%). The main pathologic types were intra-abdominal lymph nodes (68.4%), solid organ involvement (54.7%), peritoneal type (23.2%) and intestinal type (10.5%). Splenic abscesses and solid organ involvement on ultrasonography were more common in HIV-positive children (P < 0.001 and P = 0.008, respectively). Liver abscesses were associated with age less than 5 years (P = 0.03), while abdominal lymphadenopathy on ultrasonography was more common in children older than 5 years (P = 0.038). Abdominal specimens were collected in an attempt to identify Mycobacterium tuberculosis in 15 of 95 (15.8%) patients and were positive in 13 of 15 (86.7%).

CONCLUSIONS

Over 10% of children with confirmed TB had abdominal involvement. Abdominal TB should be considered in any pediatric TB case with abdominal symptoms, and ultrasonography should be the radiologic study of choice.

Abdominal ultrasound for diagnosing abdominal tuberculosis or disseminated tuberculosis with abdominal involvement in HIV-positive individuals

BACKGROUND

Accurate diagnosis of tuberculosis in people living with HIV is difficult. HIV-positive individuals have higher rates of extrapulmonary tuberculosis and the diagnosis of tuberculosis is often limited to imaging results. Ultrasound is such an imaging test that is widely used as a diagnostic tool (including point-of-care) in people suspected of having abdominal tuberculosis or disseminated tuberculosis with abdominal involvement.

OBJECTIVES

To determine the diagnostic accuracy of abdominal ultrasound for detecting abdominal tuberculosis or disseminated tuberculosis with abdominal involvement in HIV-positive individuals.To investigate potential sources of heterogeneity in test accuracy, including clinical setting, ultrasound training level, and type of reference standard.

SEARCH METHODS

We searched for publications in any language up to 4 April 2019 in the following databases: MEDLINE, Embase, BIOSIS, Science Citation Index Expanded (SCI-EXPANDED), Social Sciences Citation Index (SSCI), Conference Proceedings Citation Index- Science (CPCI-S), and also ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform to identify ongoing trials.

SELECTION CRITERIA

We included cross-sectional, cohort, and diagnostic case-control studies (prospective and retrospective) that compared the result of the index test (abdominal ultrasound) with one of the reference standards. We only included studies that allowed for extraction of numbers of true positives (TPs), true negatives (TNs), false positives (FPs), and false negatives (FNs). Participants were HIV-positive individuals aged 15 years and older. A higher-quality reference standard was the bacteriological confirmation of Mycobacterium tuberculosis from any clinical specimen, and a lower-quality reference standard was a clinical diagnosis of tuberculosis without microbiological confirmation. We excluded genitourinary tuberculosis.

DATA COLLECTION AND ANALYSIS

For each study, two review authors independently extracted data using a standardized form. We assessed the quality of studies using a tailored Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. We used the bivariate model to estimate pooled sensitivity and specificity. When studies were few we simplified the bivariate model to separate univariate random-effects logistic regression models for sensitivity and specificity. We explored the influence of the type of reference standard on the accuracy estimates by conducting separate analyses for each type of reference standard. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included 11 studies. The risks of bias and concern about applicability were often high or unclear in all domains. We included six studies in the main analyses of any abnormal finding on abdominal ultrasound; five studies reported only individual lesions.The six studies of any abnormal finding were cross-sectional or cohort studies. Five of these (83%) were conducted in low- or middle-income countries, and one in a high-income country. The proportion of participants on antiretroviral therapy was none (1 study), fewer then 50% (4 studies), more than 50% (1 study), and not reported (5 studies). The first main analysis, studies using a higher-quality reference standard (bacteriological confirmation), had a pooled sensitivity of 63% (95% confidence interval (CI) 43% to 79%; 5 studies, 368 participants; very low-certainty evidence) and a pooled specificity of 68% (95% CI 42% to 87%; 5 studies, 511 participants; very low-certainty evidence). If the results were to be applied to a hypothetical cohort of 1000 people with HIV where 200 (20%) have tuberculosis then:- About 382 individuals would have an ultrasound result indicating tuberculosis; of these, 256 (67%) would be incorrectly classified as having tuberculosis (false positives).- Of the 618 individuals with a result indicating that tuberculosis is not present, 74 (12%) would be incorrectly classified as not having tuberculosis (false negatives).In the second main analysis involving studies using a lower-quality reference standard (clinical diagnosis), the pooled sensitivity was 68% (95% CI 45% to 85%; 4 studies, 195 participants; very low-certainty evidence) and the pooled specificity was 73% (95% CI 41% to 91%; 4 studies, 202 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

In HIV-positive individuals thought to have abdominal tuberculosis or disseminated tuberculosis with abdominal involvement, abdominal ultrasound appears to have 63% sensitivity and 68% specificity when tuberculosis was bacteriologically confirmed. These estimates are based on data that is limited, varied, and low-certainty.The low sensitivity of abdominal ultrasound means clinicians should not use a negative test result to rule out the disease, but rather consider the result in combination with other diagnostic strategies (including clinical signs, chest x-ray, lateral flow urine lipoarabinomannan assay (LF-LAM), and Xpert MTB/RIF). Research incorporating the test into tuberculosis diagnostic algorithms will help in delineating more precisely its value in diagnosing abdominal tuberculosis or disseminated tuberculosis with abdominal involvement.

Tuberculosis of the Liver, Biliary Tract, and Pancreas

Tuberculosis of the liver, biliary tract, and pancreas is discussed. In addition, tuberculosis in the setting of HIV-AIDS and liver transplantation is explored. Drug-induced liver injury secondary to antituberculosis medication and monitoring and prophylactic treatment for such injury is also considered.

Chest ultrasound findings in pulmonary tuberculosis

In resource-limited countries, the diagnosis of pulmonary tuberculosis (TB) is based on clinical findings, chest radiography and the demonstration of acid-fast bacilli in sputum. Few data are available on the use of ultrasound (US) to diagnose pulmonary TB. Chest US was performed in patients with lung TB from a rural African setting, to look for signs of the disease and to clarify the role US may have in the diagnosis of pulmonary TB. Sixty adult patients diagnosed with lung TB underwent chest US. All patients had abnormal findings. The most frequent was a subpleural nodule (SUN), which was mostly multiple and also found in radiologically normal areas. Other findings were lung consolidations, cavitations, miliary patterns made of miniature SUNs, and pleural and pericardial effusions. Chest US is a complementary tool in evaluating patients with suspected lung TB in resource-limited settings where the disease has high prevalence.

Mortality in HIV-infected patients with tuberculosis treated with streptomycin and a two-week intensified regimen: data from an HIV cohort study using inverse probability of treatment weighting

Background. Despite the dramatic scale-up of antiretroviral therapy in low- and middle-income countries, tuberculosis (TB) is still the main cause of death among HIV-infected patients in resource-limited settings. Previous studies in patients with TB meningitis suggest that the use of higher doses of common anti-TB drugs could reduce mortality.

Methods. Using clinical data from an HIV cohort study in India, we compared the mortality among HIV-infected patients diagnosed with TB according to the regimen received during the first two weeks of treatment: standard anti-tuberculosis therapy (ATT) (N = 847), intensified ATT (N = 322), and intensified ATT with streptomycin (N = 446). The intensified ATT comprised double dose of rifampicin and substitution of ethambutol with levofloxacin. Multivariate analysis was performed using Cox proportional hazard models and inverse probability of treatment weighting (IPTW) based on propensity scores. Patients with TB meningitis were excluded.

Results. The use of intensified ATT alone did not improve survival. However, when streptomycin was added, the use intensified ATT was associated with reduced mortality in Cox models (adjusted hazard ratio 0.72, 95% CI [0.57–0.91]) and after IPTW (hazard ratio 0.77, 95% CI [0.67–0.96]). Other factors associated with improved survival were high serum albumin concentration, high CD4 lymphocyte cell-counts, and high glomerular filtration rates. Factors associated with increased mortality were high urea concentrations, being on antiretroviral therapy at the time of ATT initiation and high BUN/creatinine ratio. In an effect modification analysis, the survival benefits of the intensified ATT with streptomycin disappeared in patients with severe hypoalbuminemia.

Conclusion. The results of this study are in accordance with a previous study from our cohort involving patients with TB meningitis, and suggest that an intensified 2-week ATT with streptomycin could reduce mortality in HIV infected patients with TB. As this is an observational study, we should be cautious about our conclusions, but given the high mortality of HIV-related TB, our findings deserve further research.

Incidence and mortality of tuberculosis before and after initiation of antiretroviral therapy: an HIV cohort study in India

INTRODUCTION

India has the highest burden of tuberculosis (TB) in the world, but the epidemiology of HIV-associated TB is not well known.

METHODS

We describe the incidence and the mortality of TB from HIV diagnosis to antiretroviral therapy (ART) initiation (pre-ART group) and after ART initiation (on-ART group) in an HIV cohort study in Anantapur, India. Multivariable analysis of factors associated with TB was performed using competing risk regression and restricted cubic spline methods.

RESULTS

A total of 4590 patients and 3133 person-years (py) of follow-up were included in the pre-ART group, and 3784 patients and 4756 py were included in the on-ART group. In the pre-ART group, the incidence of TB was high during the first month after HIV diagnosis and dropped nearly four times soon after. In the on-ART group, the incidence of TB increased after ART initiation reaching a peak in the third month. The probability of having TB within 30 months was 22.3% (95% confidence interval [CI], 21.1-23.6) in the pre-ART group and 17.8% (95% CI, 16.3-19.3) in the on-ART group. In a multivariable analysis, women had a lower risk of TB in both groups. Poor socio-economical conditions were associated with an increased risk of TB in the pre-ART group, but not in the group on-ART. While the association between low CD4 counts and TB was strong in the pre-ART group, this association was weaker in the on-ART group, and the highest risk of TB was seen in those patients with CD4 counts around 110 cells/mm3. The cumulative incidence of mortality at 12 months in patients with TB was 29.6% (95% CI, 26.9-32.6) in pre-ART TB and 34.9% (95% CI, 31-39.1) in on-ART TB. Half deaths before ART initiation and two thirds of deaths after ART initiation occurred in patients with TB.

CONCLUSIONS

The high incidence and mortality of TB seen in this study underscore the urgent need to improve the prevention and diagnosis of HIV-associated TB in India. We found substantial differences between TB before and after ART initiation.

Directly-observed intermittent therapy versus unsupervised daily regimen during the intensive phase of antituberculosis therapy in HIV infected patients

The World Health Organization strongly recommends using daily antituberculosis therapy (ATT) during the intensive phase for HIV infected patients. India has the highest burden of tuberculosis in the world, but HIV infected patients are still receiving intermittent ATT. In this study we compared the mortality in patients who received directly-observed intermittent ATT versus self-administered daily ATT with fixed dose combinations during the intensive phase in a context of freely available antiretroviral therapy. The study included 1460 patients, 343 in the intermittent ATT group and 1117 in the daily ATT group. Baseline covariates of the two groups were balanced using inverse probability of treatment weighting based on propensity score methods. In a sensitivity analysis, continuous variables (albumin, CD4 count, and age) were modelled using restricted cubic smoothing splines. Compared with patients who received daily ATT, patients who received intermittent ATT had a 40% higher risk of mortality (1.4 hazard ratio; 95% confidence interval, 1.14-1.7). We estimated that the use of daily ATT could achieve a 10% absolute reduction in mortality at 12 months. Self-administered daily ATT was not associated with an increased risk of default from treatment. These results support the immediate implementation of daily ATT for HIV infected patients during the intensive phase in India.

Diagnostic and Prognostic Value of Serum Albumin for Tuberculosis in HIV Infected Patients Eligible for Antiretroviral Therapy: Datafrom an HIV Cohort Study in India

INTRODUCTION

Tuberculosis is difficult to diagnose and it is the leading cause of death in HIV infected individuals in developing countries. There is an urgent need of low-cost diagnostic markers for resource-limited settings.

METHODS

The study involved 1571 patients from an HIV cohort study in India with known serum albumin concentrations at the time of becoming eligible for antiretroviral therapy (ART). We investigated the diagnostic accuracy of serum albumin to predict tuberculosis within six months of ART eligibility and the prognostic value in patients who experienced tuberculosis.

RESULTS

The diagnostic accuracy of serum albumin, measured by the area under the receiver operating characteristic curve, to predict tuberculosis was 0.81 (95% confidence interval 0.78-0.83). Serum albumin concentrations <3.2 g/dL were associated with 85% specificity and <4.1 g/dL were associated with negative predictive values >90%, even in settings with high tuberculosis prevalence. Hypoalbuminemia was associated with an increased risk of mortality in patients with tuberculosis.

CONCLUSION

Serum albumin can be a useful low-cost diagnostic marker for tuberculosis in HIV infected patients eligible for ART. However, we failed to find thresholds to rule out or rule in tuberculosis. If these results are confirmed by other studies, serum albumin could be used to improve the diagnostic accuracy of intensive case finding algorithms for HIV-related tuberculosis. In patients who experience tuberculosis, hypoalbuminemia is associated with poor prognosis.

Natural History and Factors Associated with Early and Delayed Mortality in HIV-Infected Patients Treated of Tuberculosis under Directly Observed Treatment Short-Course Strategy: A Prospective Cohort Study in India

Despite the impressive global results of DOTS in India, the effectiveness of DOTS for the treatment of tuberculosis in HIV-infected patients is not well known. This is an observational prospective cohort study performed in Anantapur District, Andhra Pradesh, India. The study included 1000 DOTS antituberculosis treatment (ATT) episodes and 840 person-years. CD4 lymphocyte count was below 200 cells/mm³ in 77% of the cases, and 21% were retreatments. Two thirds were presented with extrapulmonary tuberculosis, and the most common form of extrapulmonary tuberculosis was tuberculous meningitis followed by pleuritis, abdominal tuberculosis, and lymphadenitis. Cumulative incidence of mortality was 16%, 26%, 39%, and 46% at 1, 3, 12, and 24 months, respectively. Factors associated with three-month (early) mortality were being homeless, having low CD4+ lymphocyte count, having tuberculous meningitis, belonging to a socially disadvantaged community, having more than 35 years, and being on an antiretroviral therapy at the moment of initiating the ATT. Factors associated with delayed mortality were having low CD4+ lymphocyte count, belonging to a socially disadvantaged community, receiving a category II ATT because of a previous episode of ATT and having acid fast bacilli in sputum before the ATT initiation. These findings indicate that there is an urgent need to improve the treatment of tuberculosis in HIV-infected patients in India.

Clinico-epidemiological profile of HIV/TB coinfected patients in Vadodara, Gujarat

INTRODUCTION

The HIV epidemic has posed major, almost insurmountable, challenges to tuberculosis control efforts across the world. This study analyzes the prevalence and disease profile of HIV/AIDS coinfection in Vadodara, Gujarat, India.

MATERIALS AND METHODS

This study was conducted in the HIV Referral Clinic at Vadodara, India. Using convenience sampling method, 246 HIV-positive patients coinfected with tuberculosis were enrolled. A detailed history of every case was taken followed by a thorough physical examination. Baseline and follow up laboratory and radiological investigations were carried out as appropriately warranted.

RESULTS

Out of 500 HIV positive patients who presented to the clinic during the study period, 246 (49.2%) were coinfected with tuberculosis. Out of 246 coinfected cases, 35(14.2%) presented with demonstrable and documented tuberculosis whereas in 211(85.8%) cases, tuberculosis was extemporaneously detected by actively screening the patients. Sixty nine percent of patients were males, while 10.5% of cases were below fifteen years of age. The majority (68%) of patients had manifestations of extrapulmonary tuberculosis; but pulmonary tuberculosis, which is a more common presentation in HIV-negative cases, was present in only fifty five percent of this segment of the population. Abdominal tuberculosis was the most common site (74%) amongst extrapulmonary tuberculosis involvement, followed by clinically palpable lymph nodes (22%) and pleural effusion (17%).

CONCLUSION

The prevalence of tuberculosis in HIV-positive patients in this study (49%) was substantially higher than that reported in previous studies. However, this could be attributed to a selection and/or a diagnosis bias. This study used abdominal ultrasound for the diagnosis of tuberculosis which might have obviously increased the prevalence. Moreover, these cases were not confirmed by biopsy or other definitive TB diagnostic methods.

Abdominal lymphadenopathy in children with tuberculosis presenting with respiratory symptoms

Diagnosis of pulmonary tuberculosis (PTB) in children is challenging and radiographs are often normal or non-specific. Access to the chest using ultrasound is difficult, but access to the abdomen is simple and carries no radiation burden. Diagnosis of PTB using abdominal lymphadenopathy as a surrogate for mediastinal lymphadenopathy may present a simple and accurate additional diagnostic technique that is of value in developing countries. We determined the prevalence of abdominal lymphadenopathy in paediatric patients with confirmed TB presenting with respiratory symptoms. Chest radiographs and abdominal ultrasounds of 47 children with confirmed TB and respiratory symptoms were reviewed. The prevalence of abdominal TB was determined and comparisons made between thoracic and abdominal lymphadenopathy to determine the relative value of ultrasound. On ultrasound, the prevalence of abdominal lymphadenopathy was 19% and solid organ involvement was found in 23% of patients. Some 70% of children had thoracic lymphadenopathy on chest radiography, with 89% of patients having evidence of PTB. If chest radiography were to be considered the radiological reference standard, abdominal ultrasonography had a sensitivity of 18% (95% CI 7.0–35.5%) with a specificity of 79% (95% CI 49.2–95.1%) for thoracic lymphadenopathy. Ultrasound and chest radiography in combination detected a total of 36 patients with lymphadenopathy, with a 6% improvement in the rate of lymphadenopathy detection; however, this was not statistically significant. The prevalence of abdominal TB of 23% is noteworthy. We suggest that abdominal ultrasound has a definitive adjunctive role in investigating children with suspected TB.

[Intraabdominal infection in inmunodepressed patients]

Diseases of the gastrointestinal system frequently complicate immunosuppressed patients. Endogenous flora is the principal source of infection in humans, especially in patients with dysfunction of the digestive epithelial barrier due to various factors. Bacterial translocation, traumatisms, ischemia and surgery are frequent events in the general population. In addition, important risk factors for abdominal infections in specific patients include tumoral infiltration, mucositis complicating chemotherapy and/or radiotherapy, hypoproteinemia, neutropenia and lymphocyte deficiency. Clinical pictures vary according to patients' baseline condition and the environmental setting, including nosocomial infections. The differential clinical characteristics of abdominal infections observed in distinct types of immunosuppressed patients are reviewed.

The sandwich sign of non-lymphomatous origin

PURPOSE

To investigate the etiologies of the sandwich sign other than lymphoma.

METHOD

The images of 34 patients with sonographic sandwich sign over a 5-year period were retrospectively reviewed. The etiology was based on the pathologic report of mesenteric lymph nodes, or the presence of extensive metastatic disease in case of known advanced primary cancer or disappearance of the sign after specific treatments.

RESULTS

Malignancy accounted for the majority of cases (91%), and was divided into non-Hodgkin's lymphoma (50%) and metastatic carcinomas (41%). Mycobacterium tuberculosis infection was diagnosed in a previously healthy patient, and 2 patients with acquired immunodeficiency syndrome had Mycobacterium avium-complex infection. The sandwich sign was 1 of the initial presentations in 11 cases with newly diagnosed malignancies, including 6 cases of non-Hodgkin's lymphoma and 5 cases of metastatic carcinomas.

CONCLUSION

Metastatic carcinomas, M. avium-complex, and M. tuberculosis infection may produce the sandwich sign. Searching for etiologies other than lymphoma is important in patients presenting with the sandwich sign.

Characteristics of intestinal tuberculosis in ultrasonographic techniques

OBJECTIVE

There is a paucity of data on the sonographic criteria for the diagnosis of intestinal tuberculosis. The purpose of this study was to further characterize the potential sonographic signs of intestinal tuberculosis and to increase the diagnostic sensitivity and specificity of ultrasound.

MATERIAL AND METHODS

Seven patients with a final diagnosis of gastrointestinal tuberculosis and a control group of 18 patients suffering from tuberculosis limited to the lungs were prospectively evaluated for sonographic criteria of intestinal tuberculosis and the findings were compared with those in 50 healthy controls.

RESULTS

The following signs of intestinal tuberculosis were detectable: asymmetric thickened bowel wall (100%), intramural abscesses (86%), fistula (43%), extramural abscesses (29%), mesenteric thickening (29%), "white bowel" sign (29%), hypoechoic edema of Kerckring's folds with mesenterial thrombosis (14%), enlarged mesenteric lymph nodes with inhomogeneous echotexture and circumscribed hypoechoic spots <3 mm (86%), ascites (29%) and enlarged spleen (14%). These signs were exclusively present in patients with intestinal tuberculosis as compared with patients with tuberculosis limited to the lungs or with healthy controls. We could confirm the endoscopically reported right-sided prevalence of these wall thickenings. In contrast to the reported literature, a much higher prevalence of these sonographic signs was found as they were present in all patients. Six of 7 patients (86%) showed enlarged mesenteric lymph nodes. This was particularly interesting as mesenteric lymph nodes have not been described as being enlarged in the majority of other differential diagnoses of the ileocecal region.

CONCLUSIONS

The combination of bowel-wall thickening of the ileocecal region with intramural abscesses with or without fistula, abscesses and mesenteric thickening accompanied by enlarged mesenteric lymph nodes was highly predictive of intestinal tuberculosis.

Multiple lesions of the spleen: differential diagnosis of cystic and solid lesions

Lesions in the spleen may be encountered in a variety of clinical settings ranging from asymptomatic patients to patients who are critically ill. Etiologies for multifocal splenic lesions include infectious and inflammatory processes, primary vascular and lymphoid neoplasms, metastatic disease, vascular processes, and systemic diseases. There is often overlap in the imaging appearance alone, so the clinical setting is very helpful in differential diagnosis. In the immunocompromised patient, multiple small splenic lesions usually represent disseminated fungal disease and microabscesses. The spleen is a relatively rare site for metastatic disease; patients with metastatic lesions in the spleen usually have disease in other sites as well. Breast, lung, ovary, melanoma, and colon cancer are common primary tumors that metastasize to the spleen. Vascular neoplasms of the spleen represent the majority of the nonhematologic/nonlymphoid neoplasms and commonly produce multifocal lesions. Splenic infarcts may be seen with localized processes such as portal hypertension or pancreatitis, or may arise from an embolic source. Radiologists should be aware of the spectrum of processes that may involve the spleen and the clinical context in which they occur.

The natural history of childhood-acquired hepatitis C infection in patients with inherited bleeding disorders

BACKGROUND

Although many patients with inherited bleeding disorders have been infected with hepatitis C in early childhood, the natural history of infection in this patient group remains poorly defined.

STUDY DESIGN AND METHODS

A total of 212 patients with inherited bleeding disorders born between 1976 and 1992 were evaluated for hepatitis C virus (HCV) infection, spontaneous clearance, and (by noninvasive tests) progressive liver disease.

RESULTS

A total of 120 of 212 patients had been exposed to non-HCV-inactivated clotting products, and 68 of these 120 patients (57%) were anti-HCV-positive. Of these patients, 44 (65%) had chronic hepatitis C (HCV RNA-positive) and 24 (35%) showed spontaneous clearance (HCV RNA-negative). Five patients with hepatitis C were coinfected with hepatitis B virus and/or human immunodeficiency virus (HIV). Multivariate analysis indicated that hepatitis C infection was independently associated with longer treatment period (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.3-1.9) and exposure to a larger number of donors (OR, 2.1; 95% CI, 1.1-3.9). Spontaneous HCV clearance was associated with a younger age at first exposure to clotting product (p = 0.02). After a mean infection period of 21 years, evidence of cirrhosis was present in 2 patients (5%), both of whom were coinfected with HIV.

CONCLUSION

Spontaneous HCV clearance is associated with young age at infection. Despite frequent childhood-acquired hepatitis C infection among patients with inherited bleeding disorders, progression to cirrhosis after 21 years of infection is rare. The diagnosis of cirrhosis without biopsy, however, remains challenging in this population, and new, noninvasive means must be developed to accurately identify cirrhotic patients.

[Splenomegaly and splenic pseudotumor due to tuberculosis: six new cases]

INTRODUCTION

Splenic tuberculosis is rare. The aim of this study was to remind diagnostic problems in this disease, and to evaluate the value of surgery in its management.

MATERIAL AND METHODS

Retrospective study of data of six patients (three male and three female, whose mean age was 50 years) admitted in surgical department from 1980 to 2000 for splenic tuberculosis.

RESULTS

In six cases, symptoms were poorly specific; splenomegaly and anemia were constant. In imaging studies, splenomegaly was homogeneous in four cases and heterogeneous in two. Diagnosis of tuberculosis was done without need for splenectomy in four patients. Five patients were operated on: two had diagnostic laparotomy without splenectomy, two underwent diagnostic splenectomy and one had splenectomy indicated for splenic abcess refractory to medical treatment. Four of the five operated patients recovered. The two other patients were lost of follow-up.

CONCLUSIONS

In our experience, surgery is useful in diagnosis and treatment of splenic tuberculosis.