Miliary tuberculosis: A new look at an old foe

The clinical features and prognostic factors of miliary tuberculosis in a high tuberculosis burden area

BACKGROUND

Miliary Tuberculosis (TB) remains an important infectious disease that threatens human health. The clinical characteristics and prognostic factors of miliary TB are summarized in this study.

METHODS

The clinical information of miliary TB patients between 2010 and 2022 was retrospectively analyzed. Patients with miliary TB were characterized and compared to adverse outcomes cases. Factors independently associated with adverse outcomes were determined via multivariate logistic regression analysis.

RESULTS

A total of 288 patients were analyzed, including 181 with adverse outcomes. The clinical manifestations are atypical. 88.54% Of them experienced systemic symptoms, whilst 69.79% manifested respiratory symptoms. 40.97% Presented with neurologic symptoms, while 35.07% reported gastrointestinal symptoms. The major comorbidities were pharmacological immunosuppression (21.53%), pneumoconiosis (15.28%), diabetes (10.76%), and pregnancy or postpartum (7.29%). Regarding microbiology, most patients were diagnosed via sputum or Bronchoalveolar Lavage Fluid (BALF), pleural effusion, ascites, cerebrospinal fluid, urine TB-DNA, and tuberculosis culture. Meanwhile, 2.43% of patients were diagnosed via cerebrospinal fluid NGS. Independent risk factors predictive of adverse outcomes were current smoking, leukocytosis, elevated alanine aminotransferase (ALT) levels, and the combination of lymphopenia with bone marrow tuberculosis or tuberculous lymphadenitis. The accuracy of the model was validated by an area under the ROC curve of 0.753 (95% IC 0.697-0.810).

CONCLUSIONS

The clinical manifestations of miliary TB are atypical, and early diagnosis is challenging. The major comorbidities in miliary TB patients were pharmacological immunosuppression, pneumoconiosis, diabetes, pregnancy, and postpartum. Regarding etiological detection, multi-site and multi-type specimens should be collected for a timely diagnosis. Cerebrospinal fluid mNGS test may be a viable choice in some cases. Finally, current smoking, leukocytosis, elevated ALT levels, and the combination of lymphopenia with bone marrow tuberculosis or tuberculous lymphadenitis were identified as independent risk factors for adverse outcomes.

Miliary meningeal tuberculosis - an unusual imaging presentation for an early definitive diagnosis

PURPOSE

Tuberculous meningitis (TBM) causes significant morbidity and mortality in young children. Early treatment can be initiated with magnetic resonance (MR) imaging diagnosis. We present MR-detectable miliary meningeal TB in two patients. CASE 1: A 9-year-old girl developed fevers, cough, lethargy, and seizures. Brain MRI demonstrated multiple, small, T2-dark, rim-enhancing lesions, associated with cranial nerve and leptomeningeal enhancement. CSF showed pleocytosis, low glucose, and high protein. Chest CT showed mediastinal lymphadenopathy, multiple small interstitial lung nodules, and a splenic hypo enhancing lesion. Serial bronchoalveolar lavage studies were Xpert MTB/RIF and acid-fast negative. Endobronchial US-guided biopsy of a subcarinal lymph node was positive for Xpert MTB PCR. She was started on a 4-drug treatment for TBM and dexamethasone. Contact tracing revealed a remote positive contact with pulmonary tuberculosis. CASE 2: A 17-year-old female with Crohn's disease on adalimumab developed refractory ear infections despite multiple courses of antibiotics. She underwent myringotomy, with negative aerobic ear fluid culture. Brain MRI, obtained due to persistent otorrhea, showed multiple, small, round, T2-dark lesions. CSF studies were normal. CT chest, abdomen, and pelvis to assess for disseminated disease showed left upper lobe tree-in-bud nodules, hypoattenuating splenic lesions and a left obturator internus abscess with adjacent osteomyelitis. She underwent CT-guided aspiration of the obturator muscle collection, bronchoscopy with bronchoalveolar lavage, biopsy of two preexisting chronic skin lesions, and ear fluid aspiration. QuantiFERON Gold was positive. Ear fluid was Xpert MTB/RIF assay and acid-fast stain positive. Cultures from the ear fluid, skin tissue, muscle tissue, and alveolar lavage showed growth of acid-fast bacilli. She was started on 4-drug therapy and prednisone.

CONCLUSION

Our cases highlight that TBM in many cases remains a diagnostic dilemma - both our patients presented in a prolonged atypical manner. The term miliary TB not only refers to a pattern of interstitial nodules on chest radiographs but also indicates the hematogenous spread of the disease and concurrent pulmonary and extrapulmonary involvement with high risk of TB meningitis. We promote the use of the term miliary meningeal TB - in both cases, the neuroimaging diagnosis of TB preceded both chest imaging and laboratory confirmation of the disease. Miliary meningeal nodules on MRI may have characteristic T2 low signal and may be more conspicuous in children and immunocompromised individuals where background basal meningeal enhancement is less prominent.

Unveiling insights into bovine tuberculosis: A comprehensive review

The frequent zoonotic disease known as "bovine tuberculosis" is brought on by the Mycobacterium bovis bacteria, which can infect both people and animals. The aim of this review article is to provide an explanation of the etiology, history, epidemiology, pathogenesis, clinical symptoms, diagnosis, transmission, risk factors, public health importance, economic impact, treatment, and control of bovine tuberculosis. Primarily, bovine tuberculosis affects cattle, but other animals may also be affected. Bovine tuberculosis is present throughout the world, with the exception of Antarctica. Cattle that contract bovine tuberculosis might suffer from a persistent, crippling illness. In the early stages of the disease, there are no symptoms. The tuberculin test is the primary method for detecting bovine tuberculosis in cows. Depending on its localized site in the infected animal, M. bovis can be found in respiratory secretions, milk, urine, feces, vaginal secretions, semen, feces, and exudates from lesions (such as lymph node drainage and some skin lesions). This illness generally lowers cattle productivity and could have a negative financial impact on the livestock business, particularly the dairy industry. The most effective first-line anti-tuberculosis chemotherapy consists of isoniazid, ethambutol, rifampin, and streptomycin. Second-line drugs used against bovine tuberculosis include ethionamide, capreomycin, thioacetazone, and cycloserine. To successfully control and eradicate bovine tuberculosis, developed nations have implemented routine testing and culling of infected animals under national mandatory programs.

The Importance of Clinically Correlating Tuberculosis With Indeterminate QuantiFERON Gold Test

Tuberculosis (TB) is a highly contagious airborne infection of the lungs. It can present in active form, as well as latent form. The clinical manifestations of tuberculosis can present as either subacute or chronic. Some symptoms include weight loss, night sweats, fevers, and hemoptysis. This case highlights the importance of clinical judgment and follow-up testing when patient presentation does not correlate with initial results. We share a perplexing encounter where a 34-year-old male presented with hemoptysis, fevers of unclear origin, and an indeterminate QuantiFERON Gold result and was empirically started on rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE) therapy. RIPE therapy includes the gold standard medications used to treat tuberculosis.

Disseminated Tuberculosis of the Lungs, Brain, Pleurae, Mediastinal Lymphadenopathy, and Elbow Joint in an Immunocompetent Indian Female: A First-of-Its-Type Case

Tuberculosis is usually seen in the lungs. However, the involvement of various extrapulmonary sites is due to the spread of the bacteria via blood, lymphatic, or direct inoculation. The present case is a rare presentation of tuberculosis in an Indian female who came with complaints of swelling in her right elbow joint, headache, and cough with expectoration. A diagnostic evaluation resulted in the isolation of Mycobacterium tuberculosis from the sputum samples and elbow joints, which was further supported by an exudative picture on the cerebrospinal fluid examination. The findings were supported by advanced radiometric techniques. She was commenced on an antituberculous treatment per her weight. Disseminated tuberculosis is a challenging diagnosis as there is often a delay in clinical presentation, a lack of awareness about the possibility of multiple sites with tuberculous infection in clinicians, and a time lag in the availability of the culture results.

Targeted Six-Week Intensive Physiotherapy for a Case of Tuberculous Meningitis With a Syndrome of Inappropriate Antidiuretic Hormone Secretion

Tuberculous meningitis (TBM) is a severe form of extrapulmonary tuberculosis (TB) characterized by the invasion of Mycobacterium tuberculosis into the meninges surrounding the brain and spinal cord. It triggers an intense inflammatory response, leading to neurological complications if not promptly and adequately managed. TBM often precipitates muscle weakness, neurological deficits, respiratory challenges, swallowing difficulties, joint contractures, and pain. Physiotherapy intervention is essential in treating these problems by personalized treatment strategies and treatment plans to enhance muscle strength, motor control, coordination, and overall mobility. This case report aims to highlight the significant role of physiotherapy in improving the quality of life (QOL) and functional abilities of patients with TBM. The current case report reviews the case of a 73-year-old male who presented with complaints of generalized weakness and difficulty in swallowing. The patient had a history of fever for the last six months. Magnetic resonance imaging (MRI) and high-resolution computed tomography (HRCT) diagnosed the case as TBM with miliary TB. Six weeks of targeted intensive rehabilitation program was designed according to the patient's impairments initiated from the intensive care unit (ICU) phase. The main goals of physiotherapy were to start early bed mobility, maintain joint integrity, improve postural strength and swallowing, and make the patient independent in transfer and activities of daily living (ADLs). After a six-week intensive physiotherapy (TIP-6) program, the patient exhibited significant improvements in muscle strength and independence in ADLs. This case highlights the critical role of physiotherapy in enhancing the QOL and functional abilities of patients with severe TB-related conditions.

Successful Management, in a Low-Resource Setting, of Disseminated Tuberculosis in a 3-Year Old Boy: A Case Report

Disseminated or military tuberculosis (TB) is defined as the presence of at least two non-contiguous sites of Mycobacterium tuberculosis, occurring as a result of progressive primary infection, reactivation and spread of a latent focus or due to iatrogenic origin. Disseminated TB represents a life-threatening condition, especially in at-risk children and when diagnosis and treatment are delayed. We report on a case of a 3-year old boy who presented with long-lasting unrecognised disseminated TB that was successfully managed in a low-resource setting.

Disseminated Tuberculosis of the Lungs, Pleura, Mediastinal Lymph Nodes, and Pericardium: A Rare Case Report

Tuberculosis is mainly known to affect the lungs, but it can manifest at various extrapulmonary sites. Disseminated tuberculosis is a relatively rare clinical condition, and cases with no history of the disease are sparse. A case of an 18-year-old Indian male is presented. He came with complaints of chest pain, coughing with expectoration, and loss of appetite. The diagnostic workup led to a definite diagnosis of disseminated tuberculosis with involvement of the lungs, pleura, mediastinal lymph nodes, and pericardium. He was initiated on a fixed-dose anti-tubercular treatment per the national guidelines.

Changes in Adenosine Deaminase Activity and Endothelial Dysfunction after Mild Coronavirus Disease-2019

Endothelial cells are a preferential target for SARS-CoV-2 infection. Previously, we have reported that vascular adenosine deaminase 1 (ADA1) may serve as a biomarker of endothelial activation and vascular inflammation, while ADA2 plays a critical role in monocyte and macrophage function. In this study, we investigated the activities of circulating ADA isoenzymes in patients 8 weeks after mild COVID-19 and related them to the parameters of inflammation and microvascular/endothelial function. Post-COVID patients revealed microvascular dysfunction associated with the changes in circulating parameters of endothelial dysfunction and inflammatory activation. Interestingly, serum total ADA and ADA2 activities were diminished in post-COVID patients, while ADA1 remained unchanged in comparison to healthy controls without a prior diagnosis of SARS-CoV-2 infection. While serum ADA1 activity tended to positively correspond with the parameters of endothelial activation and inflammation, sICAM-1 and TNFα, serum ADA2 activity correlated with IL-10. Simultaneously, post-COVID patients had lower circulating levels of ADA1-anchoring protein, CD26, that may serve as an alternative receptor for virus binding. This suggests that after the infection CD26 is rather maintained in cell-attached form, enabling ADA1 complexing. This study points to the possible role of ADA isoenzymes in cardiovascular complications after mild COVID-19.

Serum Protein Electrophoresis Bands As Biomarkers for Drug-Sensitive Pulmonary Tuberculosis

INTRODUCTION

India has the highest cases of tuberculosis worldwide. According to WHO (2022), the incidence of tuberculosis in India is 210 per 100,000 population. Their incidence of new positive smear cases is 75 per 100,000 population per year. In tuberculosis, the level of albumin decreases while globulin increases leading to a low albumin to globulin (A/G) ratio, and electrophoresis of serum proteins are good diagnostic approach and provides essential information for monitoring treatment outcomes.

MATERIALS AND METHODS

The present study includes 50 cases of pulmonary tuberculosis and 50 age-sex-matched healthy controls. Initially, serum protein estimation and electrophoresis were performed in newly diagnosed patients and controls. All drugs were given as National Tuberculosis Elimination Programme (NTEP) guidelines and blood samples were collected at two-month, four-month, and six-month intervals, and different serum protein fractions were compared and analyzed.

RESULTS

The total serum protein was significantly lower in the cases than in the controls; 6.12±0.61 vs. 7.02±0.56 g/dL (p˂0.0020, t-value=3.12). The mean serum albumin was also significantly lower in the cases compared to the controls; 1.65±0.69 vs. 3.87±0.47g/dL (p˂0.0001, t-value=10.98). The α1 globulin started to rise after four months of treatment and at six months level was 0.262±0.32 g/dL. The level of γ globulin continuously decreases after antituberculous treatment to 1.56±0.67 gm/dL at six months.

CONCLUSION

The cause of the decrease in total protein and albumin may be due to malnutrition leading to low cellular immunity. Serum protein level and protein electrophoresis should be analyzed as routine tests in patients before, during, and after treatment. It helps us in identifying patients at risk of pulmonary tuberculosis as well prognosis of the disease. This study is a valuable guide in deciding the effective management of tuberculosis patients with drug treatment plans and appropriate dietary intake. Hence, it highlights the complex relationship that exists between poverty and disease.

Identification of peptides presented through the MHC-II of dendritic cells stimulated with Mycobacterium avium

Mycobacterium avium (M. avium) represents a species of concern, because of its ability to modulate the host's innate immune response, and therefore influence trajectory of adaptative immunity. Since eradicative response against mycobacteria, and M. tuberculosis/M. avium, relies on peptides actively presented on a Major Histocompatibility complex-II (MHC-II) context, we assessed paradoxical stimulation of Dendritic Cell resulting on immature immunophenotype characterized by membrane minor increase of MHC-II and CD40 despite of high expression of the pro-inflammatory tumor necrosis factor alpha (TNF-α) and interleukin-6 (IL-6) in supernatants. Identification of M. avium leucine rich peptides forming short α-helices shutting down Type 1T helper (Th1), contribute to the understanding of immune evasion of an increasingly prevalent pathogen, and may provide a basis for future immunotherapy to infectious and non-infectious disease.

Miliary tuberculosis in an immune-competent Bangladeshi man-A case report

Miliary tuberculosis is a disseminated and active form of tuberculosis caused by Mycobacterium tuberculosis. It frequently affects immunocompromised patients. However, immune-competent hosts are reported rarely. Herein, we reported a case of miliary tuberculosis of a 40-year-old immune-competent Bangladeshi man presented with pyrexia of unknown origin.

Disseminated Tuberculosis Presenting as Venous Thromboembolism

Tuberculosis (TB) is one of the leading causes of morbidity and mortality throughout the world and can have both pulmonary and extrapulmonary manifestations. Among the myriad extrapulmonary manifestations of TB, deep vein thrombosis (DVT) is rare. We present the case of a 25-year-old woman who presented with progressive painful swelling of the left upper limb associated with intermittent low-grade fever. Upon evaluation, she was found to have DVT along with a subsegmental pulmonary embolism. Further workup of the patient revealed bilateral pleural effusion and constrictive pericarditis along with microbiological evidence of Mycobacterium tuberculosis. The patient was started on anti-tubercular therapy along with therapeutic anti-coagulation, after which there was a substantial clinical improvement. Though rare, this case elucidates the venous thrombosis risk associated with one of the most common diseases in developing countries.

The Problem of Host and Pathogen Genetic Variability for Developing Strategies of Universally Efficacious Vaccination against and Personalised Immunotherapy of Tuberculosis: Potential Solutions?

Rational vaccination against and immunotherapy of any infectious disease requires knowledge of how protective and non-protective immune responses differ, and how immune responses are regulated, so their nature can be controlled. Strong Th1 responses are likely protective against M tuberculosis. Understanding how immune class regulation is achieved is pertinent to both vaccination and treatment. I argue that variables of infection, other than PAMPs, primarily determine the class of immunity generated. The alternative, non-PAMP framework I favour, allows me to propose strategies to achieve efficacious vaccination, transcending host and pathogen genetic variability, to prevent tuberculosis, and personalised protocols to treat disease.

Clinical analysis of pregnancy complicated with miliary tuberculosis

BACKGROUND

Pregnancy complicated with tuberculosis is increasingly common. The clinical characteristics of pregnancy complicated with miliary tuberculosis are summarized in this study.

METHODS

A retrospective analysis of pregnant patients with miliary tuberculosis was performed in terms of epidemiology, demography, clinical characteristics, laboratory tests, treatment, and prognosis.

RESULTS

Of the 23 patients that were included, 12 became pregnant after in vitro fertilization combined with embryo transfer (IVF-ET). The average gestational age at symptom onset was 13.96 weeks, and the average time from symptom onset to diagnosis was 33 days. Clinical symptoms included fever, dyspnoea, cough, headache, abdominal pain, and chest pain. Extrapulmonary tuberculosis occurred in 10 patients, respiratory failure in 11 patients, and ARDS in 9 patients. Chest HRCT showed diffusely distributed miliary nodules in all patients. Six patients were on mechanical ventilation, two underwent ECMO, and one died. Symptoms appeared in the first trimester of nine pregnancies after IVF-ET and in the second trimester of seven natural pregnancies.

CONCLUSIONS

Miliary tuberculosis can occur in pregnant patients, especially in patients after IVF-ET. Symptoms often appear in the first trimester of pregnancy after IVF-ET and in the second trimester of natural pregnancy. Lacking specificity, the common clinical characteristics include elevated inflammation markers, anaemia, low lymphocyte count, and multiple miliary nodules shown on a chest HRCT scan. Half of patients with miliary tuberculosis may develop respiratory failure, and some may progress to ARDS. Therefore, infertile patients should be required to undergo TB screening before undergoing IVF-ET, and preventive anti-TB treatment should be given to patients with latent TB infections or untreated TB disease.Key MessageMiliary tuberculosis can occur in pregnant patients, especially in pregnant patients after IVF-ET. Symptoms often appear in the first trimester of pregnancy after IVF-ET and in the second trimester of natural pregnancy. Many patients develop respiratory failure or ARDS.

Disseminated tuberculosis following invasive procedures for peripancreatic lymph node tuberculosis with portal vein obstruction: a case report

Peripancreatic tuberculous lymphadenopathy can mimic pancreatic cancer on imaging. There have only a few reports on varices from portal vein obstruction due to abdominal tuberculous lymphadenopathy. Iatrogenic disseminated tuberculosis is also rare. Herein, we present a rare case of peripancreatic tuberculous lymphadenopathy with ruptured duodenal varices due to portal vein obstruction. The patient presented to our hospital with hematemesis. Computed tomography revealed a peripancreatic mass. Duodenal varices rupture from portal vein obstruction due to pancreatic cancer were initially suspected. The patient underwent portal vein stenting for portal vein obstruction and endoscopic ultrasound-guided fine-needle aspiration for diagnosis, which revealed granulomas indicative of tuberculosis. The patient was discharged once because fine-needle aspiration did not lead to a definitive diagnosis of tuberculosis. Subsequently, he developed disseminated tuberculosis. Peripancreatic tuberculous lymphadenopathy can cause ectopic varices with portal vein obstruction. Tuberculosis should also be included in the differential diagnosis in the case of portal vein obstruction, to facilitate early treatment and avoid unnecessary surgery. Furthermore, fine-needle aspiration or portal vein stenting for tuberculous lesions can cause disseminated tuberculosis. Since a diagnosis might not be made until after several fine-needle aspirations have been conducted, careful follow-up is necessary after the procedure for such lesions.

Extremely high levels of central nervous system involvement in miliary tuberculosis

Background

Miliary tuberculosis (TB) is one of the severest manifestations of TB that can be lethal when concomitant with the central nervous system (CNS) involvement. Bacteriological, biochemical and radiological methods for find CNS comorbidity in miliary TB was evaluated in this study.

Methods

Consecutive miliary TB adults were retrospectively enrolled from two designated TB hospitals in China. The capacities of examinations of cerebrospinal fluid (CSF), cerebral computed tomography (CT) and magnetic resonance imaging (MRI) for diagnosis of CNS involvement were assessed.

Results

Assessment of CNS involvement with a lumbar puncture and/or neuroimaging was undertaken in 282 out of 392 of acute miliary TB. Of these 282 patients, 87.59% (247/282) had CNS involvement. Cerebral contrast-enhanced MRI (96.05%, 170/177) and MRI (93.15%, 204/219) yielded significantly higher sensitivities over CSF examination (71.92%, 146/203, P < 0.001) and CT (34.69%, 17/49, P < 0.001). The sensitivity of CSF examination was superior to CT scan (P < 0.001). Although 59.65% (134/225) miliary TB patients acquired bacteriological evidence with sputum examination, the positivity was only 8.82% (21/238) for CSF examination by conventional and molecular tests.

Conclusion

Almost all miliary TB had CNS involvement and MRI demonstrated outstanding potential over other methods. Therefore, a routinely screening of CNS TB should be strongly suggested in miliary TB and MRI could be used as the initial approach in resources rich settings.

Disseminated tuberculosis complicated by hemophagocytic lymphohistiocytosis in an immunocompetent adult with favorable outcomes: A case report

Hemophagocytic lymphohistiocytosis (HLH) is an uncommon hyperinflammatory syndrome characterized by excessive activation of macrophages and T-cells with high cytokines levels, causing multiorgan dysfunction.HLH has been associated with variable infectious etiologies, such as tuberculosis(TB). TB-associated HLH (TB-HLH) is a rare condition, but it is fatal if not treated. The diagnosis of TB-HLH is challenging and might be missed if not highly considered. The classic manifestations of HLH include pancytopenia, organomegaly, lymphadenopathy, and coagulopathy. Herein, we present a young immunocompetent adult diagnosed with disseminated TB complicated by HLH. Our patient responded well to the combination of antituberculosis therapy(ATT), corticosteroid, and intravenous immunoglobulin(IVIG). This case highlights the importance of considering this fatal complication in TB patients.

Acute miliary tuberculosis in pregnancy after in vitro fertilization and embryo transfer: a report of seven cases

Background

While miliary tuberculosis (TB) in pregnancy is rare after in vitro fertilization and embryo transfer (IVF-ET), it poses a serious threat to the health of pregnant women and their fetuses. The present study aimed to describe the clinical features of miliary TB and pregnancy outcomes of patients after IVF-ET.

Methods

Data of infertile patients who received IVF-ET at Peking University Third Hospital between January 2012 and December 2017 were retrospectively analyzed. Patients who developed miliary TB during pregnancy were identified, and clinical characteristics of miliary TB were described.

Results

Out of 62,755 infertile women enrolled, 7137 (11.4 %) showed signs of prior pulmonary TB on chest X-ray (CXR). Among the 15,136 women (mean age: 33.2 ± 5.0 years) who successfully achieved clinical pregnancy, seven patients aged 28–35 years had miliary TB during pregnancy, with two patients having a complication of TB meningitis. All these patients presented with fever. Notably, old TB lesions were detected on CXR in six patients before IVF-ET; nevertheless, no anti-TB therapy was administered. Furthermore, salpingography revealed oviduct obstruction in all patients (7/7). Patients received anti-TB therapy following a diagnosis of miliary TB and were clinically cured. However, pregnancy was terminated due to spontaneous (4/7) and induced (3/7) abortion.

Conclusions

TB reactivation, mostly as miliary TB and TB meningitis, is severe in pregnant women after IVF-ET and deleterious to pregnancy outcomes. Signs of prior TB on CXR may be risk factors for TB reactivation during pregnancy.

Extrapulmonary Tuberculosis—An Update on the Diagnosis, Treatment and Drug Resistance

Pathogenic Mycobacterium tuberculosis complex organisms (MTBC) primarily cause pulmonary tuberculosis (PTB); however, MTBC are also capable of causing disease in extrapulmonary (EP) organs, which pose a significant threat to human health worldwide. Extrapulmonary tuberculosis (EPTB) accounts for about 20–30% of all active TB cases and affects mainly children and adults with compromised immune systems. EPTB can occur through hematogenous, lymphatic, or localized bacillary dissemination from a primary source, such as PTB, and affects the brain, eye, mouth, tongue, lymph nodes of neck, spine, bones, muscles, skin, pleura, pericardium, gastrointestinal, peritoneum, and the genitourinary system as primary and/or disseminated disease. EPTB diagnosis involves clinical, radiological, microbiological, histopathological, biochemical/immunological, and molecular methods. However, only culture and molecular techniques are considered confirmatory to differentiate MTBC from any non-tuberculous mycobacteria (NTM) species. While EPTB due to MTBC responds to first-line anti-TB drugs (ATD), drug susceptibility profiling is an essential criterion for addressing drug-resistant EPTB cases (DR-EPTB). Besides antibiotics, adjuvant therapy with corticosteroids has also been used to treat specific EPTB cases. Occasionally, surgical intervention is recommended, mainly when organ damage is debilitating to the patient. Recent epidemiological studies show a striking increase in DR-EPTB cases ranging from 10–15% across various reports. As a neglected disease, significant developments in rapid and accurate diagnosis and better therapeutic interventions are urgently needed to control the emerging EPTB situation globally. In this review, we discuss the recent advances in the clinical diagnosis, treatment, and drug resistance of EPTB.

Retrospective Study of Bone-TB in Oman: 2002-2019

Objective: Little information is available about the etiology, pathophysiology, risk factors, and epidemiologic features of Bone Tuberculosis (Bone-TB). In this work, we present the epidemiological data about the Bone-TB in the Sultanate of Oman.

Methods: Retrospectively, we identified and assessed those patients who were diagnosed with Bone-TB between January 2002 and December 2019 at Khoula Hospital. The following data were collected: demographics, clinical presentation, anatomical location, diagnosis, and treatment of the Bone-TB.

Results: During the study period, 115 cases of Bone-TB were diagnosed. Males were affected more than females (57.4% and 42.6%, respectively). About 30% of Bone-TB cases were primary diagnosed in other organs particularly the lungs and then after disseminated to the bone. However, the Bone-TB was detected in hip, leg, hand, shoulder, and skull bones, the most detected Bone-TB was in spine (66% of cases). After vaccination the Bacillus Calmette–Guérin (BCG) strains were identified in the bones of eight babies. Tubercle bacilli were detected by Acid-Fast Stain (AFS) in 59% of cases, and the rest of cases were confirmed using polymerase chain reaction (PCR) tests. There are two used treatment regimens, with 12.4% relapse. The gastrointestinal tract (GIT) disturbances were the most related side effects. The resistance has been detected to pyrazinamide in six cases, rifampicin in three cases, and isoniazid, streptomycin and kanamycin were detected in one case.

Conclusion: The most predominant Bone-TB cases were spine-TB that were mainly disseminated from the lungs. AFS failed to detect tubercle bacilli in 40% of cases. There is no statistical significance in relapse between the used two regimens. The death was predominant among skull-TB cases.

Tuberculosis: An Overview of the Immunogenic Response, Disease Progression, and Medicinal Chemistry Efforts in the Last Decade toward the Development of Potential Drugs for Extensively Drug-Resistant Tuberculosis Strains

Tuberculosis (TB) is a slow growing, potentially debilitating disease that has plagued humanity for centuries and has claimed numerous lives across the globe. Concerted efforts by researchers have culminated in the development of various strategies to combat this malady. This review aims to raise awareness of the rapidly increasing incidences of multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis, highlighting the significant modifications that were introduced in the TB treatment regimen over the past decade. A description of the role of pathogen-host immune mechanisms together with strategies for prevention of the disease is discussed. The struggle to develop novel drug therapies has continued in an effort to reduce the treatment duration, improve patient compliance and outcomes, and circumvent TB resistance mechanisms. Herein, we give an overview of the extensive medicinal chemistry efforts made during the past decade toward the discovery of new chemotypes, which are potentially active against TB-resistant strains.

Bifocal Tuberculosis with Adalimumab Revealed by Laryngeal Involvement: Case Report

Introduction. Anti-TNF treatment has transformed the treatment of chronic inflammatory rheumatism. Although the therapy can be highly effective, anti-TNF drugs are associated with an increased risk of tuberculosis, especially extra-pulmonary tuberculosis. Laryngeal tuberculosis is rare and its symptoms are not specific. Laryngeal tuberculosis is often secondary to another localization, particularly pulmonary. In the use of anti-TNF therapy, its development is unusual. Case report. We report a case of bifocal tuberculosis: laryngeal and pulmonary tuberculosis revealed by laryngeal involvement in a patient aged 41 years with axial spondylarthritis treated with Adalimumab. Conclusion. This presentation highlights the importance to consider the rare possibility of laryngeal tuberculosis in the presence of atypical otorhinolaryngologic signs under anti-TNF therapy and underlines the importance of looking for other tuberculosis involvement.

Newer trends in tubercular uveitis: a case series with systemic correlation

AIM

To determine the spectrum of uveitis, causes of visual loss in systemic tuberculosis (TB), role of investigations and outcome after anti-TB therapy (ATT).

METHODS

A retrospective study was conducted on 250 patients with systemic TB at a referral center in Chennai, South India from April 2016 to May 2019. Systemic workup comprised of Mantoux, chest X-ray, polymerase chain reaction (PCR) and QuantiFERON (QFT) TB Gold. Aqueous humor analysis by nested PCR or real time PCR (RT-PCR) and ancillary ophthalmic investigations such as fundus fluorescein angiography, optical coherence tomography were performed.

RESULTS

Multifocal choroiditis and vasculitis were the most common manifestations (39% and 24% respectively) together accounting for 61% of cases and they had a higher risk of recurrence (3%). Pulmonary tuberculosis (PTB) was more frequently associated with uveitis (18%). Among those with extra-pulmonary tuberculosis (EPTB), uveitis occured in miliary TB (2%), bone (1%) and abdominal TB (1%). Complications such as cystoid macular edema, choroidal neovascular membranes and macular scarring caused visual loss. Aqueous humor analysis detected mycobacterium TB antigen. Collectively, systemic investigations such as chest X-ray, Mantoux test and those performed on blood samples such as PCR and QFT were positive in 39% of patients. In inconclusive patients, nested PCR and/or RT-PCR were done on aqueous humor samples and were diagnostic in 96%. A combination of tests was diagnostic in 92%. ATT in isolation in 71% and combined with corticosteroids in 29% was used for treatment of which signs of resolution and improvement in vision started as early as 6wk in those who were started immediately on corticosteroids and ATT and longer than 3mo in those on ATT alone. Prompt treatment with ATT and corticosteroids improved vision in 23% of our patients within 2mo. Vitritis with choroiditis causes cystoid macular oedema and requires longer duration of ATT. Vision improved in 69%. Complete resolution occurred in 75% and worsening in 12%.

CONCLUSION

A combination of investigations guided by clinical suspicion helps in precise diagnosis. In diagnostic dilemmas analysis of ocular samples is reliable and confirmatory. Screening all patients and a multidisciplinary approach in TB (active, healed or during treatment) is recommended.

Etiopathogenesis, Challenges and Remedies Associated With Female Genital Tuberculosis: Potential Role of Nuclear Receptors

Extra-pulmonary tuberculosis (EPTB) is recognized mainly as a secondary manifestation of a primary tuberculosis (TB) infection in the lungs contributing to a high incidence of morbidity and mortality. The TB bacilli upon reactivation maneuver from the primary site disseminating to other organs. Diagnosis and treatment of EPTB remains challenging due to the abstruse positioning of the infected organs and the associated invasiveness of sample acquisition as well as misdiagnosis, associated comorbidities, and the inadequacy of biomarkers. Female genital tuberculosis (FGTB) represents the most perilous form of EPTB leading to poor uterine receptivity (UR), recurrent implantation failure and infertility in females. Although the number of TB cases is reducing, FGTB cases are not getting enough attention because of a lack of clinical awareness, nonspecific symptoms, and inappropriate diagnostic measures. This review provides an overview for EPTB, particularly FGTB diagnostics and treatment challenges. We emphasize the need for new therapeutics and highlight the need for the exaction of biomarkers as a point of care diagnostic. Nuclear receptors have reported role in maintaining UR, immune modulation, and TB modulation; therefore, we postulate their role as a therapeutic drug target and biomarker that should be explored in FGTB.

Corticosteroid-induced exacerbation of cryptic miliary tuberculosis to acute respiratory distress syndrome: A case report

RATIONALE

Steroid is known to cause generalized immunosuppression, thereby increasing the risk of new infection or recurrence of tuberculosis. However, corticosteroid as a culprit for exacerbation of miliary tuberculosis-from a cryptic to an overt form-has rarely been described in the literature. Moreover, miliary tuberculosis is hardly diagnosed in a living patient as a primary cause of ARDS even in TB-endemic regions. To the best of our knowledge, this is the first case of a steroid-induced progression of cryptic miliary tuberculosis to ARDS, provided with clear depiction of its radiologic evolution.

PATIENT CONCERNS

A 36-year-old male was treated with corticosteroid under suspicion of adult onset still's disease for six-week history of fever. Within 2 weeks since the initiation of corticosteroid therapy, the patient experienced acute exacerbation of cryptic miliary tuberculosis, which evolved to an overt form, appearing as miliary nodules on both chest radiograph and HRCT. Then, his condition suddenly deteriorated to severe acute respiratory distress syndrome in less than a day.

DIAGNOSIS

The final diagnosis was miliary tuberculosis complicated by severe acute respiratory distress syndrome.

INTERVENTIONS

The patient was placed on classic quadruple anti-TB treatment (isoniazide, ethambutol, rifampin, and pyrazinamide).

OUTCOMES

His fever subsided in about 6 weeks and 3 consecutive sputum AFB smears collected on different days were confirmed negative. Diffuse infiltrates on his chest x-ray were completely resolved.

LESSONS

The case described here draws a clinical and radiological picture of how an occult form of miliary TB evolved to an overt form with use of steroid, and then suddenly progressed to acute respiratory distress syndrome in an immunocompetent young male. This raises awareness on the potential risk of using corticosteroid in patients with cryptic miliary TB. There is formidable challenge in the diagnosis of miliary TB, especially in the early stages. Atypical or even normal outcomes of clinical, microbiochemical, and radiologic evaluation should not be overlooked and dedicated diagnostic work-up should be performed. For equivocal cases, active surveillance with serial radiographs can be helpful.

A systemic review on tuberculosis

Tuberculosis (TB), which is caused by bacteria of the Mycobacterium tuberculosis complex, is one of the oldest diseases known to affect humans and a major cause of death worldwide. Tuberculosis continues to be a huge peril disease against the human population and according to WHO, tuberculosis is a major killer of the human population after HIV/AIDS. Tuberculosis is highly prevalent among the low socioeconomic section of the population and marginalized sections of the community. In India, National strategic plan (2017-2025) has a national goal of elimination of tuberculosis by 2025. It requires increased awareness and understanding of Tuberculosis. In this review article history, taxonomy, epidemiology, histology, immunology, pathogenesis and clinical features of both pulmonary tuberculosis (PTB) and extra-pulmonary tuberculosis (EPTB) has been discussed. A great length of detailed information regarding diagnostic modalities has been explained along with diagnostic algorithm for PTB and EPTB. Treatment regimen for sensitive, drug resistant and extensive drug resistant tuberculosis has been summarized along with newer drugs recommended for multi drug resistant tuberculosis. This review article has been written after extensive literature study in view of better understanding and to increase awareness regarding tuberculosis, as a sincere effort that will help eliminate tuberculosis off the face of the earth in near future.

A Case Report of Widely Disseminated Tuberculosis in Immunocompetent Adult Male

Introduction: Disseminated tuberculosis (TB) is rare, affects any organ system, and presents mainly in immunocompromised populations. Typical presentation is non-specific, posing a challenge for diagnosis. Case Report: This case presents an immunocompetent male presenting with severe headaches with meningeal signs. Lab and lumbar puncture results suggested bacterial meningitis, yet initial cerebral spinal fluid cultures and meningitis/encephalitis polymerase chain reaction were negative. A chest radiograph (CXR) provided the only evidence suggesting TB, leading to further tests showing dissemination to the brain, spinal cord, meninges, muscle, joint, and bone. Discussion: This case stands to acknowledge the difficulty of diagnosis in the emergency department (ED), and the need for emergency physicians to maintain a broad differential including disseminated TB as a possibility from the beginning of assessment. In this case, emergency physicians should be aware of predisposing factors of disseminated TB in patients presenting with non-specific symptoms. They should also acknowledge that TB may present atypically in patients with minimal predisposing factors, rendering the need to further investigate abnormal CXR images despite lab results inconsistent with TB. Conclusion: While this diagnosis is easily missed, early identification in the ED can lead to optimal treatment.

Cryptic Disseminated Tuberculosis: a Secondary Analysis of Previous Hospital-Based Study

BACKGROUND

The main purpose of this study was to describe the demographic and clinical features of cryptic disseminated TB; it was also aimed to shed light on diagnostic test, procedure results, organ involvement, and outcomes of cryptic disseminated TB in patients with confirmed disseminated TB.

MATERIALS AND METHODS

We performed a secondary post hoc analysis of collected data from our previous study entitled "Disseminated Tuberculosis among Adult Patients Admitted to Hamad General Hospital, Qatar: A Five-Year Hospital-Based Study" with modified objectives. This study included patients admitted from January 1, 2006 to December 31, 2010.

RESULTS

Twenty-three patients were recruited with non-miliary patterns on chest x-ray. Their mean age was 34.4±12.6 years and 15 (65.6%) were males. The mean duration of illness was 46.13±48.4 days and the most common presenting symptom was fever in 20 patients (87%), while 3 (13%) patients had underlying medical conditions with diabetes mellitus 2 (8.7%), being the most common. Bronchoalveolar lavage (BAL) and bronchial wash (BW) fluids were Acid-fast bacilli (AFB) positive in 1/4 (25%) of the cases and culture-positive for Mycobacterium tuberculosis (M. tuberculosis) in 4/4 (100%) of all the cases. Two patients (8.7%) had positive sputum smear, while 18 (78.3%) patients had positive culture for M. tuberculosis. All except one patient completed their treatment in Qatar. One patient died one month after the start of antituberculous treatment.

CONCLUSION

Cryptic disseminated TB should be suspected when a patient from TB-endemic countries develops unexplained fever and cough despite normal or non-miliary pattern chest radiograph. Moreover, respiratory specimen cultures should be obtained from these patients, regardless of the symptoms presented and the initial site of the involved organ.

Clinical Aspects and Principles of Management of Tuberculosis

Tuberculosis over the ages, has killed more people than any other infection has. Notwithstanding the advances in modern science, clinical diagnosis sometimes remains elusive, owing principally to the frequent paucibacillary occurrence of the disease and the slow doubling time of the organism; empiric treatment is often fraught with risks in the era of increasing drug resistance.

This chapter attempts to provide an overview of the disease, beginning with the pathogenesis and its protean clinical presentations. It also discusses the recent evolution of molecular methods that have lately provided an impetus to early diagnosis with a clear opportunity to unmask drug resistance before initiating “blind”, potentially ineffective, and sometimes harmful treatment with standard therapy.

The chapter also provides insight into tuberculosis in special situations, and discusses briefly the treatments in uncomplicated cases as well as in special situations, and in instances of drug resistance. Preventive methods including current and upcoming vaccines are mentioned.

Finally, a short discussion of the sequelae of tuberculosis—which have the potential to be confused with active disease—is presented.

Miliary Tuberculosis Presenting with Hyponatremia and ARDS in an 82-Year-Old Immunocompetent Female

An immunocompetent 82-year-old female was admitted to our hospital due to fever without clear origin and hyponatremia. In the following days, an acute and bilateral pulmonary infiltrate appeared with a progressive worsening in respiratory function. Chest x-ray and CT (Computed tomography) showed bilateral reticulonodular infiltrates. Bronchoscopic aspiration and bronchoalveolar lavage (BAL), and transbronchial lung biopsy (TBBX) studies did not reveal microbiological and histopathological diagnosis. Broad-spectrum antibiotics were non-effective, and the patient died due to respiratory failure. Necropsy study revealed a miliary tuberculosis affecting lungs, liver, bone marrow, spleen, kidney, arteries, pancreas, and adrenal glands. Some weeks after the patient´s death, mycobacterial cultures from sputum, BAL and TBBX samples were positive for Mycobacterium tuberculosis.

The critically ill patient with tuberculosis in intensive care: Clinical presentations, management and infection control

Tuberculosis (TB) is one of the top ten causes of death worldwide. In 2016, there were 490,000 cases of multi-drug resistant TB globally. Over 2 billion people have asymptomatic latent Mycobacterium tuberculosis infection. TB represents an important, but neglected management issue in patients presenting to intensive care units. Tuberculosis in intensive care settings may present as the primary diagnosis (active drug sensitive or resistant TB disease). In other patients TB may be an incidental co-morbid finding as previously undiagnosed sub-clinical or latent TB which may re-activate under conditions of stress and immunosuppression. In Sub-Saharan Africa, where co-infection with the human immunodeficiency virus and other communicable diseases is highly prevalent, TB is one of the most frequent clinical management issues in all healthcare settings. Acute respiratory failure, septic shock and multi-organ dysfunction are the most common reasons for intensive care unit admission of patients with pulmonary or extrapulmonary TB. Poor absorption of anti-TB drugs occurs in critically ill patients and worsens survival. The mortality of patients requiring intensive care is high. The majority of early TB deaths result from acute cardiorespiratory failure or septic shock. Important clinical presentations, management and infection control issues regarding TB in intensive care settings are reviewed.

Miliary Tuberculosis

Miliary tuberculosis (TB) results from a massive lymphohematogenous dissemination of Mycobacterium tuberculosis bacilli and is characterized by tiny tubercles evident on gross pathology resembling millet seeds in size and appearance. The global HIV/AIDS pandemic and widespread use of immunosuppressive drugs and biologicals have altered the epidemiology of miliary TB. Considered to be predominantly a disease of infants and children in the pre-antibiotic era, miliary TB is increasingly being encountered in adults as well. The clinical manifestations of miliary TB are protean and nonspecific. Atypical clinical presentation often delays the diagnosis. Clinicians, therefore, should have a low threshold for suspecting miliary TB. Focused, systematic physical examination helps in identifying the organ system(s) involved, particularly early in TB meningitis, as this has therapeutic significance. Fundus examination for detecting choroid tubercles offers a valuable clinical clue for early diagnosis, as their presence is pathognomonic of miliary TB. Imaging modalities help in recognizing the miliary pattern, defining the extent of organ system involvement. Examination of sputum, body fluids, image-guided fine-needle aspiration cytology or biopsy from various organ sites, needle biopsy of the liver, bone marrow aspiration, and biopsy should be done to confirm the diagnosis. Cytopathological, histopathological, and molecular testing (e.g., Xpert MTB/RIF and line probe assay), mycobacterial culture, and drug susceptibility testing must be carried out as appropriate and feasible. Miliary TB is uniformly fatal if untreated; therefore, early initiation of specific anti-TB treatment can be lifesaving. Monitoring for complications, such as acute kidney injury, air leak syndromes, acute respiratory distress syndrome, adverse drug reactions such as drug-induced liver injury, and drug-drug interactions (especially in patients coinfected with HIV/AIDS), is warranted.

Patterns of ocular inflammation in patients with miliary tuberculosis

BACKGROUND

Ocular morbidity associated with systemic tuberculosis is common. The clinical picture varies from anterior uveitis, intermediate uveitis and posterior uveitis to even panuveitis. There is little data on the correlation between specific systemic presentations and the ocular inflammation. We conducted a retrospective review of the ocular findings in the case records of patients admitted with a diagnosis of miliary tuberculosis. These patients were then referred for a more detailed ophthalmic evaluation.

METHODS

We analysed the case records of patients with a clinical diagnosis of miliary tuberculosis over a 10-year period at Lilavati Hospital  and Research Center, Mumbai.

RESULTS

In total, 11 immunocompetent patients were identified. All 22 eyes showed normal findings on slit lamp examination. Dilated fundus examination showed single or multiple tubercles. In our cohort, the ocular findings were exclusively in the form of choroidal tuberculosis, either unilaterally or bilaterally. Slit lamp examination revealed no anterior segment inflammation Conclusions: We suggest that this pattern of choroidal/retinal tuberculosis in the absence of anterior and intermediate segment inflammation is specific for miliary tuberculosis and may be related to a specific immune response.