Tuberculosis and malignancy

Life-Threatening Stridor due to Laryngeal Tuberculosis in the COVID-19 Era: Report of a Case

Laryngeal tuberculosis is the most frequent granulomatous disease of the larynx and it is prone to be diagnosed as cancer. COVID-19 pandemic caused considerable disruption in tuberculosis service provisions both in the primary care and hospital settings. This report describes a rare case of life-threatening stridor in a patient who presented with an ulceroproliferative laryngeal mass later confirmed as laryngeal tuberculosis. Urgent tracheostomy was performed. The patient's sputum and the computed tomography of the chest revealed a pulmonary, as well as laryngeal tuberculosis. The patient was commenced on a 24 week course of anti-tuberculous treatment which was interrupted because of a mild course of hospital-acquired coronavirus infection. 3 months after initial treatment for tuberculosis, his sputum cultures became negative. Flexible laryngoscopy was performed at our department 4 months after commencement of treatment, demonstrating complete regression of the lesion and symmetrical laryngeal mobility, hence the patient was successfully decannulated and discharged to be followed up to his community hospital. In the time of COVID-19 pandemic, we should never underestimate other severe infectious diseases.

Thyroid tuberculosis associated with papillary microcarcinoma: case report and review of literature

Introduction

Thyroid tuberculosis (TB) is extremely rare. Infection may first occur in the thyroid gland or may be secondary to TB in other parts of the body. The diagnosis is rarely made clinically because the disease's variable presentation often resembles that of a malignancy or an euthyroid nodular goiter.

Case report

We present the case of a 40-year-old woman, who presented multiple thyroid nodules in both lobes. Two of these nodules were classified as EU-TIRADS V (European Thyroid Imaging and Reporting Data System). The ultrasound also found an adenopathy of the inferior part of the jugular lymphatic chain, in favor of malignancy. The histopathological examination after total thyroidectomy showed thyroid TB, associated to a papillary microcarcinoma of the right thyroid lobe, and the final examination of the adenopathy showed similar granulomas with caseous necrosis, and no signs of metastasis.

Clinical discussion

Thyroid TB is very rare. Its diagnosis is difficult due to a lack of specific signs and symptoms, which is why the diagnosis is most commonly made on pathological examination after thyroid surgery. It is well known that mycobacterial infection creates an environment of chronic and persistent inflammation, with possible DNA damage. This can create a microenvironment that is highly conductive to carcinogenesis, which could explain the discovery of papillary microcarcinoma in addition to thyroid TB in our patient.

Conclusion

This report presents a rare case of malicious growth development of thyroid nodules and thyroid TB. Therefore, physicians must always be vigilant when managing thyroid nodules, as there is always the possibility of malignant lesions associated to an inflammatory or infectious cause.

Tuberculosis and childhood cancer - A review of literature

Tuberculosis and malignancy are major public health problems in developing countries like India and causes significant morbidity and mortality. Mycobacterium tuberculosis is an aerobic acid-fast bacilli which is an important pathogen especially complicating clinical status of paediatric oncology patients and treatment of infection with this bacilli is challenging in this subpopulation of patients because of ongoing immunosuppression and relative lack of published guidelines. Atypical presentations of tuberculosis in children also complicate the diagnosis and management. All the more, in tuberculosis endemic area lung cancer may be mistakenly diagnosed as tuberculosis or vice versa and this wrong diagnosis increases the burden on country's health status. It is noted that tuberculosis prevalence is high in children with haematological malignancy and head and neck tumours compared to other solid organ tumours. Moreover, it is found that morbidity and mortality from tuberculosis is more in children from WHO listed high TB burden countries who undergo hematopoietic stem cell and solid organ transplantation. Use of immune checkpoint inhibitors as novel therapy in treatment of childhood malignancies has led to modification of the body's immunological response and has resulted in increased latent tuberculosis infection reactivation as one immune-related infectious consequence. Latent TB infection screening is important concept in management of paediatric oncology patients. Currently, the tests employed as screening diagnostics for LTBI are interferon-gamma release assay (IGRA) blood test and the tuberculin skin test (TST). Various regimens have been suggested for the treatment of LTBI. But, after a positive IGRA or TST and prior to latent TB treatment, active tuberculosis should be ruled out by detailed history taking, examination and appropriate investigations so as to minimize the risk of drug resistance with anti-tuberculosis monotherapy used in LTBI treatment. To add on to literature, Non tuberculous mycobacteria are universally present environmental organisms. However, in immunocompromised children especially in subpopulation of malignancy, NTM is known to cause infections which needs protocol based management. Also importance has to given to implementation of adequate preventive and corrective measures to prevent such opportunistic infection in paediatric oncology subpopulation. In this review, we provide an overview of tuberculosis in paediatric oncology patients and summarize the expansive body of literature on the tuberculosis mimicking carcinoma, tuberculosis burden in transplantation patients and those receiving immune check point inhibitors, latent TB infection screening and management, and NTM infection in children with malignancy.

A single hepatic mass with two tales: hepatic tuberculosis and hepatocellular carcinoma

Hepatic tuberculosis (HTB) is an uncommon manifestation of tuberculous infections, and there has been no proven causal link between HTB and hepatocellular carcinoma (HCC). We herein present a rare case of a synchronous presentation of HTB and HCC within a single hepatic mass. A 57-year-old Chinese gentleman with recently diagnosed sigmoid adenocarcinoma was found to have a left lower lobe pulmonary nodule and solitary hepatic mass on staging computed tomography. Biopsies showed the hepatic mass to have both HTB and HCC components. This serves as a reminder that HTB is an important differential to consider for space-occupying lesions in the liver. Histological evaluation of suspected hepatic malignancies is recommended to exclude the presence of HTB in appropriate clinical settings.

Suspicious lung lesions for malignancy: the lesion-to-spinal cord signal intensity ratio in T2WI and DWI–MRI versus PET/CT; a prospective pathologic correlated study with accuracy and ROC analyses

Background

The multi-detector computed tomography (MDCT) and tissue biopsy are the gold standards for the evaluation of lung malignancies. However, there is a wide range of pulmonary indeterminate lesions that could mimic lung cancer. Furthermore, the diagnosis of malignancy could be challenging if the lesion is small and early presenting by a part-solid or ground-glass nodule or if surrounded by parenchymal lung reaction with consolidation and atelectasis. The previous literature focused on the role of diffusion-weighted image–magnetic resonance imaging (DWI) and the apparent diffusion coefficient (ADC) mapping in the evaluation of lung malignancy. A novel quantitative T2 assessment is provided and tested in this study. Aim of the work: To evaluate the accuracy of specific non-invasive quantitative magnetic resonance imaging (MRI) parameters in the characterization of suspicious lung lesions and the discrimination between the malignant and benign nature. They included the lesion-to-spinal cord signal intensity ratio in T2-WI and DWI as well as the mean and minimum apparent diffusion coefficient (ADC) values. This is performed using a prospective pathologic correlated study with receiver-operating characteristics (ROC) analysis and comparison with positron emission tomography (PET-CT) accuracy results.

Results

This study was prospectively performed during the period between June/2021 and June/2022. It was conducted on 43 suspicious lung lesions detected by MDCT. MRI and PET/CT examinations were performed for all patients, and the results were compared to the final diagnosis obtained after biopsy and pathological assessment, using the statistical tests of significance and P-value. Cutoff values were automatically calculated, and then, accuracy tests and ROC analyses were performed. Five expert radiologists and a single consulting pulmonologist participated in this study. The inter-rater reliability ranges between good and excellent with the intra-class correlation coefficient (ICC) ranging between 0.85 and 0.94. In T2-WI: The lesion-to-spinal cord signal intensity ratio was higher in the malignant group (1.35 ± 0.29) than in the benign group (0.88 ± 0.40), (P < 0.001). At the estimated cutoff value (> 1), the sensitivity was 96.43%, the specificity was 80.00%, and AUC = 0.86. In b500-DWI: The lesion-to-spinal cord signal intensity ratio was higher in the malignant group (0.70–1.35) than in the benign group (0.20–0.70) (P < 0.001). At the estimated cutoff value (> 0.7), the sensitivity was 71.43%, the specificity was 86.67%, and AUC = 0.86. The mean and minimum ADC values were lower in the malignant group (0.6–1.3 and 0.3–1.1 × 10–3 mm2/s) than the benign group (1–1.6 and 0.7–1.4 × 10–3 mm2/s), (P < 0.01 and < 0.001, respectively). At their estimated cutoff values (≤ 1.2 and ≤ 0.9 × 10–3 mm2/s, respectively), the sensitivity was (71.4 and 85.7%), specificity was (83.3 and 66.7%), respectively, and AUC = 0.77 for both. PET/CT had 96.4% sensitivity, 92.3% specificity, and AUC = 0.94.

Conclusions

PET-CT remains the most specific and sensitive tool for the differentiation between benign and malignant lesions. The lesion-to-cord signal intensity ratios in T2WI and DWI-MRI and to a minor extent the mean and minimum ADC values are also considered good parameters for this differentiation based on their accurate statistical results, particularly if PET/CT was not available or feasible. The study added to the previous literature a novel quantitative T2WI assessment which proved a high sensitivity equal to PET/CT with a lower but a good specificity. The availability, expertise, time factor, and patients' tolerance remain challenging factors for MRI.

Concomitant squamous cell carcinoma of the bladder and renal tuberculosis: A case report from northern Tanzania

Concomitant squamous cell carcinoma (SCC) and renal tuberculosis (TB) are a rare presentation. It is associated with poor prognosis and poses a challenge in the management. To the best of our knowledge, we present a challenging first document case of locally advanced SCC of the bladder with coactive renal tuberculosis.

Case Report: Metastatic Neck Nodes of Unknown Origin with Concurrent Tuberculous Lymphadenitis. Is Fine Needle Aspiration and Cytology (FNAC) Adequate?

Presentation with cervical lymphadenopathy would usually have an aetiology of neoplasm, infection or reactive cause. Dual pathology of regional metastasis with simultaneous occurrence of tuberculous lymphadenopathy is rather rare. Herein the authors present a case of primary occult carcinoma and tuberculous lymphadenopathy in an unfortunate patient. The reliability of fine-needle aspiration cytology as a first-line investigation, with alternative methods in approaching cervical lymphadenopathy, was further dissected.

Necrotizing granulomatous inflammation mimicking skeletal metastasis: a possible differential diagnosis

Tuberculosis is an endemic disease in India for decades, and its coexistence in the patients with malignancy cannot be ignored. The non-specific uptake of 2-deoxy-2-[fluorine-18] fluoro-d-glucose in active infection and malignancy can affect the diagnosis and management of patients. However, characteristic anatomical features of the lesion aid not only in its localization but also in diagnosis. We share an interesting case of necrotizing granulomatous inflammation of dorsal spine mimicking skeletal metastases in a treated case of carcinoma cervix.

10-Year Retrospective Review of the Etiologies for Meningitis With Elevated Adenosine Deaminase in Cerebrospinal Fluid: Etiologies Other Than TB

Purpose

An elevated adenosine deaminase (ADA) level in the cerebrospinal fluid (CSF) is considered a reliable marker of tuberculous meningitis (TBM). However, CSF-ADA levels can also be elevated in other diseases. We aimed to find the most common diagnosis of patients with elevated CSF-ADA levels for the last 10 years.

Methods

We retrospectively investigated the diagnoses of all patients with elevated CSF-ADA (ADA ≥ 10 IU/L) levels between 2010 and 2019 at the Samsung Medical Center. Definite TBM was defined based on microbiological evidence. Clinical TBM was defined based on the brain imaging and response to the standard TB treatment. We compared the laboratory characteristics of the three most common diagnoses.

Results

CSF-ADA levels were elevated in 137 (5.6%) of 2,600 patients. The most common diagnoses included hematologic malignancy (HM; n = 36, 26.2%), TBM (n = 26, 19.0%), and viral meningitis (VM; n = 25, 18.2%). CSF-ADA levels did not differ significantly between TBM [median (interquartile range (IQR)), 20.2 IU/L (13.8–29.3)] and HM [16.5 (12.8–24.0)]. However, CSF-ADA levels were lower in VM [14.0 (11.0–16.1)] than in TBM (p = 0.027). Lymphocyte-dominant pleocytosis was more common in VM [77.0% (70.8–81.5)] than in TBM [16.0 (3.0–51.0), p = 0.015] or HM [36.0 (10.0–72.0); p = 0.032]. Interestingly, the CSF characteristics of clinical TBM were similar to those of VM but not definite TBM.

Conclusion

The most common diagnoses with elevated CSF-ADA levels were HM, followed by TBM and VM. Clinicians should carefully consider the differential diagnoses in patients with elevated CSF-ADA levels, especially those in the early stage of meningitis without microbiological evidence for TBM.

Concurrent ascending colon adenocarcinoma and ileocecal tuberculosis: A case report

RATIONALE

Few cases have been reported of the coexistence of tuberculosis and adenocarcinoma of the large bowel. We report a rare case of concurrent ascending colon adenocarcinoma and ileocecal tuberculosis, which were nearly indistinguishable from one another.

PATIENT CONCERNS

A 59-year-old man visited our clinic with dizziness and anorexia.

DIAGNOSIS

Computed tomography revealed a mass in the ascending colon with ill-defined nodules in the liver. A colon biopsy showed adenocarcinoma with multinucleated giant cells. The liver nodules were confirmed to be metastatic adenocarcinomas.

INTERVENTIONS

Ant tuberculosis medications were administered prior to surgery. Two weeks later, a laparoscopic right hemicolectomy and radiofrequency ablation of the liver were performed.

OUTCOMES

The final pathology confirmed adenocarcinoma with chronic granulomatous inflammation and giant cells.

LESSONS

In this patient, the cancer was in an advanced stage and had no history of tuberculosis infection. Thus, in this case, the malignancy seemed to create the proper environment for either reactivation of a latent tuberculosis infection or, less likely, for the acquisition of a primary mycobacterial infection. In conclusion, clinicians should be aware of the possibility of concurrent colon adenocarcinoma and intestinal tuberculosis.

Pulmonary Tuberculosis and Risk of Lung Cancer: A Systematic Review and Meta-Analysis

Pulmonary tuberculosis (TB) is a known risk factor for lung cancer. However, a detailed analysis of lung cancer type, age, sex, smoking, and TB burden associated with geographic and socioeconomic status has not been performed previously. We systematically appraised relevant observational studies reporting an association between pulmonary TB and lung cancer. All studies were included in the primary analysis, and studies that used robust TB diagnostic methods, such as validated medical diagnostic codes, were included in the secondary analysis. Thirty-two articles were included. The association between the history of pulmonary TB and diagnosis of lung cancer was statistically significant (OR 2.09, 95% CI: 1.62–2.69, p < 0.001). There was a high heterogeneity (I² = 95%), without any publication bias. The analysis indicated a high association in advanced articles describing stringent pulmonary TB diagnosis (OR 2.26, 95% CI: 1.29–3.94, p = 0.004). The subgroup analyses suggested a significant association in countries with medium or high TB burdens, from East Asia and the Pacific region, and upper-middle income countries. Heterogeneity within the subgroups remained high in a majority of the subgroup analyses. A meta-regression analysis revealed that younger patients showed a significantly higher association between TB and lung cancer (regression coefficient = 0.949, p < 0.001). The history of pulmonary TB is an independent risk factor for lung cancer, especially in younger patients diagnosed with pulmonary TB. Clinicians should be aware of this association while treating young patients with a history of pulmonary TB.

Assessment of anti-PD-(L)1 for patients with coexisting malignant tumor and tuberculosis classified by active, latent, and obsolete stage

BACKGROUND

It is not a rare clinical scenario to have patients presenting with coexisting malignant tumor and tuberculosis. Whether it is feasible to conduct programmed death-(ligand) 1 [PD-(L)1] inhibitors to these patients, especially those with active tuberculosis treated with concurrent anti-tuberculosis, is still unknown.

METHODS

This study enrolled patients with coexisting malignancy and tuberculosis and treated with anti-PD-(L)1 from Jan 2018 to July 2021 in 2 institutions. The progression-free survival (PFS), objective response rate (ORR), and safety of anti-PD-(L)1 therapy, as well as response to anti-tuberculosis treatment, were evaluated.

RESULTS

A total of 98 patients were screened from this cohort study, with 45 (45.9%), 21 (21.4%), and 32 (32.7%) patients diagnosed with active, latent, and obsolete tuberculosis, respectively. The overall ORR was 36.0% for anti-PD-(L)1 therapy, with 34.2%, 35.5%, and 41.2% for each subgroup. Median PFS was 8.0 vs 6.0 vs 6.0 months (P=0.685) for each subgroup at the time of this analysis. For patients with active tuberculosis treated with concurrent anti-tuberculosis, median duration of anti-tuberculosis therapy was 10.0 (95% CI, 8.01-11.99) months. There were 83.3% (20/24) and 93.3% (42/45) patients showing sputum conversion and radiographic response, respectively, after anti-tuberculosis therapy, and two patients experienced tuberculosis relapse. Notably, none of the patients in latent and only one patient in obsolete subgroups showed tuberculosis induction or relapse after anti-PD-(L)1 therapy. Treatment-related adverse events (TRAEs) occurred in 33 patients (73.3%) when treated with concurrent anti-PD-(L)1 and anti-tuberculosis. Grade 3 or higher TRAEs were hematotoxicity (n = 5, 11.1%), and one patient suffered grade 3 pneumonitis leading to the discontinuation of immunotherapy.

CONCLUSIONS

This study demonstrated that patients with coexisting malignant tumor and tuberculosis benefited equally from anti-PD-(L)1 therapy, and anti-tuberculosis response was unimpaired for those with active tuberculosis. Notably, the combination of anti-PD-(L)1 and anti-tuberculosis therapy was well-tolerated without significant unexpected toxic effects.

Tongue cancer in a patient with pulmonary tuberculosis. Case report

Tuberculosis and malignant neoplasms are a global threat, these diseases claim millions of lives and cause tremendous suffering to people worldwide. Tuberculosis can mask cancer and create preconditions for carcinogenesis. The article presents a clinical case of tongue cancer in a patient with pulmonary tuberculosis. Patient B.N., 45 years old, was admitted to the FSBI Novosibirsk Tuberculosis Research Institute with complaints of a "sore place" on the tongue, pain in the right half of the tongue, enlargement of the submandibular lymph nodes on the right The tongue hurts for about 1,5 years, but over the last 2 months, condition has worsened. The patient noticed an increase in the size of lesion on the tongue and increased pain, especially during meals (he can eat only after pain relief, for which he takes Nimesulide 4 pills a day). In recent days, he felt also epigastric pain for which he didnt visit a doctor. Tongue biopsy was performed, and histological analysis revealed cancer. The patient was diagnosed with fibrous-cavernous tuberculosis of the upper lobe of the right lung, infiltration and seeding phase; mycobacterium tuberculosis (+); broad drug resistance (HRSECmKmPasCsOfl); gastric ulcer (0,5 cm), exacerbation stage; chronic erosive gastritis, exacerbation stage; malignant neoplasm of the floor of the mouth on the right T3(4)N1M1. With this diagnosis, the patient was discharged for further treatment by oncologists. Physicians need to have a high alertness for cancer in patients with tuberculosis, especially those in the high-risk group. A minimum of standard diagnostic procedures will allow you to verify the diagnosis timely.

An unusual association of adenocarcinoma and isolated tuberculosis of prostate gland

Adenocarcinoma of prostate is the most common primary prostatic malignancy in the world. Isolated prostate tuberculosis is an uncommon type of tuberculosis. Concomitant occurrence of both conditions is extremely rare. We report two cases of adenocarcinoma and tuberculosis of the prostate. The patients were 83 and 74 years old, respectively. They presented obstructive and irritative symptoms of the lower urinary tract. The prostatic finding and prostate-specific antigen were abnormals. The diagnosis of prostatic tuberculosis and adenocarcinoma was made by histologic analysis after transurethral resection of prostate. The treatment is based on chemotherapy anti-tuberculosis and hormonotherapy. Tuberculosis and malignancy may co-exist in some cases and clinicians must have a high index of suspicion for tuberculosis, especially in patients from endemic areas, in order to initiate early and proper treatment.

Is Mycobacterium tuberculosis carcinogenic to humans?

We highlight the ability of the tuberculosis (TB) causing bacterial pathogen, Mycobacterium tuberculosis (Mtb), to induce key characteristics that are associated with established IARC classified Group 1 and Group 2A carcinogenic agents. There is sufficient evidence from epidemiological case-control, cohort and meta-analysis studies of increased lung cancer (LC) risk in pre-existing/active/old TB cases. Similar to carcinogens and other pathogenic infectious agents, exposure to aerosol-containing Mtb sprays in mice produce malignant transformation of cells that result in squamous cell carcinoma. Convincing, mechanistic data show several characteristics shared between TB and LC which include chronic inflammation, genomic instability and replicative immortality, just to name a few cancer hallmarks. These hallmarks of cancer may serve as precursors to malignant transformation. Together, these findings form the basis of our postulate that Mtb is a complete human pulmonary carcinogen. We also discuss how Mtb may act as both an initiating agent and promoter of tumor growth. Forthcoming experimental studies will not only serve as proof-of-concept but will also pivot our understanding of how to manage/treat TB cases as well as offer solutions to clinical conundrums of TB lesions masquerading as tumors. Clinical validation of our concept may also help pave the way for next generation personalized medicine for the management of pulmonary TB/cancer particularly for cases that are not responding well to conventional chemotherapy or TB drugs.

Increased risk of secondary lung cancer in patients with tuberculosis: A nationwide, population-based cohort study

BACKGROUND

Tuberculosis (TB) presents a global threat in the world and the lung is the frequent site of metastatic focus. A previous study demonstrated that TB might increase primary lung cancer risk by two-fold for more than 20 years after the TB diagnosis. However, no large-scale study has evaluated the risk of TB and secondary lung cancer. Thus, we evaluated the risk of secondary lung cancer in patients with or without tuberculosis (TB) using a nationwide population-based dataset.

METHODS

In a cohort study of 1,936,512 individuals, we selected 6934 patients among patients with primary cancer and TB infection, based on the International Classification of Disease (ICD-p-CM) codes 010-011 from 2000 to 2015. The control cohort comprised 13,868 randomly selected, propensity-matched patients (by age, gender, and index date) without TB exposure. Using this adjusted date, a possible association between TB and the risk of developing secondary lung cancer was estimated using a Cox proportional hazards regression model.

RESULTS

During the follow-up period, secondary lung cancer was diagnosed in 761 (10.97%) patients with TB and 1263 (9.11%) patients without TB. After adjusting for covariates, the risk of secondary lung cancer was 1.67 times greater among primary cancer in the cohort with TB than in the cohort without TB. Stratification revealed that every comorbidity (including diabetes, hypertension, cirrhosis, congestive heart failure, cardiovascular accident, chronic kidney disease, chronic obstructive pulmonary disease) significantly increased the risk of secondary lung cancer when comparing the TB cohort with the non-TB cohort. Moreover, the primary cancer types (including head and neck, colorectal cancer, soft tissue sarcoma, breast, kidney, and thyroid cancer) had a more significant risk of becoming secondary lung cancer.

CONCLUSION

A significant association exists between TB and the subsequent risk for metastasis among primary cancers and comorbidities. Therefore, TB patients should be evaluated for the subsequent risk of secondary lung cancer.

[Morphological characteristics of pulmonary tuberculosis concurrent with lung cancer]

The pathogenetic relationship between pulmonary tuberculosis and lung cancer in their concurrence is now still the subject of discussion.

OBJECTIVE

To study the pathogenetic relationship between pulmonary tuberculosis and lung cancer.

MATERIAL AND METHODS

The investigators examined surgical material from 51 patients (41 men) aged 41-73 years (mean age, 63.7 years) with pulmonary tuberculosis concurrent with lung cancer. They also studied tumors, tuberculous caverns, infiltrates, and foci with surrounding macroscopically intact lung tissue, as well as fibrotic changes by histological, histochemical and immunohistochemical examinations.

RESULTS

Previous tuberculosis can be considered as a risk factor for lung cancer. Central cancer was more common in patients with inactive, chronic tuberculosis with a predominance of fibrotic processes in the root of the lung and in its hilar zones. Fibrous-cavernous tuberculosis and cavernous tuberculosis were more frequently concurrent with central cancer; peripheral tumors mainly occurred in infiltrative tuberculosis and tuberculomas.

CONCLUSION

The findings suggest that in a number of cases, cancer and tuberculosis may be anatomically close, developing in the same anatomical unit - the lung. However, this does not indicate an unambiguous etiopathogenetic relationship between pulmonary tuberculosis and lung cancer. The relationships between pulmonary tuberculosis and lung cancer are much more complex and do not fit into the simple scheme of cause-and-effect relations.

Synthesis of novel indolo[3,2-c]isoquinoline derivatives bearing pyrimidine, piperazine rings and their biological evaluation and docking studies against COVID-19 virus main protease

A series of hybrid indolo[3,2-c]isoquinoline (δ-carboline) analogs incorporating two pyrimidine and piperizine ring frameworks were synthesized. Intending biological activities and SAR we propose replacements of fluorine, methyl and methoxy of synthetic compounds for noteworthy antimicrobial, antioxidant, anticancer and anti-tuberculosis activities. Among these compounds 3a, 4a and 5e were progressively strong against E. coli and K. pneumonia. Whereas, compounds 4a, 5a and 6a with addition of various functional groups (OCH₃, CH₃) were excellent against S. aureus and B. subtilis. Compound 5c exhibited strong RSA and dynamic ferrous ion (Fe²⁺⁾ metal chelating impact with IC₅₀ of 7.88 ± 0.93 and 4.06 ± 0.31 µg/mL, respectively. Compound 5e was considerably cytotoxic against all cancer cells displaying activity better than the standard drug. Compounds 6b and 6e inhibited M. tuberculosis (MIC 1.0 mg/L) considerably. Molecular docking studies indicate that compounds 4d, 5a, 5b, 6b and 6f exhibited good interactions with 6LZE (COVID-19) and 6XFN (SARS-CoV-2) at active sites. The structure of the synthesized compounds were elementally analyzed using IR, ¹H, ¹³C NMR and mass spectral information.

IL-6 in inflammation, autoimmunity and cancer

IL-6 is involved both in immune responses and in inflammation, hematopoiesis, bone metabolism and embryonic development. IL-6 plays roles in chronic inflammation (closely related to chronic inflammatory diseases, autoimmune diseases and cancer) and even in the cytokine storm of corona virus disease 2019 (COVID-19). Acute inflammation during the immune response and wound healing is a well-controlled response, whereas chronic inflammation and the cytokine storm are uncontrolled inflammatory responses. Non-immune and immune cells, cytokines such as IL-1β, IL-6 and tumor necrosis factor alpha (TNFα) and transcription factors nuclear factor-kappa B (NF-κB) and signal transducer and activator of transcription 3 (STAT3) play central roles in inflammation. Synergistic interactions between NF-κB and STAT3 induce the hyper-activation of NF-κB followed by the production of various inflammatory cytokines. Because IL-6 is an NF-κB target, simultaneous activation of NF-κB and STAT3 in non-immune cells triggers a positive feedback loop of NF-κB activation by the IL-6-STAT3 axis. This positive feedback loop is called the IL-6 amplifier (IL-6 Amp) and is a key player in the local initiation model, which states that local initiators, such as senescence, obesity, stressors, infection, injury and smoking, trigger diseases by promoting interactions between non-immune cells and immune cells. This model counters dogma that holds that autoimmunity and oncogenesis are triggered by the breakdown of tissue-specific immune tolerance and oncogenic mutations, respectively. The IL-6 Amp is activated by a variety of local initiators, demonstrating that the IL-6-STAT3 axis is a critical target for treating diseases.

Pseudotumour presentation of pulmonary tuberculosis

Pulmonary tuberculosis manifesting as a mass lesion, thus, mimicking a lung carcinoma is an unusual radiographic presentation of tuberculosis (TB). The common radiologic patterns and clinical presentations are well known and documented. We report two cases of pulmonary tuberculosis with a neoplastic appearance on chest imaging diagnosed histologically. A 21 – year old female with cough, weight loss, anorexia and an unremarkable physical examination. Chest radiography showed a right apical mass suggestive of lung cancer. Histology of the lesion revealed parenchymal pulmonary tuberculosis. A 49-year old male with left-sided chest pain, cough, anorexia, weight loss, mild pallor with an unremarkable chest examination. Chest imaging showed a left apical mass and mediastinal lymphadenopathy. Microscopic examination of the mass confirmed pulmonary tuberculosis. Pseudotumour pulmonary tuberculosis is a rare clinical entity that can lead to diagnostic challenges and must be considered in the differential diagnosis when mass lesions are seen on chest imaging, especially in TB endemic areas.

Concomitant hepatic tuberculosis and hepatocellular carcinoma: a case report and review of the literature

BACKGROUND

Hepatocellular carcinoma (HCC) is the most common primary liver malignancy that is strongly associated with chronic liver disease. Isolated hepatic tuberculosis is an uncommon type of tuberculosis. Concomitant occurrence of both conditions is extremely rare.

CASE PRESENTATION

We report the case of a 47-year-old man who presented with fever and abdominal pain for 3 months prior to presentation. He reported a history of anorexia and significant weight loss. Abdominal examination revealed a tender, enlarged liver. Abdominal computed tomography (CT) demonstrated a solid heterogeneous hepatic mass with peripheral arterial enhancement, but no venous washout, conferring a radiological impression of suspected cholangiocarcinoma. However, a CT-guided biopsy of the lesion resulted in the diagnosis of concomitant HCC and isolated hepatic tuberculosis.

CONCLUSION

A rapid increase in tumor size should draw attention to the possibility of a concomitant infectious process. Clinicians must have a high index of suspicion for tuberculosis, especially in patients from endemic areas, in order to initiate early and proper treatment.

Lung gene expression signatures suggest pathogenic links and molecular markers for pulmonary tuberculosis, adenocarcinoma and sarcoidosis

Previous reports have suggested a link between pulmonary tuberculosis (TB), which is caused by Mycobacterium tuberculosis (Mtb), and the development of lung adenocarcinoma (LUAD) and sarcoidosis. Furthermore, these lung diseases share certain clinical similarities that can challenge differential diagnosis in some cases. Here, through comparison of lung transcriptome-derived molecular signatures of TB, LUAD and sarcoidosis patients, we identify certain shared disease-related expression patterns. We also demonstrate that MKI67, an over-expressed gene shared by TB and LUAD, is a key mediator in Mtb-promoted tumor cell proliferation, migration, and invasion. Moreover, we reveal a distinct ossification-related TB lung signature, which may be associated with the activation of the BMP/SMAD/RUNX2 pathway in Mtb-infected macrophages that can restrain mycobacterial survival and promote osteogenic differentiation of mesenchymal stem cells. Taken together, these findings provide novel pathogenic links and potential molecular markers for better understanding and differential diagnosis of pulmonary TB, LUAD and sarcoidosis.

Previous work has suggested potential links between Mycobacterium tuberculosis infection and the development of both lung cancer and sarcoidosis, in addition to tuberculosis. Here, Qiyao Chai, Zhe Lu, Zhidong Liu and colleagues report a transcriptomic analysis of lung tissue from tuberculosis, lung adenocarcinoma, and sarcoidosis patients and find that while many disease-linked expression changes are shared between the three diseases, each also has distinct transcriptional signatures that could be useful as molecular markers.

Cancer obscures extrapulmonary tuberculosis (EPTB) at a tertiary hospital in Northern Malawi

Data on the prevalence of extrapulmonary tuberculosis (EPTB) patients are limited in many African countries including Malawi. We conducted a retrospective review of all histology reports for cancer suspected patients at Mzuzu Central Hospital (MZCH) between 2013 and 2018 to determine the proportion of EPTB cases among cancer suspected patients and characterised them epidemiologically. All reports with inconclusive findings were excluded. In total, 2214 reports were included in the review, 47 of which reported EPTB, representing 2.1% (95% CI 1.6-2.8). The incidence of EPTB was significantly associated with sex, age and HIV status. Men were more than twice (OR 2.1; 95% CI 1.2-3.9) as likely to have EPTB as women while those with HIV were more than six times (OR 6.4; 95% CI 1.7-24.8) as likely to have EPTB compared to those who were HIV-negative. EPTB demonstrated an inverse relationship with age. The highest proportion of EPTB was found from neck lymph nodes (10.3% (5.4-17.2)). A reasonable number of EPTB cases are diagnosed late or missed in Malawi's hospitals. There is a need for concerted efforts to increase EPTB awareness and likely come up with a policy to consider EPTB as a differential diagnosis in cancer suspected patients.

Disseminated tuberculosis confounding a co-morbid primary CNS lymphoma

Primary central nervous system lymphoma is notoriously challenging to diagnose in immunocompetent patients as it is an uncommon diagnosis. We present a case of synchronous diagnosis with tuberculosis. A 60-year-old woman presented with cognitive difficulties, memory loss, social withdrawal, unintentional weight loss, and night sweats, the work-up of which ultimately identified multiple brain lesions and mediastinal adenopathy. Brain biopsy showed lymphohistiocytic infiltrate, while mediastinal node histopathology showed necrotizing granulomas, and cultures grew Mycobacterium tuberculosis. The patient was initiated on anti-tuberculosis therapy. However, follow-up brain MRI demonstrated disease progression, prompting repeat brain biopsy, which in turn confirmed the diagnosis of diffuse large B-cell lymphoma. Although unrelated synchronous diagnoses are rare, the potential for clinically significant confounding is considerable-particularly where disease markers may overlap, as is often the case with infectious, inflammatory, and neoplastic processes. The present case illustrates the importance of diligence in ruling out competing diagnosis, and timely action when an anticipated finding or response-to-treatment is not observed.

Intestinal tuberculosis in a patient with end-stage renal disease on hemodialysis: A case report

RATIONALE

Intestinal tuberculosis (TB) is rarely seen in patients with end-stage renal disease (ESRD). We report an intestinal TB case with a clinical presentation similar to that of colon cancer in a patient with ESRD on hemodialysis.

PATIENT CONCERNS

A 49-year-old man presented with a 3-month history of general weakness and anorexia. He had been treated for stage 5 chronic kidney disease (CKD) due to diabetic nephropathy for the last 3 years. His blood urea nitrogen and serum creatinine levels were 96.9 and 8.1 mg/dL, respectively, at the time of admission; azotemia was accompanied by severe anemia, hypoalbuminemia, hyperkalemia, and metabolic acidosis. Hemodialysis was initiated for suspected exacerbation of uremia; however, intermittent fever, night sweats, and abdominal discomfort persisted.

DIAGNOSES

Abdominal computed tomography (CT) and whole-body F-fluorodeoxyglucose positron emission tomography were indicative of ascending colon cancer with lymph node metastases. However, colonoscopy with biopsy revealed the formation of submucosal caseating granuloma and acid-fast bacillus.

INTERVENTIONS

We initiated quadruple therapy with isoniazid, rifampicin, pyrazinamide, and ethambutol. The patient continued the quadruple regimen for the first 2 months before switching to dual therapy and received anti-TB medications for a total of 12 months.

OUTCOMES

After 9 months of standard anti-TB chemotherapy, polypoid residual lesions were noted during follow-up colonoscopy. Laparoscopy-assisted ileocecal resection was performed. No findings suggestive of recurrence of colonic TB were observed on follow-up abdominal CT at 6 months after discontinuation of anti-TB medications.

LESSONS

If non-specific uremic symptoms persist in patients with advanced CKD, the possibility of extrapulmonary TB such as intestinal TB must be considered. Also, in patients with radiologic suspicion of colon cancer, endoscopy with biopsy should be performed promptly to exclude colonic TB with similar clinical manifestations.

Misdiagnosis of a multi-organ involvement hematogenous disseminated tuberculosis as metastasis: a case report and literature review

Background

Tuberculosis (TB) is a great mimicker and diagnostic chameleon, and prone to be diagnosed as malignancy. Even though many reports have described the differences between pulmonary TB and lung cancer, the atypical systemic hematogenous disseminated TB (HDTB) is very rare and more confusing in clinical practice.

Case presentation

A 73-year-old man, HIV-negative, was hospitalized to the local county hospital because of chest pain, low-grade fever, asthenia, anorexia and weight loss for the pasting two months. The CT findings of the two lungs showed multiple round or round-like nodules of different sizes, with clear boundaries and partial fusion. The level of serum CA19–9 was significantly higher than normal, and progressively increased. There were multiple enlarged lymph nodes in the neck, mediastinum, abdominal cavity and pelvic cavity. The symptoms were diagnosed as hematogenous spread of gastrointestinal tumor in the local county hospital. However, when transferred to our provincial hospital, through comprehensive dynamic analysis, this patient was diagnosed as atypical systemic HDTB, no cancer at all. Through routine anti-TB therapy for one year, the patient was recovered very well at the follow-up of half year after withdrawal.

Conclusions

In the past, most TB misdiagnosis cases involved in single organ and were finally confirmed through invasive examination. This case enriched clinical experiences in the diagnosis of atypical HDTB. We encouraged clinicians to establish a dynamic thinking for diagnosis and treatment and emphasized the value of biopsy and ¹⁸F-FDG-PET in distinguishing TB and cancer.

Pulmonary Tuberculosis is Associated with Elevated Risk of Lung cancer in Korea: The Nationwide Cohort Study

Objective: Although previous studies suggest that previous pulmonary tuberculosis was associated with increased risk of lung cancer. It remains controversial whether pulmonary tuberculosis is a risk factor for lung cancer. Our study was aimed to examine the association between pulmonary tuberculosis and lung cancer risk in Korean.

Methods: The Korean National Health and Nutrition Examination Survey database was linked with the Korean National Cancer Incidence Database to examine the occurrence of pulmonary tuberculosis and lung cancer. The linked databases were also merged with causes of death database of Statistics Korea. The Cox-proportional hazards model was used to estimates the hazard risk of lung cancer for Korean adults aged ≥40 years with pulmonary tuberculosis.

Results: Of 20,252 total participants, 2,640 (13.0%) had old pulmonary tuberculosis (a medical history of pulmonary tuberculosis or radiologically inactive tuberculosis). After adjusting for all covariates, the hazard ratio of lung cancer among patients with old pulmonary tuberculosis was 3.24 (95% CI, 1.87‒5.62) compared to the control group. According to smoking status, the hazard ratios of lung cancer for never smokers, ex-smokers, and current smokers among participants with old pulmonary tuberculosis were 3.52 (95% CI, 1.17‒10.63), 2.16 (95% CI, 0.89‒5.24), and 3.71 (95% CI, 1.49‒9.22) compared to the control group, respectively.

Conclusions: Korean adults with old pulmonary tuberculosis have a higher risk of lung cancer, compared to general population without pulmonary tuberculosis.

Tuberculosis Infection in a Patient Treated With Nivolumab for Non-small Cell Lung Cancer: Case Report and Literature Review

Nivolumab (PD-1 inhibitor) and other immune checkpoint inhibitors are used primarily to promote reactivation of anti-tumor immunity. However, due to their generalized immunorestorative properties, these agents may also trigger an unusual spectrum of side-effects termed immune-related adverse events. In the case of the lung, pulmonary infiltrates in patients treated with the anti-PD-1 inhibitors, nivolumab, or pembrolizumab, especially patients with non-small cell lung cancer, can result from immune-related pneumonitis, which, until fairly recently was believed to be of non-infective origin. This, in turn, may result in progression and pseudo-progression of disease. An increasing body of evidence has, however, identified pulmonary tuberculosis as an additional type of anti-PD-1 therapy-associated, immune-related adverse event, seemingly as a consequence of excessive reactivation of immune responsiveness to latent Mycobacterium tuberculosis infection. The current case report describes a 56-year old Caucasian female who presented with microbiologically-confirmed tuberculosis infection while on nivolumab therapy for non-small cell lung cancer. Notably, the patient, seemingly the first described from the African Continent, had not received immunosuppressive therapy prior to the diagnosis of tuberculosis.

[Intermittent abdominal pain and abdominal distension with fatigue and massive ascites in a 13-year-old boy]

A 13-year-old boy was admitted due to intermittent abdominal pain for one year with massive ascites. The purified protein derivative (PPD) test after admission yielded positive results (3+), and ascites examination revealed a yellow color. There were 634×10⁹ nucleated cells/L in the ascites, among which 82.2% were mononuclear cells and 17.8% were multinuclear cells. The Rivalta test yielded a positive result and revealed that the ascites was exudate, suggesting the possibility of tuberculosis infection. The symptoms were not relieved after isoniazid-rifampicin anti-tuberculosis therapy and symptomatic/supportive treatment. Plain CT scan of the abdomen and contrast-enhanced CT showed that the lesion was located at the left wall of the transverse colon, with uneven thickening of the peritoneum and heterogeneous enhancement. Colonoscopic biopsy found signet ring cells in the mucosa and immunohistochemical examination revealed Syn (-), CgA (-), CD56 (-), CK(pan) (+), CDX-2 (+), CK20 (+), Muc-1 (+) and Ki-67 (+, about 80%). PET-CT scan showed an abnormal increase in fluorodeoxyglucose metabolism, which was shown as a mass near the splenic flexure of the transverse colon, with a maximum standard uptake value of 9.9, indicating a highly active lesion; this was consistent with the metabolic changes of malignant tumors. Surgical operation was performed and intraoperative exploration revealed massive ascites, a hard mass located at the hepatic flexure of the colon, involvement of the serous coat and surrounding tissues, stenosis of the bowel, lymph node enlargement around the superior mesenteric vessels and the gastrocolic ligament, and multiple metastatic nodules in the greater omentum, the abdominal wall and the pelvic cavity. The results of postoperative pathology were consistent with those of colonoscopic biopsy, i.e., poorly differentiated mucinous adenocarcinoma of the transverse colon and partly signet-ring cell carcinoma. Therefore, the boy was diagnosed with colon signet-ring cell carcinoma with peritoneal metastasis and tuberculosis infection. When a child is suffering from intractable abdominal pain, unexplained intestinal obstruction and massive intractable ascites, the possibility of malignancy should be considered. Abdominal plain CT scan as well as contrast-enhanced CT scan should be performed as early as possible, and enteroscopy should be performed when necessary.

Clinical features of octogenarian patients with tuberculosis at a tertiary hospital in South Korea

Objective

The growth of the older population is a great challenge for tuberculosis (TB) control in South Korea. This study was performed to investigate the clinical characteristics of and treatment outcomes among octogenarian patients with TB.

Methods

We retrospectively analyzed the medical records of 109 patients with TB (age of ≥80 years) from January 2014 to March 2017. Clinical, microbiologic, and radiologic findings were obtained.

Results

Fifty-five patients (50.5%) were male, the mean age of the patients was 83.8 years, and 75 patients (68.8%) had pulmonary TB. All patients with pulmonary TB underwent either chest X-ray or chest computed tomography examination, and the results showed that only one-third (n = 33, 39.3%) had active lesions suggestive of TB. Twenty-nine patients (26.4%) had an unfavorable outcome (21 died and 8 were lost to follow-up). Only two TB-related deaths occurred, and both were caused by respiratory failure. Among the 15 non-TB-related deaths, the progression of malignancy and sepsis were the most frequent causes of death.

Conclusions

A high mortality rate was observed in octogenarian patients with TB, and most of these deaths were non-TB-related. Among all causes of mortality, solid malignancy was a significant risk factor for death.

Early Onset of Squamous Cell Carcinoma Arising From Tuberculosis Verrucosa Cutis

A 72-year-old man presented with a chronic scaly verrucous plaque over his right knee for nine months. The lesion was preceded by a well healed scar sustained five years back from a road traffic accident. He was given multiple courses of systemic antibiotic and antifungal medications but to no avail. A skin biopsy confirmed cutaneous tuberculosis. The area of plaque subsided significantly with antituberculosis treatment. However, during the second month of treatment, a new onset of a red fleshy granulating growth developed on the pre-existing site. A repeat skin biopsy revealed squamous cell carcinoma (SCC). He was subsequently referred for surgical excision. This is presumably the first reported case of SCC arising from tuberculosis verrucosa cutis. While most malignant transformations from tuberculosis has been thought to develop after a long period of time (usually more than twenty-five years), this case report showed that it may also occur within a short period of time. Awareness on this condition is important because any delay in diagnosis and treatment may have detrimental consequences.

Extrapulmonary Tuberculosis of Lymph Node Coexist with Diffuse Large B-cell Lymphoma: A Case Report

Extrapulmonary tuberculosis (TB) coexistent with lymphomas in the same organ are rare. Here, we report a case of a 14-year-old male patient who had cauliflower-like ulcerated mass over cervical lymphadenopathy. He was diagnosed extrapulmonary TB. Unresponsiveness of anti tubercular treatment (anti-tubercular) treatment after 6 months, he was diagnosed as diffuse large B-cell lymphoma.

Intracystic Papillary Carcinoma in a Male Breast: Thirty Years after Orchiectomy

Papillary carcinoma of the breast is an extremely rare form of breast carcinoma in males. We report a case of an 83-year-old man who presented with a retroareolar palpable mass, associated with bloody nipple discharge. Cytological characteristics were rare clusters and papillary formations with enlarged hyperchromatic nuclei, surrounded by erythrocytes. Having in mind that a reliable cytological diagnosis of papillary carcinoma cannot be made and that all papillary lesions observed in cytological material should be excised for histological examination, breast conserving surgery (BCS) was performed.

Histologically, cystic ducts were lined with atypical papillary formations bridging the duct lumen, but with the absence of both myoepithelial cells and stromal invasion. Prolactin and testosterone serum levels were decreased. Immunohistochemical examination on actin, estrogen and progesteron receptors was negative.

The authors have pointed out that the patient had left orchiectomy, induced by tuberculous orchiepididymitis with scrotal fistula, performed thirty years before. Twelve months after breast conserving surgery, the patient is still alive.

Evaluation of coexistence of cancer and active tuberculosis; 16 case series

Introduction

Tuberculosis is an important risk factor for cancer. Pulmonary TB and lung cancer(LC) may mimic each other especially in the aspect of the clinical and radiological features. The aim of the study was to evaluate the features and risk factors of cases with coexistence cancer and active TB.

Methodology

We retrospectively reviewed the medical records of patients with coexisting TB and cancer a period from 2009 to 2014. We evaluated demographic data, the ways diagnosis of TB cases, the location of TB and cancer, TB treatment results of the cases.

Results

We recorded 374 TB cases in our dyspensary at this study period. In 16 (4%) of these cases, a coexistence of cancer and TB was detected. The male/female ratio was 12/4. The mean age was 62,12 ± 15,13 years. There were TST results except three cases. There were ten pulmonary TB and six extra-pulmonary TB (four peripheral lymphadenopathy TB, one abdominal TB lymphadenopathy and one salivary gland TB). Cancer types were as follows; eight lung cancer, two breast cancer, one base of tongue, one endometrium cancer, one hypopharyngeal cancer, one stomach cancer, one bladder cancer and one maxillary cancer. Diagnosis of all cases was confirmed by bacteriologic and/or histopathological examination. Squamous cell carcinoma was the most common type of cancers. This rate was 9/16. All TB cases were new. There were risk factors out of two case in the cases. Five cases were died during TB treatment. Others completed TB treatment without any complication.

Conclusions

In our study, the coexistence of LC and pulmonary TB was more common. The local immunity is deteriorated in cancer cases. If there is pulmonary infiltrates in lung or peripheral lymphadenopathy, we must search tuberculosis too out of metastatic lesion and other infectious diseases. We should not make delay in the diagnosis of active TB in cancer cases.

Invasive mucinous adenocarcinoma with lepidic-predominant pattern coexisted with tuberculosis: a case report

We observed a rare case of invasive mucinous adenocarcinoma (IMA) with a lepidic-predominant pattern accompanied by pulmonary tuberculosis. An 85-year-old man with repeated cough and sputum was admitted to Xinhua Hospital. T-SPOT test result was 212 pg/ml (reference value of negative is < 14 pg/ml), Mycobacterium tuberculosis culture was positive, and tuberculin skin test (PPD) was negative (skin induration < 5 mm). The patient was treated with several courses of antibiotics and anti-tuberculosis treatments. Repeated chest CT scans showed disease progression. Bronchoscopy yielded negative results. PET-CT scans showed negative results. A percutaneous lung biopsy revealed mucin-secreting cells lining the alveolar walls. IMA with a lepidic-predominant pattern was diagnosed after invasiveness was found after experimental treatments. Simultaneous occurrence of pulmonary tuberculosis and lung cancer are common; however, the present case of IMA having a lepidic-predominant pattern and coexisting with active tuberculosis has not been reported yet.

Non-pulmonary cancer risk following tuberculosis: a nationwide retrospective cohort study in Lithuania

BACKGROUND

Lithuania remains one of the highest tuberculosis burden countries in Europe. Epidemiological studies have long pointed to infections as important factors of cancer aetiology, but the association between tuberculosis and the risk of non-pulmonary cancers has rarely been tested and results have been inconsistent. The aim of this population-based cohort study was to examine the risk of cancer among patients diagnosed with tuberculosis using data from Lithuanian Tuberculosis, Cancer and Resident's Registries.

METHODS

The study cohort included 21,986 tuberculosis patients yielding 1583 cancers diagnosed during follow-up (1998-2012). Standardized incidence ratios (SIRs) and 95% confidence intervals (95% CIs) were calculated to compare the incidence of cancer among cohort participants with the general population for overall, non-pulmonary, site-specific cancers, as well as for subgroups of smoking-related, alcohol-related, hormone-related and haematological cancers.

RESULTS

The SIRs of all cancers combined were 1.89, 95% CI: 1.79-2.00 in men and 1.34, 95% CI: 1.19-1.50 in women. Risk was increased 3-fold within the first year following diagnosis; it decreased during later years, although remained significantly elevated for ≥5 years. Elevated long-term increased risks persisted for non-pulmonary cancers overall, and for cancers of mouth and pharynx, oesophagus, stomach, larynx, cervix uteri and leukaemias. Tuberculosis was associated with a decreased risk of melanoma. Increased risks were observed for smoking-related cancers in men (SIR 1.95, 95% CI: 1.79-2.13) and women (SIR 1.46, 95% CI: 1.22-1.73), alcohol-related cancers in men (SIR 2.40; 95% CI: 2.14-2.68) and haematological cancers in men (SIR 1.73, 95% CI: 1.33-2.23). The risk of hormone-related cancers was 18% lower (SIR = 0.82, 95% CI: 0.66-0.997) among women, the inverse association was weaker among men (SIR = 0.95, 95% CI: 0.84-1.07).

CONCLUSIONS

The risk of total and several non-pulmonary cancers was elevated in a cohort of tuberculosis patients. The recommendation for the awareness of this association among physicians is warranted. Analysis suggests a reduction in risk of hormone-related cancers and melanoma.

ALK-positive anaplastic large cell lymphoma undiagnosed in a patient with tuberculosis: a case report and review of the literature

Background

Due to a similarity between the features of lymphoma and the features of tuberculosis, lymphoma may go unrecognized and undiagnosed in patients with tuberculosis.

Case presentation

A 33-year-old Thai man presented to our center with typical clinical manifestations of tuberculous lymphadenitis, with negative tests for both acid-fast bacilli and fungi, and negative polymerase chain reaction for Mycobacterial tuberculosis complex. The disease was not responding to anti-tuberculosis treatment and he developed both pericardial effusion and progressive lymphadenopathy. Large lymphoma cells were evident in the pericardial effusion, and a review of the previous lymph node biopsies confirmed the existence of ALK-positive anaplastic large cell lymphoma and tuberculous lymphadenitis. Moreover, when the tests were repeated, he was found to be positive for both acid-fast bacilli and Mycobacterial tuberculosis complex. The presence of typical morphology of tuberculous lymphadenitis and inattentional blindness may explain why the presence of large lymphoma cells was overlooked in one of the previous lymph node biopsies. Our patient developed severe pneumonia with profound septic shock due to carbapenem-resistant Enterobacteriaceae and died within days.

Conclusions

Given that tuberculosis and lymphoma can share common features, this case highlights the importance of thoroughly reviewing all foregoing relevant patient data (most notably pathology samples) in order to rule out the presence of lymphoma that may exist within the shadow of typical morphology of tuberculous lymphadenitis.

Ileocaecal and transverse colonic tuberculosis mimicking colonic malignancy - A case report

INTRODUCTION

Gastrointestinal tuberculosis is common in the developing world especially in the lower socioeconomic groups. In elderly, it may mimic malignancy.

CASE PRESENTATION

A 46-year-old female presented with a 6 month history of diffuse pain in abdomen with low grade fever and loss of weight and appetite. Clinically, differential of malignancy of the large bowel was considered. The computerized tomography(CT) scan of the abdomen revealed a diffuse concentric long segmental thickening of terminal ileum, ileo ceacal junction, ascending colon and narrowing of the transverse colonic end of the splenic flexure suggesting an infective etiology. Colonoscopy showed an ulcero-nodular lesion at the splenic flexure raising the possibility of colonic cancer and thickening of ascending colon and caecum. Colonoscopic biopsy from both sites, on histopathology, showed a moderate mixed inflammation and occasional lymphoid collection and crypt abscesses in the lamina propria giving a differential of tuberculosis or Crohn's disease. Biopsy smear showed occasional acid fast bacilli(AFBs) and the gene Xpert detected mycobacterium tuberculosis(MTB). The patient was started on anti Koch's therapy(AKT).

DISCUSSION

In this case the differential diagnosis was malignancy of the colon, inflammatory bowel disease and tuberculosis as all these conditions may have similar clinical profile and radiological findings. Tuberculosis of bowel was considered as the most probable diagnosis due to the CT findings. But the colonoscopy suggested malignant etiology.

CONCLUSION

Possibility of tuberculosis should be kept in mind while dealing with synchronous lesions in large intestine.

Carcinomatous pleuritis and pericarditis accompanied by pulmonary tuberculosis

Although both lung cancer and pulmonary tuberculosis (TB) commonly occur in clinical practice, little attention has been paid to their coexistence. A 62‐year‐old female was admitted with acute dyspnoea secondary to cardiac tamponade. During her admission, a mass lesion harbouring air bronchograms in the right upper lobe rapidly increased in size. Surgical lung, pericardial, and pleural specimens yielded TB from a nodule in the right upper lobe and lung adenocarcinoma from the pericardium and pleura. Anti‐tuberculous therapy was administered and gefitinib was subsequently started after the positive identification of epidermal growth factor receptor (EGFR) mutation (exon 19 deletion). The patient's general condition gradually improved with the anti‐tuberculous and the EGFR‐tyrosine kinase inhibitor (EGFR‐TKI) treatment. Dual pathology is important to consider in patients with atypical radiological appearances. In those with proven EGFR mutation positive for lung cancer and pulmonary TB, sequential anti‐tuberculous medication followed by EGFR‐TKI treatment is advised.