Disseminated tuberculosis after pregnancy progressed to paradoxical response to the treatment: report of two cases

Peritoneal and Pulmonary Tuberculosis in a Postpartum Female with Elevated Cancer Antigen 125 and Ascites

BACKGROUND

Peritoneal tuberculosis is a rare form of extrapulmonary tuberculosis and presents a challenging diagnosis because of its nonspecific clinical manifestations. Peritoneal TB mimics other pathologies, including abdominal carcinomatosis, especially when the patient presents with ascites and an elevated cancer antigen (CA)-125 levels. Case Presentation. A postpartum 20-year-old Hispanic female recently discharged after transverse cesarean surgery, presented to the ER with fever, chills, edema, abdominal distension, nausea, and vomiting. The patient was febrile, tachycardic, and hypotensive. Chest X-ray demonstrated alveolar and interstitial consolidations; chest CT revealed tree-in-bud opacities in the right lower lobe, suggestive of atypical (TB)/fungal infection. CT of the abdomen and pelvis demonstrated ascites, omental thickening, peritoneal thickening, and mesenteric adenopathy, suggestive of carcinomatosis. She was admitted with a presumed diagnosis of sepsis secondary to pneumonia and started empirically on broad-spectrum antibiotics without clinical improvement. A battery of oncology markers was ordered and revealed a mildly elevated cancer antigen (CA)-125. Diagnostic paracentesis showed lymphocytic predominance with positive mycobacteria PCR, elevated adenosine deaminase (ADA), and no malignant cells. Subsequently, the sputum acid-fast bacilli (AFB) stain returned positive for tuberculosis, confirming the diagnosis of pulmonary tuberculosis. A peritoneal biopsy was obtained and demonstrated caseating granulomas consistent with peritoneal tuberculosis. The patient was started on standard antituberculosis therapy with clinical improvement.

CONCLUSIONS

This case highlights the need for a high-level of suspicion for peritoneal tuberculosis in a patient with pulmonary tuberculosis who presents with intra-abdominal ascites, omental thickening, peritoneal thickening, and mesenteric lymphadenopathy, despite the presence of an elevated CA-125 level.

Pelvic and central nervous system tuberculosis complicated by a paradoxical response manifesting as a spinal tuberculoma: a case report

Background

The post-partum period is a risk factor for tuberculosis (TB), possibly including the period after miscarriage as illustrated here. This case demonstrates how non-specific symptoms can hide widely disseminated TB.

Case presentation

A healthy 26-year-old female with a history of recent miscarriage presented to the emergency department with non-specific symptoms of headache, abdominal pain, and sub-acute fevers. She had immigrated to the United States from the Marshall Islands 9 years prior. Two months prior to presentation she had a miscarriage at 18 weeks of pregnancy. On admission, transvaginal ultrasound revealed retained products of conception and abdominal computed tomography revealed findings consistent with tubo-ovarian abscesses and peritonitis. The obstetrics and gynecology service performed dilation and curettage (D&C) to remove retained products of conception. Acid-fast bacilli cultures from cerebrospinal fluid as well as specimens from D&C and intra-abdominal abscesses subsequently all grew TB. She was diagnosed with TB meningitis, peritonitis, endometritis, and tubo-ovarian abscesses. Her treatment course was complicated by a paradoxical response resulting in a spinal tuberculoma causing lower extremity weakness. The tuberculoma was treated with surgical decompression as well as continuation of treatment with anti-tubercular chemotherapy and steroids.

Conclusion

Disseminated and extrapulmonary TB can present with non-specific symptoms. Recognition of risk factors for TB is critical for prompt diagnostic evaluation and treatment of this deadly disease. A paradoxical reaction needs to be taken into consideration when any new neurological symptoms occur during TB treatment.

Multiple Extrapulmonary Tuberculous Abscesses Developed Postpartum in a Non-HIV Patient Under Anti-tuberculosis Chemotherapy

Although abscess formation constitutes a recognized complication of tuberculous lymphadenitis, the concomitant development of multiple tuberculous abscesses in the course of tuberculous lymphadenitis has rarely been described in the literature among HIV-negative patients under appropriate chemotherapy. Adherence and sensitivity to the administered anti-tuberculosis chemotherapy have to be verified in such patients. We report a case of deteriorating tuberculous lymphadenitis, presenting with the development of multiple extrapulmonary abscesses (cervical, psoas, and retroperitoneal) in an HIV-negative patient who had complied with appropriate anti-tuberculosis chemotherapy for four months. Mycobacterium tuberculosis was the identified pathogen in specimens from the abscesses. Continuation of anti-tuberculosis medications and concurrent administration of antibiotics, along with CT-guided percutaneous drainage of the psoas abscess, resulted in gradual resolution of the patient's lesions. Interestingly, our patient had recent childbirth, indicating a potential association between the immunomodulatory processes during the postpartum period and the development of the so-called paradoxical reaction. Awareness of such complications should be raised, as a timely recognition and subsequent therapeutical treatment are essential for a favorable outcome.

Postpartum Ankle Pain: A Suspected Complex Regional Pain Syndrome or a Rare Cause of Septic Arthritis?

Ankle tuberculosis is a relatively rare condition and may develop after hematogenous dissemination from the pulmonary origin, particularly in cases of immunosuppression. Both pregnancy and delivery are relatively immunosuppressive states, and immune modulations during these periods can contribute to the pathogenesis of disseminated tuberculosis. A 26-year-old mother presented with severe, continuous, and debilitating pain in the left ankle, lasting for three months after delivery and associated with fever. Inspection demonstrated ankle swelling and redness, with a cold and cyanotic forefoot. Ankle radiograph and musculoskeletal ultrasound evaluation were obtained. Tibiotalar joint arthrocentesis revealed purulent liquid suggestive of septic arthritis and an emergent arthroscopic washout of the ankle was performed. The synovial mycobacterial culture was posteriorly positive and the diagnosis established was both pulmonary and osteoarticular tuberculosis. A comprehensive rehabilitation program was then implemented to achieve maximum functional gains. This report presents a rare case of ankle tuberculosis diagnosed in the postpartum period. Early evaluation, treatment, and adequate rehabilitation interventions can be crucial to promote functionality and enhance the quality of life.

Varying clinical presentations of nontuberculous mycobacterial disease : Similar to but different from tuberculosis

The incidence rate of pulmonary nontuberculous mycobacterial disease (PNTMD) in Japan is the highest among major industrialized nations. Although the typical clinical course and radiological manifestations of PNTMD are different from those of pulmonary tuberculosis (TB), confusion about these mycobacterial diseases leads to a diagnostic pitfall. Diagnostic challenges include the coexistence of Mycobacterium tuberculosis (MTB) and nontuberculous mycobacteria (NTM), false positives for NTM in MTB nucleic acid amplification tests, microbial substitution, and abnormal radiological manifestations caused by NTM. Features of extrapulmonary NTM diseases, such as pleurisy, vertebral osteomyelitis, and disseminated disease, are different from the corresponding tuberculous diseases. Moreover, the immunological background of the patient (status of human immunodeficiency virus infection with or without antiviral therapy, continuation or discontinuation of immunosuppressive therapy, use of immune checkpoint inhibitor, pregnancy and delivery, etc.) influences the pathophysiology of mycobacterial diseases. This review describes the varying clinical presentations of NTM disease with emphasis on the differences from TB. J. Med. Invest. 68 : 220-227, August, 2021.

[Parardoxical reaction following tuberculosis treatment in non HIV-infected patients]

A paradoxical reaction is the worsening of prior existing, or the appearance of, new tuberculous lesions, following the initiation of treatment with anti-tuberculous drugs, after the exclusion of poor compliance, malabsorption, drug interaction or multiresistant mycobacteria. Well known and well managed in the context of HIV coinfection, it is not well known outside this context. An increasing number of publications have described this syndrome. This review aims to describe the pathogenic, epidemiological, clinical, prognostic and therapeutic elements of non-HIV-associated paradoxical reactions. It involves a reversal of the Mycobacterium tuberculosis-induced immunodepression along with a heightened detrimental pro-inflammatory profile caused by efficient drug treatment. Extra-thoracic locations, especially lymph nodes and neurological, malnutrition and initial lymphopenia are the principal risk factors. The median delay is 40±20 days after the onset of treatment. Corticosteroids are the mainstay of the management. Anti-TNF-α drugs show good results in corticosteroid refractory cases. The prognosis is good overall except in neurological forms. The place of preventive methods remains to be established.

Paradoxical Reaction In The Form Of New Pulmonary Mass During Anti-Tuberculosis Treatment: A Case Series And Literature Review

Introduction

Paradoxical reaction refers to deterioration of the original tuberculosis lesions or emergence of new infiltrative lesions during anti-tuberculosis treatment. The common manifestations of paradoxical reaction include new pleural effusion, cerebral tuberculosis and lymphadenitis. Paradoxical reaction manifested by new pulmonary mass is rare.

Patients and methods

This article summarizes and analyzes the clinical manifestations, chest CT, laboratory findings, treatments, pathological biopsy results of five patients diagnosed as paradoxical reaction in the form of new pulmonary mass. A literature review related to paradoxical reaction was conducted.

Results

Five patients diagnosed as pulmonary tuberculosis or tuberculous pleuritis received systematic anti-tuberculosis treatmensssts. New pulmonary masses were found by CT scans during the follow-ups. The patients were negative for tumor markers, examination of rheumatoid connective tissue disease and G/GM test. The original anti-tuberculosis treatments were continued. All of the masses were diminished gradually.

Conclusion

Paradoxical reaction needs to be taken into consideration when a new pulmonary mass occurs during anti-tuberculosis treatments. The diagnosis should be based on the patients’ clinical manifestations, laboratory results, imaging examinsssations and lung biopsy examinations. The original anti-tuberculosis therapy can be continued in patients without severe clinical symptoms. A close follow-up is needed.

Primary tuberculous psoas abscess as a postpartum complication: Case report and literature review

BACKGROUND

Primary psoas abscess is an unusual clinical entity rarely encountered in the postpartum period. Only seven cases have been reported to date. Here, we present a woman with a primary psoas abscess caused by Mycobacterium tuberculosis and occurred 2 months following a normal vaginal birth. We highlight the difficulties in the management of this uncommon condition in light of the relevant literature.

CASE DESCRIPTION

A 34-year-old woman who was previously healthy was presented at 2 months' postpartum with important right sciatica and low back pain without fever. Examination of the abdomen revealed tenderness in the right iliac fossa but obstetric/gynecologic and neurologic examinations were normal. The patient had an elevated C-reactive protein level and computed tomography (CT)-scan demonstrated a large psoas abscess on the right side without sacroiliac or spine abnormalities. Initial posterior lumbar percutaneous drainage was useful, but no pathogens were identified. The patient was discharged home with oral antibiotics therapy (amoxicillin/clavulanate and metronidazole). Four weeks later, the follow-up CT-scan showed a re-accumulation of the abscess cavity. Subsequently, the patient underwent a right anterolateral laparotomy with a retroperitoneal approach for abscess drainage. Again, no microorganisms were found. However, diagnosis of tuberculosis was established on histopathologic study. She was successfully treated with antituberculous drugs with a good outcome.

CONCLUSIONS

Most primary psoas abscesses present with a delay in diagnosis because of the rarity of this infectious disease, the lack of specific symptoms and signs, and its similarity to many differential diagnoses. When suspected, CT-scan and/or magnetic resonance imaging help in making an accurate diagnosis and facilitate percutaneous or open surgical drainage of the abscess. Correct and fast identification of the microorganisms in addition to appropriate usage of antibiotic regimen improves the outcome.