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Chopra P, Gupta S, Chopra D. Multifocal presentation of cutaneous tuberculosis in a HIV positive patient. J R Coll Physicians Edinb 2024; 54:64-65. [PMID: 38456258 DOI: 10.1177/14782715241238784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024] Open
Affiliation(s)
| | - Sharang Gupta
- Department of Dermatology, Government Medical College, Patiala, PB, India
| | - Dimple Chopra
- Department of Dermatology, Government Medical College, Patiala, PB, India
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COULIBALY F, CISSOKO Y, BOUH AI, GANDAYE DE, SOUMARÉ M, KONATÉ I, DAO S. [Ear tuberculosis concomitant with pulmonary localization in an HIV-immunosuppressed patient, in Bamako, Mali]. Med Trop Sante Int 2023; 3:mtsi.v3i4.2023.415. [PMID: 38390009 PMCID: PMC10879891 DOI: 10.48327/mtsi.v3i4.2023.415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 10/31/2023] [Indexed: 02/24/2024]
Abstract
Introduction/Rationale Tuberculosis remains a major public health issue. It is an opportunistic pathology, very common in HIV-immunocompromised persons, classifying it at the WHO stage 4. Ear tuberculosis remains a rare and under-diagnosed clinical form. We report here a case of ear tuberculosis concomitant with pulmonary localization in an HIV-immunosuppressed person on triple antiretroviral therapy aged 32 years hospitalized in Bamako (Mali) to discuss the diagnostic and therapeutic difficulties posed by this rare localization. Description of the case The patient had a chronic productive cough, otalgia and right chronic purulent otorrhea. The search for acid-resistant bacilli was positive for direct examination in gastric casing fluid and swabbing of the ear pus, confirming the diagnosis of tuberculosis. Anti-tuberculosis treatment instituted for 6 months associated with adjuvants resulted in complete healing of the patient. Discussion/conclusion Although rare, ear localization must be actively sought. Etiological treatment must be instituted upon confirmation of the diagnosis to avoid complications and sequelae.
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Affiliation(s)
- Farimadiané COULIBALY
- Service de Maladies infectieuses et tropicales du Centre hospitalier universitaire du Point G, Bamako, Mali
| | - Yacouba CISSOKO
- Service de Maladies infectieuses et tropicales du Centre hospitalier universitaire du Point G, Bamako, Mali
- Faculté de Médecine et d'odontostomatologie de l'Université des Sciences, des techniques et des technologies, Bamako, Mali
- Centre de recherche et de formation sur la Tuberculose et le VIH (CEREFO), Bamako, Mali
| | - Aden Ibrahim BOUH
- Service de Maladies infectieuses et tropicales du Centre hospitalier universitaire du Point G, Bamako, Mali
| | - Djokdelna Ezéchiel GANDAYE
- Service de Maladies infectieuses et tropicales du Centre hospitalier universitaire du Point G, Bamako, Mali
| | - Mariam SOUMARÉ
- Service de Maladies infectieuses et tropicales du Centre hospitalier universitaire du Point G, Bamako, Mali
| | - Issa KONATÉ
- Service de Maladies infectieuses et tropicales du Centre hospitalier universitaire du Point G, Bamako, Mali
- Faculté de Médecine et d'odontostomatologie de l'Université des Sciences, des techniques et des technologies, Bamako, Mali
- Centre de recherche et de formation sur la Tuberculose et le VIH (CEREFO), Bamako, Mali
| | - Sounkalo DAO
- Service de Maladies infectieuses et tropicales du Centre hospitalier universitaire du Point G, Bamako, Mali
- Faculté de Médecine et d'odontostomatologie de l'Université des Sciences, des techniques et des technologies, Bamako, Mali
- Centre de recherche et de formation sur la Tuberculose et le VIH (CEREFO), Bamako, Mali
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Bézy C, Noirhomme S, Montigny P, Abouhamad P, Jouret F, Georges B. [ Multifocal tuberculosis despite immunocompetence]. Rev Med Liege 2023; 78:165-172. [PMID: 36924155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
Tuberculosis is one of the deadliest infectious disease. Its annual incidence was 10 million cases in 2019. We report the case of a 40 years old immunocompetent patient presenting with two large subcutaneous masses in his back. The diagnosis work-up will reveal multifocal tuberculosis with pulmmonary, vertebral, muscular and lymph node lesions. This case is unusual due to its presentation in an immunocompetent patient. Several laboratories have conducted experiments to isolate characteristics of the host that would allow the infection to spread despite the absence of an immunosuppressive medical condition. We also analyze the role of the PET scanner in the initial assessment and its interest in the monitoring of extra-pulmonary disease under anti-tuberculosis treatment. Multifocal tuberculosis cases are no longer the preserve of the immunocompromised and can be found in our industrialized countries. We must enonciate this diagnosis in front of unusual presentations. The delay in consultation, but also the delay of treatment, allows more widespread infections.
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Affiliation(s)
- Coline Bézy
- Service de Médecine interne générale-Néphrologie, CHRSM, Namur, Belgique
| | - Séverine Noirhomme
- Service de Médecine interne générale-Infectiologie, CHRSM, Namur, Belgique
| | | | | | | | - Benoît Georges
- Service de Médecine interne générale-Néphrologie, CHRSM, Namur, Belgique
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Kpossou AR, Adjadohoun S, Diallo K, Badarou S, Ngamo G, Sokpon CNM, Vignon RK, Takin R, Yekpè P, Sehonou J, Biaou O. [ Multifocal tuberculosis simulating multimetastatic colon cancer in an immunocompetent black African patient: a case report]. Pan Afr Med J 2021; 39:167. [PMID: 34539963 PMCID: PMC8434783 DOI: 10.11604/pamj.2021.39.167.26879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 05/04/2021] [Indexed: 12/04/2022] Open
Abstract
La tuberculose multifocale est rare chez le sujet immunocompétent. Caractérisée par une atteinte d´au moins deux sites extra-pulmonaires, associée ou non à une atteinte pulmonaire, elle est souvent de diagnostic difficile. Nous rapportons un cas de tuberculose multifocale chez un sujet noir africain non immunodéprimé au Centre National Hospitalier et Universitaire Hubert Koutoukou Maga (CNHU-HKM) de Cotonou au Bénin. Il s´agissait d´un jeune homme de 23 ans, sans antécédent particulier, admis pour une douleur abdominale diffuse, associée à une altération de l´état général. L´examen clinique objectivait un état de dénutrition sévère et une ascite de moyenne abondance. L´imagerie à travers les différentes modalités (radiographie du thorax, échographie et tomodensitométrie (TDM)) a objectivé de multiples lésions pulmonaires, hépatiques, pancréatiques, osseuses, ganglionnaires et coliques ayant d´abord fait suspecter un processus tumoral multi-métastatique. Une coloscopie avait ensuite montré une lésion bourgeonnante du caecum, dont les biopsies ont permis de mettre en évidence des Bacilles de Koch par GeneXpert. L´examen anatomo-pathologique des biopsies coliques et le GeneXpert des crachats avaient permis de confirmer la tuberculose multifocale. Mis sous traitement antituberculeux et soutien nutritionnel, l´évolution était marquée par le décès du patient. La tuberculose multifocale demeure une maladie grave, de diagnostic difficile, source d´errance diagnostique en milieu tropical d´autant plus si elle survient sur un terrain immunocompétent.
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Affiliation(s)
- Aboudou Raïmi Kpossou
- Clinique Universitaire d'Imagerie Méficale, Centre National Hospitalier Universitaire Hubert Koutoukou Maga (CNHU-HKM), Cotonou, Bénin
| | - Sonia Adjadohoun
- Clinique Universitaire d'Imagerie Méficale, Centre National Hospitalier Universitaire Hubert Koutoukou Maga (CNHU-HKM), Cotonou, Bénin
| | | | - Salim Badarou
- Clinique Universitaire d'Imagerie Méficale, Centre National Hospitalier Universitaire Hubert Koutoukou Maga (CNHU-HKM), Cotonou, Bénin
| | - Gabriel Ngamo
- Clinique Universitaire d'Imagerie Méficale, Centre National Hospitalier Universitaire Hubert Koutoukou Maga (CNHU-HKM), Cotonou, Bénin
| | - Comlan N'déhougbèa Martin Sokpon
- Clinique Universitaire d'Imagerie Méficale, Centre National Hospitalier Universitaire Hubert Koutoukou Maga (CNHU-HKM), Cotonou, Bénin
| | - Rodolph Koffi Vignon
- Clinique Universitaire d'Imagerie Méficale, Centre National Hospitalier Universitaire Hubert Koutoukou Maga (CNHU-HKM), Cotonou, Bénin
| | - Romulus Takin
- Laboratoire d'Anatomie Pathologique, Centre de Cancérologie de Cotonou, Cotonou, Bénin
| | - Patricia Yekpè
- Clinique Universitaire d'Imagerie Méficale, Centre National Hospitalier Universitaire Hubert Koutoukou Maga (CNHU-HKM), Cotonou, Bénin
| | - Jean Sehonou
- Clinique Universitaire d'Imagerie Méficale, Centre National Hospitalier Universitaire Hubert Koutoukou Maga (CNHU-HKM), Cotonou, Bénin
| | - Olivier Biaou
- Clinique Universitaire d'Imagerie Méficale, Centre National Hospitalier Universitaire Hubert Koutoukou Maga (CNHU-HKM), Cotonou, Bénin
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Wang C, Luan Y, Liu S, Zhao M, Zhang H, Li W, Li Z, Hu X, Peng L. Multifocal tuberculosis simulating a cancer-a case report. BMC Infect Dis 2020; 20:495. [PMID: 32650727 PMCID: PMC7350195 DOI: 10.1186/s12879-020-05209-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 06/29/2020] [Indexed: 11/29/2022] Open
Abstract
Background Tuberculosis is a disease that may affect any organ of the body. Multifocal tuberculosis involving multiple systems with associated symptoms are rare, which makes the diagnosis challenging. Distinguishing multifocal tuberculosis from lesions metastatic from system malignancy is difficult. Single detection method is difficult to make a diagnosis. A combination of multiple methods is essential. Case presentation A 17-year-old male presented with a 20 days weakness of lower limbs, which aggravated for 6 days. The PET/CT showed increased metabolism of ileocecal intestinal and terminal ileum wall, multiple enlarged lymph node (LNs), multiple osteolytic bone lesions, and soft tissue intensity belong T7 and T8 vertebrae. To confirm the diagnosis of the disease, a biopsy of the mediastinum lymph nodes was carried out. Polymerase chain reaction (PCR) test of the specimen was positive for the Mycobacterium tuberculosis, the T-SPOT and Xpert MTB/RIF test were also positive, which suggested the presence of Mycobacterium tuberculosis. The final diagnosis was multifocal tuberculosis, the patients received the resection of the mass in the spine. Anti-tuberculosis drugs were given. The myodynamia and muscle tension of the patients recovered following the therapy. Conclusions Our results indicated that Multifocal tuberculosis should also be taken into consideration when lesions metastatic from system malignancy were suspected from images results even without the clinical symptoms of tuberculosis, and combination of multiple diagnosis methods were essential for the diagnosis of multifocal disease.
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Affiliation(s)
- Congxiao Wang
- Department of the Interventional Medical Center, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Ying Luan
- Jiangsu Key Laboratory of Molecular and Functional Imaging, Department of Radiology, Zhongda Hospital, Medical School of Southeast University, Nanjing, 210009, China
| | - Shifeng Liu
- Department of the Interventional Medical Center, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Mingwei Zhao
- Qingdao Chest Hospital, Qingdao, 266000, Shandong, China
| | - Hao Zhang
- Department of the Interventional Medical Center, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Wei Li
- Department of the Interventional Medical Center, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Zixiang Li
- Department of the Interventional Medical Center, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Xiaokun Hu
- Department of the Interventional Medical Center, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Lijing Peng
- Department of Clinical Laboratory, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China.
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Xu P, Gao QL, Wang YJ, Guo CF, Tang MX, Liu SH, Deng A, Wang YX, Li YB, Zhang HQ. rs6127698 polymorphism in the MC3R gene and susceptibility to multifocal tuberculosis in southern Chinese Han population. Infect Genet Evol 2020; 82:104292. [PMID: 32240798 DOI: 10.1016/j.meegid.2020.104292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 02/15/2020] [Accepted: 03/19/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To investigate the relationship between melanocortin-3 receptor (MC3R) gene polymorphism and tuberculosis (TB) susceptibility in Han population in southern China. METHODS A total of 341 patients with TB (173 with pulmonary TB and 168 with multifocal TB) and 359 healthy controls were enrolled. Genotyping was performed by PCR and DNA sequencing, and detection of protein was performed by western blot. RESULTS The distributions of genotype and allele frequencies of rs6127698 differed significantly between the pulmonary and multifocal TB groups, and between the multifocal TB and control groups. The GG genotype was significantly more common among multifocal TB patients than among pulmonary TB patients (P = .009) and those in the control group (P = .001) under the recessive model. GG+GT genotype was more common in multifocal TB than in pulmonary TB (P < .01) and control group (P < .01) under the dominant model. G allele was more common in multifocal TB than in pulmonary TB (P < .0167) and control group (P < .0167). Patients with multifocal TB had an increased expression of MC3R protein than healthy controls (P < .05). CONCLUSIONS In the southern Chinese Han population, the MC3R rs6127698 polymorphism, which accompanying an increased expression of MC3R protein,was associated with susceptibility to multifocal TB. Presence of the G allele increased the risk of developing multifocal TB.
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Affiliation(s)
- Peng Xu
- Department of Spine Surgery, Xiangya Spinal Surgery Center, Xiangya Hospital, Central South University, Changsha 410008, People's Republic of China
| | - Qi-le Gao
- Department of Spine Surgery, Xiangya Spinal Surgery Center, Xiangya Hospital, Central South University, Changsha 410008, People's Republic of China
| | - Yun-Jia Wang
- Department of Spine Surgery, Xiangya Spinal Surgery Center, Xiangya Hospital, Central South University, Changsha 410008, People's Republic of China.
| | - Chao-Feng Guo
- Department of Spine Surgery, Xiangya Spinal Surgery Center, Xiangya Hospital, Central South University, Changsha 410008, People's Republic of China
| | - Ming-Xing Tang
- Department of Spine Surgery, Xiangya Spinal Surgery Center, Xiangya Hospital, Central South University, Changsha 410008, People's Republic of China
| | - Shao-Hua Liu
- Department of Spine Surgery, Xiangya Spinal Surgery Center, Xiangya Hospital, Central South University, Changsha 410008, People's Republic of China
| | - Ang Deng
- Department of Spine Surgery, Xiangya Spinal Surgery Center, Xiangya Hospital, Central South University, Changsha 410008, People's Republic of China
| | - Yu-Xiang Wang
- Department of Spine Surgery, Xiangya Spinal Surgery Center, Xiangya Hospital, Central South University, Changsha 410008, People's Republic of China
| | - Yan-Bing Li
- Department of Clinical Laboratory, Xiangya Hospital, Central South University, Changsha 410008, People's Republic of China
| | - Hong-Qi Zhang
- Department of Spine Surgery, Xiangya Spinal Surgery Center, Xiangya Hospital, Central South University, Changsha 410008, People's Republic of China
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Desnos L, Kom-Tchameni R, Razafindrakoto H, Fryder I, Janoyer M, Elenga N. Multifocal tuberculosis revealed by spinal tuberculosis in an eleven-year-old Guianese child. ACTA ACUST UNITED AC 2017; 110:234-7. [PMID: 28936787 DOI: 10.1007/s13149-017-0570-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Accepted: 07/09/2017] [Indexed: 10/18/2022]
Abstract
Multifocal tuberculosis in a child is rare event. Here we report a case of multifocal tuberculosis revealed by spinal tuberculosis in an eleven-year-old French Guianese girl. This observation underlines the difficulties, the consequences of delay, and the necessity of an early diagnosis of this disease for children.
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Amraoui N, Krich S, Meziane M, Gallouj S, Abid H, Elmrini A, Moumna K, Harmouch T, Mernissi F. Cutaneous tuberculosis revealing multifocal tuberculosis in immunocompetent patients. Int J Mycobacteriol 2016; 4:255-7. [PMID: 27649875 DOI: 10.1016/j.ijmyco.2015.05.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Revised: 05/08/2015] [Accepted: 05/09/2015] [Indexed: 11/17/2022] Open
Abstract
Multifocal tuberculosis (TB) is rare. It occurs especially in immunocompromised patients. Association with skin involvement is rarer, and few cases are reported in the literature. The present study reports 7 cases of multifocal TB with cutaneous localization in immunocompetent patients. Cutaneous forms of TB included in this series are: gummas, scrofuloderma, vasculitis TB and lupus TB. The patients had at least two extra skin locations, namely: osteoarticular, lung, pleural, scrotal, muscular, digestive, laryngeal, nodal and splenic locations. These patients had no context of immunosuppression which is uncommon, but should be kept in mind, especially in endemic countries.
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Affiliation(s)
- N Amraoui
- Department of Dermatology Venereology, Hassan II University Hospital Fez, Morocco.
| | - S Krich
- Department of Dermatology Venereology, Hassan II University Hospital Fez, Morocco
| | - M Meziane
- Department of Dermatology Venereology, Hassan II University Hospital Fez, Morocco
| | - S Gallouj
- Department of Dermatology Venereology, Hassan II University Hospital Fez, Morocco
| | - H Abid
- Department of Orthopedy and Traumatology B4, Hassan II University Hospital Fez, Morocco
| | - A Elmrini
- Department of Orthopedy and Traumatology B4, Hassan II University Hospital Fez, Morocco
| | - K Moumna
- Department of Pathology, Hassan II University Hospital Fez, Morocco
| | - T Harmouch
- Department of Pathology, Hassan II University Hospital Fez, Morocco
| | - F Mernissi
- Department of Dermatology Venereology, Hassan II University Hospital Fez, Morocco
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Abstract
Multifocal tuberculosis is defined as the presence of lesions affecting at least two extrapulmonary sites, with or without pulmonary involvement. This retrospective study of 10 cases aims to investigate the clinical and evolutionary characteristics of multifocal tuberculosis. It included 41 cases with tuberculosis collected between 1999 and 2013. Ten patients had multifocal tuberculosis (24%): 9 women and 1 man, the average age was 50 years (30-68 years). Our patients were correctly BCG vaccinated. The evaluation of immunodepression was negative in all patients. 7 cases had lymph node tuberculosis, 3 cases digestive tuberculosis, 2 cases pericardial tuberculosis, 2 cases osteoarticular tuberculosis, 1 case brain tuberculosis, 2 cases urinary tuberculosis, 4 cases urogenital tuberculosis, 1 case adrenal tuberculosis, 1 case cutaneous and 1 case muscle tuberculosis. All patients received anti-tuberculosis treatment for a mean duration of 10 months, with good evolution. Multifocal tuberculosis is difficult to diagnose. It can affect immunocompetent patients but often has good prognosis. Anti-tuberculosis therapy must be initiated as soon as possible to avoid sequelae.
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Affiliation(s)
- Amel Rezgui
- Service de Médecine Interne, CHU Sahloul, Sousse, Tunisie
| | | | - Anis Mzabi
- Service de Médecine Interne, CHU Sahloul, Sousse, Tunisie
| | - Monia Karmani
- Service de Médecine Interne, CHU Sahloul, Sousse, Tunisie
| | - Chadia Laouani
- Service de Médecine Interne, CHU Sahloul, Sousse, Tunisie
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10
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Ali Chaudhry L, Al-Solaiman S. Multifocal tuberculosis: Many faces of an old menace. Int J Mycobacteriol 2013; 2:58-69. [PMID: 26785791 DOI: 10.1016/j.ijmyco.2013.01.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 01/04/2013] [Accepted: 01/13/2013] [Indexed: 10/27/2022] Open
Abstract
UNLABELLED Tuberculosis continues to be a major health problem, and is among the leading causes of morbidity and mortality worldwide. Pulmonary tuberculosis is the commonest and epidemiologically the most important type of tuberculosis as the source of spread in the community. Some patients presenting with pulmonary tuberculosis also have associated multifocal extra-pulmonary tuberculosis and vice versa. Among these patients, some have predisposing factors for the development of disseminated tuberculosis, such as a heavy Mycobacterial load, weak or impaired innate or acquired immunity owing to diabetes, immune therapies, substance abuse or AIDS. Multifocal tuberculosis is characterized by the presence of large multifocal tuberculosis areas in the same or different adjacent or distant organs. This study presents a series of 20 patients with multifocal tuberculosis. MATERIALS AND METHODS The patients' records were reviewed to locate those with multifocal tuberculosis as well as pulmonary tuberculosis during the period between 4/2003 and 12/2010. A total of 1,388 patients with confirmed open pulmonary tuberculosis were admitted at the tuberculosis center within the Dammam Medical Complex. Out of this group of patients, 20 cases (1.5%) were found to have multifocal tuberculosis. CONCLUSION Multifocal tuberculosis is observed both in immunocompetent as well as in those with weak or compromised immune systems. A thorough physical examination is required even in those confirmed pulmonary cases of tuberculosis to suspect and find extra-pulmonary involvement, because it is important from the management and prognostic perspective. The ultimate outcome under DOTS (directly observed treatment short course) was good in the majority of these cases, and only a few of them required surgical intervention.
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Affiliation(s)
- Liaqat Ali Chaudhry
- Chief of Tuberculosis Centre, Dept. of Medicine & Chest Diseases, Dammam Medical Complex (MOH), Saudi Arabia.
| | - Shehab Al-Solaiman
- Chief of Infectious Diseases, Dept. of Medicine, Dammam Medical Complex (MOH), Saudi Arabia
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