Undiagnosed tuberculosis associated with hemophagocytic lymphohistiocytosis due to improper use of corticosteroid

INTRODUCTION

Hemophagocytic lymphohistiocytosis (HLH) is a rare and life-threatening hematologic disease segregated into familial (primary) and acquired (secondary) subtypes. Hyperinflammation and HLH occur when the immune system fails to clear activated macrophages and histiocytes. Infections, malignancies, and rheumatologic disorders are the major triggers leading to HLH. Miliary tuberculosis is a serious disease with a lymphohematogenous spread of Mycobacterium tuberculosis, which is known to be one of the causative agents of HLH. Miliary tuberculosis and HLH have atypical presentations which are similar to routine diseases. Hence, physicians may face challenges to diagnose and treat these complications.

CASE REPORT

We report the case of a 60-year-old man with a history of prolonged fever, shortness of breath, jaundice, altered mental status, undiagnosed lower back pain, and overuse of parenteral betamethasone. Miliary tuberculosis was diagnosed by diffuse, vague random micronodules in both lungs and positive acid-fast bacilli in bronchoalveolar lavage and bone marrow aspiration and biopsy. Moreover, compatible presentation and pancytopenia, hypertriglyceridemia, high serum level of ferritin and fibrinogen-derived products, and evidence of hemophagocytosis on bone marrow aspirate led to the diagnosis of HLH. Unfortunately, despite nearly two months of an anti-tuberculosis regimen (standard and salvage) and eight doses of etoposide, he eventually passed away after clinical improvement.

CONCLUSIONS

Irrational and indiscriminate use of glucocorticoids can be a devastating cause of the spread of tuberculosis and its rare complications, such as HLH.

A study of analysis on prevalence, serological marker and prognosis of tuberculosis in tertiary care hospital

BACKGROUND

Tuberculosis is an infectious disease responsible for a significant cause of ill health. According to the WHO global tuberculosis report 2021. 9.9 million cases fell sick with TB in 2020. Significantly, the prevalence of tuberculosis in India is 25%.

OBJECTIVE

To analyze the prevalence of tuberculosis in the suburban areas of the metropolitan city in South India. To analyze the serological marker and prognosis of tuberculosis among males and females. To determine the importance of molecular testing - PCR confirmation on TB after AFB smear.

METHODS

A retrospective study to analyze 462 patients enrolled by the respiratory medicine department on suspecting pulmonary- 356 (M-264 & F-92) and extra-pulmonary-106 (M-73&F-33) patients and diagnosed Zhiel-Neelsen staining, Mantoux test, Chip-based RT-PCR test, Erythrocyte sedimentation rate, and analyzed serological test such as C-Reactive Protein, Chemiluminescence immune assay.

RESULTS

23 patients were positive in Ziehl-Neelsen staining, 65 were positive in molecular True-Nat PCR test, Mantoux skin test induration in 10 patients, 98 TB Positive patients examined in the serological analysis, 1 & 3 patients reacted in HIV/HBsAg, and HBsAg test respectively, by chemiluminescence immunoassay, 8 PTB and 4 EPTB and 47 non-TB patients were positive in C-reactive protein, 46 TB and 94 non-TB patients detected abnormal values out of these 160 patients in ESR test.

CONCLUSION

The Prevalence of tuberculosis is significantly rising, especially in the middle-aged population. The rapid molecular diagnostics to detect TB are highly sensitive and specific. Serological markers are essential for the analysis of disease prognosis and need to focus on the guidance of DOTS and RNTCP to End TB.

Arteriovenous thrombosis in a patient with miliary tuberculosis complicated by a left ventricular mass and its treatment

INTRODUCTION

Tuberculosis (TB) is considered one of the two greater long-term global public health threats than the coronavirus disease 2019 (COVID-19) pandemic. Although venous thromboembolism has a low prevalence of 3.5% among patients with active TB, miliary TB complicated by arteriovenous thrombosis is a rare and potentially life-threatening condition.

CASE STUDY

We present here an unusual case of a 32-year-old man with a two-month history of shortness of breath and painful swelling in the right lower extremity. In addition, elevated plasma levels of platelets, white blood cells, neutrophils, and D-dimer were observed upon his admission to the hospital. The patient was diagnosed with miliary TB complicated by arteriovenous thrombosis in the right lower extremity and a left ventricular mass measuring 3.5 × 1.7 cm. He was successfully treated with anti-TB drugs and low molecular weight heparin followed by warfarin, aspirin and clopidogrel.

CONCLUSIONS

This case study demonstrates that a patient with miliary TB complicated by arteriovenous thrombosis and a left ventricular mass can be cured with timely diagnosis and appropriate treatment. The implications of this report are to raise awareness about miliary TB and arteriovenous thrombosis, to improve diagnosis and treatment, and to reduce patient mortality through sharing our successful experience with clinicians and healthcare providers in the developing countries of the world.

The role of early blood purification for miliary tuberculosis presenting as acute respiratory distress syndrome in pregnancy: A case report

RATIONALE

Acute respiratory distress syndrome (ARDS) in miliary tuberculosis (TB) remains rare, especially in pregnant women. The role of blood purification is potential in managing ARDS due to miliary TB.

PATIENT CONCERNS

A 36-year-old woman presenting with difficulty breathing 6 hours before admission. She never had any constitutional symptoms due to TB.

DIAGNOSES

ARDS in TB was diagnosed based on the deterioration of PaO2/FiO2, increased acute phase reactants, positive gene-Xpert, and typical chest x-ray of miliary TB.

INTERVENTIONS

A C-section was performed and followed by continuous venovenous hemofiltration to tackle her inflammatory condition. antituberculosis drugs were given after the transaminases showed declining trends.

OUTCOMES

No major complications associated with continuous venovenous hemofiltration occurred. After 14 days of hospitalization, the patient's clinical condition improved and was finally discharged.

LESSONS

This case underscores the potential role of blood purification in ARDS due to miliary TB in pregnancy.

A rare case of miliary tuberculosis in a patient with NSCLC receiving PD1 inhibitor therapy, mimicking autoimmune pneumonitis

ABSTRACT

Immune checkpoint inhibitors (ICIs) are widely used for the treatment of various types of cancer. One of the possible immune-related adverse effects of ICI is pneumonitis, which is a life-threatening condition that can present as a variety of radiographic patterns, so it can be difficult to differentiate from infectious cases of pneumonia based on radiological findings alone. We present a rare case of miliary tuberculosis (M. tuberculosis) in a patient receiving programmed death-1 (PD-1) inhibitor therapy mimicking autoimmune pneumonitis and possible pathophysiological mechanisms of this unexpected event. We presented a 52-year-old patient with stage IV non-small-cell lung carcinoma (NSCLC) who was admitted to the hospital with radiological and clinical signs of pneumonitis caused by immunotherapy-Pembrolizumab. During hospitalization, she was clinically, laboratory, and microbiologically processed and her diagnosis of M. tuberculosis was confirmed. Initial treatment started with corticosteroids as a pneumonitis treatment, and because there was no adequate response, and the diagnosis of tuberculosis was confirmed, treatment with a four-regimen antituberculotic drug started. On a control, CT scan regression in distribution and number of changes in lungs occurred. After a while, patient died due to hepatic failure. There are not many reported cases of pulmonary tuberculosis in patients receiving immunotherapy; to our knowledge, no cases of M. tuberculosis in a patient with lung cancer were described. Since there is a different approach to the treatment of tuberculosis and pneumonitis, we presented our dilemmas and literature review in this article. A multidisciplinary approach (oncologist, radiologist, microbiologist, etc.) is essential in a case like this.

Clinical analysis of pregnancy complicated with miliary tuberculosis

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Rapidly Evolving and Fatal Miliary Tuberculosis and COVID-19 Infection in an Infant

Tuberculosis (TB) and SARS-CoV-2 (COVID-19) are two important infectious diseases causing morbidity and mortality worldwide. Active TB infection can stimulate host immune responses and together with COVID-19, may lead to cytokine storm and immune dysregulation leading to multi-organ failure. We present a rare case of both miliary tuberculosis and SARS-CoV-2 co-infection in an infant who was a 6-month-old previously healthy term boy. He had persistent cough and congestion, became severely ill, and was brought to the emergency department. He was found to be COVID-19 positive by PCR test. Laboratory studies showed pancytopenia, elevated inflammatory markers, and an abnormal coagulation profile with coagulopathy. He developed strokes, severe sepsis, and electrolyte abnormalities, and declined rapidly within 6 days. Autopsy examination showed multifocal micro-abscesses in multiple organs, which on microscopic examination showed necrotic foci teeming with Mycobacteria and were culture positive for M. tuberculosis Neuropathological examination showed infarction in the right middle and posterior cerebral artery territories. This patient helps illuminate some immunological and pathological aspects of two co-occurring infectious diseases and the susceptibility for the development of fatal complications with SARS-CoV-2 infection in the pediatric population.

Ruxolitinib and tuberculosis: A case report with brief review

JAK 2 inhibitors are widely used for the treatment of primary myelofibrosis. Ruxolitinib is the most commonly used JAK inhibitor in clinical practice. We report two cases of Primary Myelofibrosis who developed tuberculosis on active treatment with ruxolitinib. Our first case was a 48 year male who developed disseminated tuberculosis during fourth month of treatment and second case was a 50 year male developing tubercular lymphadenitis during second month of treatment respectively. These case reports indicate reactivation of underling tubercular infection as a very dreaded complication of this treatment. The prevalence of tuberculosis is much higher in India compared to the west. A thorough pretreatment evaluation should ideally be done using Mantoux test or interferon gamma release assay (IGRA) to rule out latent tuberculosis. Furthermore, the patients should be counselled regarding the possibility of reactivation of infections including tuberculosis. Also, proper follow up is the need of hour in all patients on any kind of immunomodulators.

Disseminated tuberculosis associated with autoimmune haemolytic anaemia and adrenal deficiency: a rare association

Tuberculosis (TB) is one of the greatest masqueraders in medical practice and can have manifestations involving any organ or organ systems of the body. The presentation of disseminated TB can range from typical features like fever, weight loss and fatigue to protean manifestations. We share the case of an elderly man who presented to us with weight loss, anaemia, weakness and lymphadenopathy involving thoracic and intraabdominal locations. Work up of anaemia revealed features of Coombs-positive autoimmune haemolytic anaemia (AIHA) and evaluation of weakness showed laboratory results consistent with adrenal insufficiency. Biopsy of the abdominal lymphnode yielded caseating granulomas with CB-NAAT positivity for Mycobacterium tuberculosis Anti-TB chemotherapy with short-term replacement dose of systemic steroids corrected the haemolysis, anaemia and addisonian crisis. The case alerts clinicians regarding the uncommon association of TB with Coombs positive AIHA and adds one more aetiology to the pathogenesis of anaemia in TB. Furthermore, the occurrence of AIHA and hypoadrenalism in the same patient with TB is exceedingly rare and has not been reported.

Haemophagocytic lymphohistiocytosis in a patient with familial Mediterranean fever and miliary tuberculosis: a case report

Haemophagocytic lymphohistiocytosis (HLH) is a lethal complication of several infections, especially viral origin. Mycobacterium tuberculosis infection can also lead to HLH, yet it is an uncommon trigger. Considering the role of increased cytokines in HLH, autoinflammatory conditions, such as familial Mediterranean fever (FMF), might contribute to its development. Nevertheless, the possible relationship between FMF and HLH has been suggested only in some case reports. We present a case of FMF who admitted to the hospital with consitutional symptoms and chest pain regarding to recurrent pericarditis. On a blood test, pancytopenia and elevated acute phase reactants were seen. Fluorine-18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography demonstrated positive FDG uptake sites on both the right and left surrenal glands, the visceral layer of pericard, and reactive lymphadenomegalies at multiple mediastinal regions. Bone marrow biopsy revealed haemophagocytosis. Methylprednisolone treatment was initiated. Despite immunosuppressive treatment, clinical and biochemical parameters deteriorated; thus, a thorax computed tomography was executed. Findings were consistent with miliary tuberculosis infection. M. tuberculosis was detected in blood culture and bronchoalveolar lavage culture material. Also, bone marrow and surrenal biopsy material revealed necrotising caseating granuloma.

Esophageal tuberculosis as an unusual cause of dysphagia: a case report

Esophageal tuberculosis is a rare cause of infectious esophagitis, even in countries with endemic tuberculosis. This impairment is often secondary. We report a case of secondary esophageal tuberculosis in an immunocompetent patient, clinically revealed by dysphagia. Esophagogastroduodenoscopy showed a large ulcer in the middle third of the esophagus with a fistula opening in the center of the ulcer. Histopathological examination of multiple esophageal tissue biopsies revealed epithelioid cell granulomas without caseous necrosis. We completed with Computed Tomography (CT) scan of the chest which revealed a fistula of the middle third of the esophagus, multiple mediastinal necrotic adenopathies and diffuse pulmonary micronodules suggesting miliary tuberculosis. Sputum examination for acid-fast-bacilli was positive. Anti-tuberculosis treatment resulted in a good response with complete remission. It is therefore important to recognize and include this entity in the differential diagnosis of patients with dysphagia particularly in countries with a high incidence of tuberculosis.

Peripheral Gangrene Associated with Disseminated Tuberculosis - a Rare Manifestation

With global resurgence of M. tuberculosis infection, cases of extra pulmonary TB have also shown an increase. Tuberculosis is a major cause of morbidity and mortality in India. Although disseminated tuberculosis can affect most of the organs, vasculitis presenting as peripheral gangrene as a manifestation of tuberculosis is very rare. We report the case of a 70 years old male who presented with gangrene of left leg complicating disseminated tuberculosis.

Haematological profiles after Intensive phase of Anti Koch Treatment with special emphasis on bone marrow changes

BACKGROUND

Tuberculosis remains a major public health problem in various parts of the world. It leads to various haematological changes. Study of these haematological changes will help better patient management.

OBJECTIVE & METHODS

It is to evaluate haematological changes in tuberculosis patients and compare the result with special emphasis to bone marrow changes as active case search is sharply decreasing the miliary tuberculosis. It is also to evaluate the patients with before and after the Intensive Phase of Anti Koch Treatment. Sputum positive and sputum negative tuberculosis patients confirmed by other ancillary techniques were included into this study. It is conducted at a tertiary level hospital in rural area.

RESULT

In this study bone marrow hypercellularity was of erythroid series with only 1.92% patients showed granuloma in bone marrow aspiration. In addition to bone marrow changes, significant changes were evident in haemoglobin level, Erythrocyte Sedimentation Rate (ESR) Total White Blood Cell count and RBC count.

DISCUSSION

In majority cases this study showed Erythroid Hyperplasia. It is sharp contrast with other study where myeloid hyperplasia was evident. This study also differs from other study where high number of bone marrow granuloma was reported. In this study only 1.92% cases showed bone marrow granuloma. This study also documented higher number of anaemic cases mostly because of the institute serves poor and tribal population.

CONCLUSION

In our study the cases showing granuloma and hyperplasia of myeloid series were limited. With introduction of Directly Observed Treatment and house to house active case search helped to sharply decrease bone marrow granuloma by limiting multi-organ spread. This study showed, ESR level may be considered as prognostic parameters of tuberculosis.

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

RATIONALE

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

PATIENT CONCERNS

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

DIAGNOSIS

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

INTERVENTIONS

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

OUTCOMES

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

LESSONS

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

Discrete cutaneous lesions in a critically ill patient treated only for AIDS and miliary tuberculosis: a case report of disseminated histoplasmosis

Histoplasmosis is a systemic mycosis caused by the dimorphic fungus Histoplasma capsulatum, with disseminated histoplasmosis (HD) being one of its clinical forms. As a consequence of the HIV-AIDS pandemic, HD has become prevalent not only in regions that are recognized as endemic but also in areas not considered endemic, such as Europe and Asia. Its clinical manifestations are varied and mimic several infectious diseases, mainly tuberculosis. In endemic areas, it is the first manifestation of AIDS in 50 to 70% of patients. The diagnosis of histoplasmosis is difficult and HD can lead to death if not diagnosed early and if proper treatment is not instituted. The present report presents a patient with a recent diagnosis of HIV-AIDS, in treatment for miliary tuberculosis, who was diagnosed with disseminated histoplasmosis because of his dermatological manifestations.

Kaposi-like manifestations in a newly diagnosed AIDS transgendered patient with silicone embolism syndrome and disseminated tuberculosis

The use of liquid silicone for cosmetic procedures can yield serious sequelae including embolization and pneumonia. We describe a recent case of silicone embolism syndrome occurring together with systemic tuberculosis in a transgendered patient newly diagnosed with AIDS. She presented with fever, hematochezia, lymphadenopathies, purple nodular lesions and lower limb edema. HIV test was positive. A chest X-Ray showed interstitial infiltrates and a tomography showed necrotic lymph nodes and pulmonary nodules with blurred borders, suggesting Kaposi sarcoma. Psychomotor impairment then occurred in the absence of tomographic signs of acute neurological events. The Mycobacterium tuberculosis genome was isolated from stool and bronchial washing samples. Histological examination of a necrotic lymph node showed lymphoadenopathy due to silicone accumulation. Moreover, the patient presented fever and swelling of lower limbs; a tomography showed multiple foreign body granulomas. After starting antitubercular, antiretroviral and antibiotic treatment she reported symptomatic improvement including a mild recovery of motor-slowing. There are few reports about silicone-induced pulmonary disease in HIV-1 infected patients and, as far as we know, none of them describes an overlapping pulmonary involvement due to Mycobacterium tuberculosis infection. Even if extensive clinical and radiologic evidence is suggestive of Kaposi sarcoma (fever, severe immunodeficiency, multiple cutaneous nodules, hematochezia, diffuse lymphoadenopathies), it is possible to see Kaposi-like manifestations in patients with systemic silicone embolization. With this article we wish to stress the attention on the possible overlap of more than one concurrent disease in an immunocompromised host.

Jejunal multiple perforations for combined abdominal typhoid fever and miliary peritoneal tuberculosis

Typhoid fever and tuberculosis, considered rare diseases in western countries, is still considered a notable problem of health issue in developing countries. The gastrointestinal manifestations of typhoid fever are the most common and the typhoid intestinal perforation (TIP) is considered the most dangerous complication. Abdominal localization of tuberculosis is the 6^th most frequent site for extra pulmonary involvement, it can involve any part of the digestive system, including peritoneum, causing miliary peritoneal tuberculosis (MPT). This is the case report of a 4 years old girl with multiple jejunal perforations in a setting of contemporary miliary peritoneal tuberculosis and typhoid fever occurred in "Hopital Saint Jean de Dieu" in Tanguietà, north of Benin. The patient was admitted in the emergency department with an acute abdomen and suspect of intestinal perforation, in very bad clinical conditions, underwent emergency laparotomy. The finding was a multiple perforations of the jejunum in a setting of combined abdominal typhoid fever and miliary peritoneal tuberculosis. Typhoid intestinal perforations and peritoneal tuberculosis are a very rare cause of non-traumatic peritonitis in western country, but still common in developing country. Considering the modern migratory flux and the diffusion of volunteer missions all around the world, the western surgeon should know this pathological entities, and the best treatments available, well known by surgeons with experience of working in developing countries. The combination of both TIP and MPT in the same patient, is a very rare finding which can worsen the outcome of the patient itself.

Central nervous system tuberculosis following delayed and initially missed lung miliary tuberculosis: a case report

Central nervous system (CNS) tuberculosis includes three clinical entities: tuberculous meningitis, intracranial tuberculoma, and spinal tuberculous arachnoiditis. All three categories are encountered frequently in regions of the world where the incidence of TB is high. Meningeal tuberculosis is a medical emergency: it is the most severe, lethal and disabling form of tuberculosis. Early diagnosis and treatment can be lifesaving. Even, in developed countries the diagnosis of tuberculous meningitis is difficult, frequently delayed or missed, and is often not microbiologically confirmed. Here I report a case of miliary tuberculosis, in a patient with diabetes mellitus and chronic kidney disease, but without HIV infection. Although the patient had regular contact with healthcare staff (hemodialysis), miliary tuberculosis diagnosis was considerably delayed. This patient, subsequently evolved into tuberculous meningitis. In spite of quadruple anti-tuberculosis treatment, corticosteroids, and general supportive care, this case resulted in death.

[Disseminated tuberculosis in a patient with overlap syndrome, challenges in preventing]

Patients with autoimmune rheumatic diseases are at increased risk for developing infections and these are associated with increased morbidity and mortality from these diseases, especially in patients with systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis and autoimmune inflammatory myopathies. The objective of this paper is to address the challenges in detecting latent tuberculosis in immunosuppressed patients and the initiation of prophylactic treatment because currently there are no well-defined guidelines indicating what action to take for detection and treatment; so far the available scientific evidence is scarce and some methodological shortcomings.

Miliary tuberculosis: the role of necropsy studies

This case study of generalized miliary tuberculosis in a Brazilian man without AIDS is reported in order to emphasize the role of histopathological study for diagnosis. We comment on a recent Indian study involving 40 cases of surgical and necropsy specimens in which the diagnosis of tuberculosis was made, as well as a previous Brazilian case report. The authors believe that non-specialists should be better informed about the possibility of miliary tuberculosis, which involves clinical diagnostic challenges. Despite limitations, minimally invasive necropsy may be an alternative to elucidate causes of death in low-income countries.

A scoring system to effectively evaluate central nervous system tuberculosis in patients with military tuberculosis

There is currently no convenient way to effectively evaluate whether a miliary tuberculosis patient is complicated with central nervous system (CNS) tuberculosis. We aimed to find such a way by analyzing the clinical data of these patients. Fifty patients with confirmed miliary tuberculosis and 31 patients with confirmed miliary tuberculosis complicated with CNS tuberculosis from 2010 to 2014 were selected. Their general conditions, clinical features and laboratory tests were analyzed. Factors that were significantly different between them were chosen to performed multivariate and univariate logistic regression analyses, and factors with significant P values were used to establish a scoring system. Eight factors, i.e., age, cough, nausea, headache, hemoglobin (HGB), serum albumin (ALB), C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), were significantly different (P < 0.05). Multivariate logistic regression analysis showed that ALB was the independent risk predictor (HR = 1.29, 95% CI 1.09–1.52, P < 0.01), whereas the others were non-independent predictors except age (P < 0.05). The scoring system was based on a summation of the scores of the assigned values of the seven predictors and had an area under the curve (AUC) of 0.86 to confirm CNS tuberculosis, with a sensitivity of 81.5% and a specificity of 81.4% at a score of 0.75 and with a specificity of 95.3% at a score of 2.75. In contrast, a score below -0.75 excluded CNS tuberculosis, with a sensitivity of 88.9% and a specificity of 62.7%. The scoring system should be useful to evaluate whether a miliary tuberculosis patient is complicated with CNS tuberculosis and could help doctors avoid excessive investigation.

Miliary Tuberculosis in a Young Woman with Hemophagocytic Syndrome: A Case Report and Literature Review

We herein report a rare case of miliary tuberculosis-associated hemophagocytic syndrome (HPS) complicated with respiratory failure. A 19-year-old Japanese woman with a fever, general malaise, and chest radiograph abnormalities was referred to our hospital. After admission, she developed respiratory failure with pancytopenia. A histological examination of lung and bone marrow biopsy samples revealed noncaseating granulomas without evidence of acid-fast bacilli or lymphoma. In addition, a bone marrow biopsy showed marked histiocyte hyperplasia with hemophagocytosis, and a bronchoalveolar lavage fluid culture grew Mycobacterium tuberculosis. Therefore, a diagnosis of miliary tuberculosis-associated HPS was made. The patient was successfully treated with antituberculous therapy.

Fulminant Miliary Tuberculosis With Adult Respiratory Distress Syndrome Undiagnosed Until Autopsy: A Report of 2 Cases and Review of the Literature

Despite an overall decline in the incidence of tuberculosis (TB), the percentage of cases representing miliary TB has remained stable. We report 2 cases of fatal miliary TB that remained unrecognized until autopsy, occurring within a 6-month period at 1 Detroit institution. These cases represent the wide range of presentation of miliary TB, from an acute fulminant course to a cryptic prolonged course with subtle clinical findings. Both cases shared a common end point with the development of adult respiratory distress syndrome.

The successful treatment of refractory respiratory failure due to miliary tuberculosis: survival after prolonged extracorporeal membrane oxygenation support

Acute respiratory distress syndrome (ARDS) has high morbidity and mortality. Although uncommon, pulmonary tuberculosis (TB) can cause ARDS in patients with extensive pulmonary parenchymal involvement. Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is an accepted alternative option in refractory hypoxemic respiratory failure. It may normalize gas exchange and allow lung rest, avoiding ventilator induced lung injury. We report the case of a 44-year-old woman who developed ARDS secondary to pulmonary TB. Despite anti-TB treatment and mechanical ventilation, patient had persistent refractory hypoxemia. In order to prevent further lung injury, VV-ECMO support was performed for 73 days. Although the patient experienced several complications, patient was successfully managed on VV-ECMO. VV-ECMO support, in combination with anti-TB drugs, is a useful tool in the treatment of ARDS with refractory hypoxemia caused by miliary TB.

Tuberculous Fasciitis in Polymyositis: A Rare Case of Extrapulmonary Tuberculosis

A 71-year-old woman with polymyositis presenting with left thigh pain and an intermittent fever was admitted to Osaka Rosai Hospital. We initially diagnosed that her pain and fever were caused by a soft tissue infection because her polymyositis was controlled. She did not respond to various antibiotic therapies. Chest computed tomography demonstrated miliary tuberculosis (TB). Ziehl-Neelsen staining of liver biopsy specimens revealed epithelioid cell granuloma and acid-fast bacilli. Therefore, we finally diagnosed the lesion as TB fasciitis that improved with anti-TB drug therapy. The atypical presentation of TB fasciitis demonstrates the clinical importance of eliminating TB infections in immunocompromised hosts.

[A CASE OF MILIARY TUBERCULOSIS ASSOCIATED WITH HEPATOSPLENIC ABSCESSES APPEARING DURING ANTI-TUBERCULOUS TREATMENT]

A 27-year-old man with a 4-month history of treatment for miliary tuberculosis at another hospital was admitted to our hospital for continued treatment. Computed tomography showed new lesions in the S8 area of the liver and spleen, despite resolution of chest radiographic findings. Because these new lesions were still present after 8 months of treatment, we performed laparoscopic drainage of the liver abscess. Purulent material drained from the lesion revealed positive polymerase chain reaction results for Mycobacterium tuberculosis, and identification of granuloma with infiltrating lymphocytes and plasma cells confirmed the diagnosis of tubercular liver abscess. Pathological changes in the spleen over the clinical course were also regarded as representing tubercular abscess. Postoperative course was good, and tuberculosis treatment ended after 12 months. Tubercular liver abscess subsequently showed prominent reduction, and the tubercular splenic abscess disappeared on abdominal ultrasonography. Tubercular hepatosplenic abscesses appearing during tubercular treatment are rare. We report this valuable case in which laparoscopic drainage of a liver abscess proved useful for diagnosis and treatment.

Delayed diagnosis of cholestatic drug-induced liver injury treated with corticosteroid for adrenal insufficiency secondary to miliary tuberculosis

Drug-induced liver injury (DILI) in a patient with multiple comorbidities is often challenging to diagnose because liver injury can be attributed to multiple disease processes. Delayed treatment of DILI could have fatal consequences and, therefore, understanding the features and risks of DILI is crucial. We report a unique case of a patient who was admitted for severe sepsis of unknown etiology. This patient was later found to have miliary tuberculosis (TB) with associated adrenal insufficiency, complicated by acute cholestatic liver injury. Liver injury fully improved after initiation of corticosteroid for the treatment of adrenal insufficiency. The most likely pathophysiology of acute liver injury was DILI, given the clinical course of liver injury and the liver biopsy result of non-caseating granulomas. Although five different antibiotics including ciprofloxacin, metronidazole, vancomycin, imipenem/cilastatin, and cefepime were provided, the timing of liver injury and pharmacology of each drug imply that ciprofloxacin was the most likely antibiotic causing DILI, given the pharmacology of each antibiotics. This case is unique because miliary TB was complicated by adrenal insufficiency and drug-induced cholestatic liver injury, but acute liver injury was fully reversed after corticosteroid treatment. This implies an immune-mediated etiology of DILI, especially ciprofloxacin-induced cholestatic liver injury. DILI is challenging to diagnose in the setting of multiple comorbidities. Therefore, it is crucial that clinicians are to be aware of signs and symptoms of DILI, in that delayed diagnose and treatment may have fatal consequences.

[A TUBERCULOUS PSEUDO-ANEURYSM OF THE ABDOMINAL AORTA COMPLICATED BY MILIARY TUBERCULOSIS]

A 66-year-old man was transferred to our hospital on November 2010 owing to a diagnosis of miliary tuberculosis. Treatment was initially started with INH, RFP, PZA, and EB. However, PZA and EB were discontinued because of their adverse effects. Subsequently, chest radiographic and laboratory findings gradually improved. However, the patient experienced lumbago, which exacerbated towards the end of March 2011. An abdominal CT scan showed an abdominal mass at the L3-L5 level between the abdominal aorta and lumbar vertebra. On the basis of the findings of abdominal ultrasonography, MRI, and PET-CT, infectious abdominal aortic aneurysm was highly suspected. Therefore, vascular graft replacement surgery was performed at the beginning of May 2011. The result of histopathological analysis showed the presence of acid-fast bacteria in the aneurysm and the lymph nodes around it, revealing that the aneurysm was due to systemic miliary tuberculosis. After the surgery, the patient was administered LVFX in addition to INH and RFP for 18 months and showed no recurrence.

[Immune reconstitution inflammatory syndrome related with infliximab interruption in patient with Crohn's disease and active tuberculosis]

Tumor necrosis factor alpha inhibitors are associated with an increased risk of active tuberculosis. However, its interruption in this setting may trigger a paradoxical response to tuberculosis treatment, as an immune reconstitution inflammatory syndrome. We present the case of a 36-year-old patient, with Crohn's disease, treated with infliximab for the last 8 years, who was admitted with miliary tuberculosis. A pan-susceptible Mycobacterium tuberculosis strain was isolated. Infliximab was interrupted and standard antituberculous therapy was started, as well as systemic corticotherapy, without any clinical or radiological improvement. After exclusion of other opportunistic infections and primary or acquired immunodeficiency, we considered the possibility of an immune reconstitution inflammatory syndrome triggered by infliximab interruption. Thus, infliximab was reintroduced after 2 months of antituberculous therapy and clinical and radiological improvement was observed.

A cannonball through the chest: disseminated tuberculosis, threatening the aortic arch

BACKGROUND

In 2012 the World Health Organization reported 8.7 million new cases of Tuberculosis worldwide, causing 1.4 million deaths (1). Despite modern drug therapy, this disease continues to present in novel ways and mimic other diseases causing misdiagnosis.

AIM

We report this case to educate on the reason to suspect atypical Tuberculosis presentation, even if a common disease is diagnosed, when Tuberculosis remains in the differential. We also demonstrate that with globalization and patient moving between countries, that these presentations can occur in locations, where such atypical manifestations are very uncommon.

CASE

We report on a 48 year old man with one month of malaise, fever, productive cough, night sweats, chills, pleuritic chest pain, weight loss and progressive non-painful swelling on his thorax. Initial diagnoses of interstitial pneumonia and a thoracic subcutaneous abscess were made. Needle drainage was attempted, with thick purulent material returned. When the sternum was not struck with the needle, a thoracic computed tomography scan was performed. A milliary pattern was noted in the lungs, with a large abscess present anteriorly, completely obliterating the manubrium, approaching the aorta with distant lesions. Subsequent analysis showed the material to be pan-sensitive M. Tuberculosis.

CONCLUSION

The issue that this case raises is that when tuberculosi is in the differential, even common diseases may in fact be atypical manifestations of tuberculosis. In addition, when a shallow surgical procedure is going to be performed on the thoracic soft tissues, particularly when tuberculosis is suspected, imaging of the thorax should be obtained.

Fatal disseminated cryptococcosis resembling miliary tuberculosis in a patient with HIV infection

A 51-year-old man was transferred to our hospital due to acute respiratory failure that had progressed over four days. A chest X-ray and thoracic computed tomography scan showed multiple faint micronodules randomly distributed throughout both lungs with ground glass opacity, suggesting miliary tuberculosis or Pneumocystis jirovecii pneumonia with acute respiratory distress syndrome. Six hours after admission, the patient died of septic shock. Later, the cryptococcal antigen titer was found to be markedly elevated (1/65,536), with a positive result for anti-human immunodeficiency virus and a low CD4 cell count (12/μL). The present case is reminder that disseminated cryptococcosis with HIV infection can be misdiagnosed as miliary tuberculosis based on radiological findings.

[Job's syndrome and miliary tuberculosis]

The hyper Immunoglobulin E syndrome, also known as Job's syndrome, is a rare primary immunodeficiency, its mechanisms of inheritance maybe recessive or dominant autosomal. It is characterized by high levels of IgE, eosinophilia, skin abscesses, eczema, chronic mucocutaneous candidiasis and recurrent pulmonary infections all of which contribute to the development of pneumatoceles and bronchiectasis. The most frequently isolated bacteria is Staphylococcus aureus. Currently, despite the highest survival of patients, lymphomas and other opportunistic infections have been reported. There are few reports of patients with Mycobacterium tuberculosis infection associated with hyper IgE syndrome. Therefore it is relevant that we report a case history of a patient with pulmonary tuberculosis, presenting miliary tuberculosis and severe respiratory compromise, who responded positively to standard anti-tuberculous treatment with first line drugs.

[A case of miliary tuberculosis complicated by a tuberculous aneurysm of the thoracic aorta]

An 85-year-old woman was admitted to our hospital with the chief complaint of fever. Antibiotics were not effective and a chest computed tomography scan revealed a diffuse micronodular shadow and thoracic aortic aneurysm. Subsequently, a bronchoscopy sputum culture was positive for Mycobacterium tuberculosis. Two months after the initiation of chemotherapy, the thoracic aortic aneurysm enlarged despite the improvement in lung findings. Tuberculous aneurysms are quite rare, but can be critical and acute. Therefore, caution should be exercised when treating such patients.

Tuberculous meningitis--a case report

In this paper we present a case of a 58 years old male with a rare form of extrapulmonary tuberculosis--tuberculous meningitis (TBM). Tuberculous meningitis is usually caused by hematogenous spread of Mycobacterium from lungs. The TBM is a severe disease with high mortality. The symptoms usually increase gradually and in the course of the disease 3 clinical stages (prodromal phase, phase of neurological symptoms and phase of paresis) may be differentiated. Cerebrospinal fluid examination, chest x-ray and sputum culture are crucial for diagnosis of TBM. The proper diagnosis and early causative treatment significantly improve the outcome of the disease.

[Pneumocystis pneumonia and generalized tuberculosis in HIV-infected patients]

The paper describes a clinical case of pneumocystis pneumonia in the presence of generalized tuberculosis in a female patient with HIV infection. The lack of prevention of pneumocystosis and its late diagnosis and treatment resulted in a fatal outcome. The problem of early clinical diagnosis in the concurrent course of secondary involvements is discussed.

Challenges in the diagnosis & treatment of miliary tuberculosis

Miliary tuberculosis (TB) is a potentially lethal disease if not diagnosed and treated early. Diagnosing miliary TB can be a challenge that can perplex even the most experienced clinicians. Clinical manifestations are nonspecific, typical chest radiograph findings may not be evident till late in the disease, high resolution computed tomography (HRCT) shows randomly distributed miliary nodules and is relatively more sensitive. Ultrasonography, CT and magnetic resonance imaging (MRI) are useful in discerning the extent of organ involvement by lesions of miliary TB in extra-pulmonary locations. Fundus examination for choroid tubercles, histopathological examination of tissue biopsy specimens, conventional and rapid culture methods for isolation of Mycobacterium tuberculosis, drug-susceptibility testing, along with use of molecular biology tools in sputum, body fluids, other body tissues are useful in confirming the diagnosis. Although several prognostic markers have been described which predict mortality, yet untreated miliary TB has a fatal outcome within one year. A high index of clinical suspicion and early diagnosis and timely institution of anti-tuberculosis treatment can be life-saving. Response to first-line anti-tuberculosis drugs is good but drug-induced hepatotoxicity and drug-drug interactions in human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) patients pose significant problems during treatment. However, sparse data are available from randomized controlled trials to define the optimum regimen and duration of treatment in patients with drug-sensitive as well as drug-resistant miliary TB, including those with HIV/AIDS.

Acute respiratory distress syndrome with miliary tuberculosis

A 71-year-old man was admitted to the hospital complaining of productive cough and weight loss. Physical examination showed fine bilateral basal crackles. Laboratory findings showed elevated liver enzymes. Tuberculin skin test and sputum smear for acid-fast bacilli were negative. On the fifth day of admission, he deteriorated and developed severe respiratory distress. A chest radiograph demonstrated worsening pulmonary infiltrates. He was electively intubated and was put on a mechanical ventilator. The chest CT scan revealed diffuse bilateral pulmonary nodules and airspace disease. Based upon the clinical suspicion of acute respiratory distress syndrome associated with miliary tuberculosis (TB), empiric treatment with antituberculosis and systemic steroids was started. He was extubated after 6 days. The diagnosis of miliary TB was confirmed by a thoracoscopic lung biopsy. He was discharged with a near normal chest radiograph and was followed up as an outpatient.

Association of tibial osteomyelitis and pneumonitis due to miliary tuberculosis in a patient with systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease, which has great prevalence and uncommon manifestations of opportunistic infectious diseases, mainly due to the multiple abnormalities of the immune system and the immunosuppressive effect of the medications used in its treatment. Patients whit SLE have an increased incidence of tuberculosis, and osteoarticular involvement occurs in 1%-3% of the cases, manifesting as pain, reduction in mobility, and increased osteoarticular volume. The radiographic findings are often nonspecific. Magnetic resonance imaging (MRI) is an useful test to define the severity of bone involvement; however, the etiological diagnosis can only be established by use of synovial fluid or bone cultures or the histological study of the affected areas. Due to the lack of specificity of the findings, there is usually a mean diagnosis delay of 11 months. We report the case of a female patient with SLE and predisposing factors for tuberculosis infection/reactivation. The MRI was important to define bone involvement, and the etiological diagnosis was established by use of bone biopsy. The patient also had lung involvement due to miliary tuberculosis, shown on plain chest radiography and CT scan and confirmed on culture of Mycobacterium tuberculosis in the sputum. There was a 1.5-month delay in beginning therapy, which is considered a short time when compared to the reports in the literature. In conclusion, bone tuberculosis, although rare, should always be remembered as a differential diagnosis of patients with SLE and osteomyelitis, mainly those with history of pulmonary tuberculosis.

Short duration respiratory illness with abducens palsy in a young man

Acute onset of diplopia associated with high-grade fever, sore throat and cough without features of raised intracranial tension in a young patient is an uncommon presentation. A diagnosis of abducent nerve palsy due to pontine tuberculoma associated with miliary tuberculosis was made based on sputum examination, chest x-ray and MRI. On diagnosis, monocular patching of the left eye was performed to avoid diplopia and primary antitubercular drugs with systemic steroids were given. An unfortunate 48 h delay in starting the antitubercular treatment likely decreased the probability of survival.