The Great Masquerader - TB Osteoarthritis

OBJECTIVES

TB arthritis is a rarely reported entity in Western literature and its ability to masquerade as many other diseases makes it difficult to diagnose. We report an interesting case of TB arthritis of the ankle.

METHODS

We present a 44 year-old diabetic Chinese male with a recent history of worsening pain, swelling, and redness in his left foot with an abscess and X-ray findings consistent with Charcot foot.

RESULTS

At first, the presentation was believed to be Charcot's foot with MSSA osteomyelitis but after the wound culture and bone biopsy were both positive for Mycobacterium tuberculosis as well, the diagnosis of tuberculous arthritis was confirmed.

CONCLUSIONS

While the prevalence of TB and other diseases is low in the majority of the United States, we still need to be aware of such diseases in populations with increasing migration and be cognizant of the potential impact of a patient's background on a diagnosis is critical to properly diagnosing and treating patients. Vascular surgeons may be seeing patients with abscesses of the lower extremities and may miss the diagnosis if cultures for TB are not sought.

[Multiple intestinal perforations due to tuberculosis: a case report and review of the literature]

The incidence of tuberculosis in Italy steadily decreased until two decades ago, but the infection is now frequently diagnosed in common clinical practice. The Authors describe a rare acute abdominal presentation of the disease featuring a double intestinal perforation in a subject affected by pulmonary, renal and gastrointestinal miliary tuberculosis. A review of the literature is also presented. Intestinal resection is the treatment of choice in such cases, even if it leads to frequent, major complications, but the authors stress that there may be a possibility for a less radical form of management of these patients.

Obstructing mass lesion of epiglottis: it can be tubercular

We report a case of 60-year old male who had difficulty in breathing as well as in swallowing. On examination, he was found to be having proliferative growth of epiglottis and right aryepiglottic fold mimicking neoplasm. So emergency tracheostomy was performed and biopsy taken. He was found to be having asymptomatic miliary mottling on routine x-ray chest PA view. Further on HRCT, it turned out to be lesion suggesting tubercular etiology. Histopathology (epiglottic biopsy) report confirmed the whole process as tubercular. The patient recovered promptly in due course with anti-tubercular treatment. Point remains to be seen that if we can avoid tracheostomy and its complications in such cases.

A case of miliary tuberculosis presenting with bowel perforation

Tuberculosis is a disease that should never be underestimated. It can affect anybody at any age. Doctors in the West do not have much experience of peritonitis secondary to tuberculosis. It is a condition that requires urgent and aggressive management as it can be fatal, even in the young and fit, as this case report illustrates.

Differenzialdiagnose „steriler“ phlegmonöser Entzündungen der Hand

INTRODUCTION

Bacterial infections represent a large proportion of emergencies in hand surgery. In some cases, pyoderma gangrenosum and mycobacterial infection may present with the same symptoms of swelling, pain, and purulent secretion. In these cases, operative treatment would be harmful. Therefore two cases-pyoderma gangrenosum and tuberculosis-are presented here in relation to common bacterial hand infection.

METHODS

Using two case reports of diseases that only rarely affect the hands, their relevance to differential diagnosis is shown with reference to the literature.

RESULTS

In both cases, we found clinical symptoms of bacterial hand infection with negative bacterial smear tests. After several debridements, pyoderma gangrenosum of the dorsum of the hand was diagnosed in one patient after pyodermiform lesions at the thigh and the nasal septum were detected and pre-existing colitis ulcerosa was taken into consideration. Corticoid therapy induced complete remission. The second patient with similar clinical symptoms had been operated on at another hospital several times before being transferred to our institution. The presumptive diagnosis of pyoderma gangrenosum was made, and under treatment with prednisone the symptoms quickly improved. After 2 weeks, the wound conditions and the patient's condition rapidly worsened. Following amputation at the upper arm level, the patient died of septic multiple organ failure. Autopsy studies revealed tuberculous sepsis originating from the hand.

DISCUSSION

Patient history should be evaluated carefully because of its value to correct diagnosis. In case of negative smear tests, especially from immunocompromised, elderly patients and in patients with a history of pulmonary tuberculosis, Ziehl-Neelsen staining should be obtained. In case of multilocular affection or pre-existing chronic inflammatory bowel disease, the presumptive diagnosis of pyoderma gangrenosum can be confirmed by biopsies from the lesions margin. In both cases, unnecessary traumatizing operations could thus be avoided and treatment optimized.

A rare complication of miliary tuberculosis: intestinal perforation

Small bowel perforation is a rare complication of miliary tuberculosis. We report the case of a 21-year old patient who developed a small bowel perforation 70 days after the initiation of adequate tuberculosis treatment. We also present a review of the literature.

Pulmonary miliary tuberculosis with multiple intracerebral tuberculous granulomas--report of two cases

Although intracerebral tuberculomas are common in countries where tuberculosis is still endemic, miliary tuberculosis with involvement of the central nervous system is exceptionally rare. We report two cases of pulmonary miliary tuberculosis with multiple intracerebral tuberculomas.

Massive posterior fossa tuberculous abscess developing in a young child treated for miliary tuberculosis. Possible role of very rapid acetylation of isoniazid

A 21-month-old infant presented with acute obstructive hydrocephalus due to a large tuberculous abscess in the posterior fossa 3 months after starting treatment for miliary tuberculosis. Insertion of a ventriculo-peritoneal shunt resulted in some clinical improvement but subsequent neurological deterioration occurred due to massive enlargement of the tuberculous abscess despite apparently adequate antituberculosis therapy. Repeated drainage procedures of the abscess eventually resulted in resolution and clinical improvement. As part of the workup for poor weight gain and the unusual clinical course, the patient's acetylation status for isoniazid was determined and found to be very rapid. Doubling the daily dose of isoniazid was followed by a dramatic weight increase and further clinical improvement. Decreasing the load of tuberculous antigen by draining the abscesses and increasing the pulse exposure of isoniazid is the best possible explanation for the clinical improvement finally seen in this patient.

Laparoscopic diagnosis of abdominal tuberculosis

Abdominal tuberculosis (TB) is an uncommon condition in Western societies although Europe and America have noted an increase of this condition in immigrants and AIDS patients. This report documents three diagnosed cases of abdominal TB over a 12-month period in a Melbourne western suburbs teaching hospital which services a large migrant population. We also review the literature on this condition. If migrants present with diffuse abdominal symptoms, the diagnosis of abdominal tuberculosis should always be considered. Laparoscopy should replace diagnostic laparotomy as the definitive diagnostic tool.

Tuberculosis of the small bowel with perforation and hematogenous spread in a renal transplant recipient

A 41-year-old male was admitted because of acute abdomen. A flat plate of the abdomen suggested pneumoperitoneum and a chest X-ray an infiltrate in the right upper lobe. The patient was a renal allograft recipient and was on immunosuppressive therapy with azathioprine, cyclosporine and steroids. At laparatomy inflammatory thickening of the bowel wall was found in the terminal ileum with necrotic areas and two sites of perforation. The involved terminal ileum was removed together with a right hemicolectomy. The resected segment showed exudative ileal tuberculosis and fibrinous and purulent peritonitis. During the postoperative period rapid hematogenous spread of tuberculosis developed with progressive reduction of respiratory function followed by ARDS. Autopsy revealed tuberculosis in all organs including the transplanted kidney.

Uncommon forms of mastitis

Three different types of chronic mastitis were seen in a review of cases over a twenty-five-year-period. These were tuberculous mastitis, non-specific granulomatous mastitis, and oleogranulomatous mastitis. Their common modes of presentation and some of the difficulties encountered in diagnosing these lesions are discussed.

[Resection of the lung in tuberculosis]

The results of surgical treatment in 175 patients (two patients were subjected to bilateral pulmonary resection) are reported. Fibrous-cavernous tuberculosis was observed in 92 patients. The complex of preoperative management comprised increased doses of ascorbic acid to prevent postoperative capillary hemorrhages. Postoperative complications developed in 23 patients, these were liquidated in 20 cases. There were 3 deaths. A complete cure was gained in 99 patients, considerable improvement--in 71, some improvement--in 2. Late results were followed up in 160 patients within the period from 1 to 4 years. The recurrent tuberculous process was noted in 6 cases.