Tuberculosis cutis miliaris disseminata due to multidrug-resistant Mycobacterium tuberculosis in AIDS patients

Two patients with AIDS and disseminated tuberculosis characterized by cutaneous involvement are reported. They developed a maculopapular skin eruption, from which a multidrug-resistant Mycobacterium tuberculosis strain was isolated. In both cases the clinical course was rapidly fatal. Tuberculosis cutis miliaris disseminata should be differentiated from the skin lesions frequently seen in HIV-infected patients, especially from folliculitis. In patients with tuberculosis, the appearance of cutaneous lesions may be due to the haematogenous dissemination of mycobacteria. Therefore, early identification of the causative organism by use of optimal microbiological methods is fundamental.     

Poncet's disease and papulonecrotic tuberculid in a patient infected with the human immunodeficiency virus

We report the case of a 27-year-old patient with the human immunodeficiency virus (HIV) infection who presented with a 2-week history of crops of painful, red papules over the trunk and extremities, together with a sterile, symmetric polyarthritis involving the small and large joints. Histologic study of a skin biopsy specimen demonstrated features of papulonecrotic tuberculid. Analytical and microbiologic studies ruled out tuberculous infection. Both the synovial and the skin processes were considered to be an immune response secondary to Mycobacterium tuberculosis infection. Specific treatment was established, and there was marked improvement in both the skin and joint symptoms. This case illustrates the complex relationship between the host and the HIV, suggesting an immune dysregulation cause for both the synovial and the skin lesions.     

The present situation, treatment and prognosis of drug-resistant pulmonary tuberculosis. Cooperative Study Unit of Chemotherapy of Tuberculosis of the National Sanitoria in Japan

We studied 266 patients with drug-resistant pulmonary tuberculosis at national sanatoria in Japan. The patients included 218 men (mean age, 58 years) and 48 women (mean age, 62 years). The levels of isoniazid and rifampicin resistance were determined at 1 mcg/mL and 50 mcg/mL, respectively. The results were as follows. (1) Most patients with drug-resistant pulmonary tuberculosis were middle-aged or past middle-aged. (2) There were many cases of drug-resistant pulmonary tuberculosis in previously treated tuberculosis patients with active disease and several cases in previously untreated pulmonary tuberculosis patients. However, in some previously untreated patients active tuberculosis was convert relatively easily to inactive tuberculosis. (3) Concerning life style, bachelors who drank heavily were more likely to develop drug-resistant pulmonary tuberculosis. (4) Most cases of drug-resistant pulmonary tuberculosis had at least one cavity on chest radiographs. (5) Several patients with drug-resistant tuberculosis left the hospital against the advice of their attending doctors; therefore, it was difficult to treat their illnesses. (6) In more than half the cases in which Mycobacterium tuberculosis was resistant to isoniazid and rifampicin, tolerance to streptomycin and ethanbutol was also seen. (7) When patients with drug-resistant pulmonary tuberculosis continued to have tuberculous bacilli in their sputum after 3 months of chemotherapy, there was a tendency for them to expectorate tuberculous bacilli in their sputum. For these drug-resistant tuberculosis patients, we must pay attention not only to the medical aspects but also to the social aspects of their disease.     

Cutaneous involvement in chronic myelomonocytic leukemia

BACKGROUND: Chronic myelomonocytic leukemia has been associated with various nonspecific cutaneous manifestations. Rarely has the leukemia been reported to directly affect the skin. METHODS: This case documents the progression of a patient who ultimately developed chronic myelomonocytic leukemia, by clinical examination, hematologic parameters, dermatopathology, and bone marrow pathology. RESULTS: The skin showed nonspecific cutaneous involvement, progressing to specific leukemic lesions parallel with increasing systemic and hematologic involvement. CONCLUSIONS: Chronic myelomonocytic leukemia can manifest with lesions of leukemia cutis. The possibility of nonspecific cutaneous involvement in the preleukemic phase exists.     

Miliary tuberculosis associated with subcutaneous tuberculous abscess

A 62-year-old woman was admitted because of a tumor on her right thigh, fever, generalized lymphadenopathy, and diffuse nodular shadows on chest X-ray films. She was given a diagnosis of miliary tuberculosis based on the findings of a cervical lymph-node biopsy and a broncho-alveolar lavage. Acute respiratory failure and disseminated intravascular coagulation developed, but resolved after the start of anti-tuberculous therapy. The tumor on the right thigh was diagnosed as a subcutaneous tuberculous abscess because tuberculous bacilli were detected in tumor tissue samples obtained by aspiration. The patient's fever disappeared and the abnormal shadows on her chest X-ray films receded significantly after drainage of the subcutaneous abscess. These findings suggested that miliary tuberculosis was associated with the subcutaneous tuberculous abscess in this case.     

Dermatophytic disease: exuberant hyperkeratosis with cutaneous horns

BACKGROUND: Dermatophytic disease is a chronic dermatophytosis involving the skin and viscera and caused by benign dermatophytes which cross the skin barrier. We present a case presenting previously unreported giant cutaneous horns. CASE REPORT: A male Algerian patient aged 29 years consulted for chronic skin disease which had progressed for 2 years. Manifestations included warts, papulonodules, eczematiform lesions, lichenifications, alopecia, onyxis, multiple node enlargement and giant cutaneous horns on the plantar aspect of the feet making walking difficult. The patient's kinhood included 10 members and the patient's parents were first cousins; no other family member had a similar disease state. Laboratory findings included eosinophilia (11%, 550 cells/mm3), an inflammatory syndrome, and normal phosphorus and calcium levels despite demineralization of the hands and feet. The tuberculin interdermal reaction was positive but the trichophytine interdermal reaction was negative. Trichophyton violaceum was found in all mycological samples from skin and nails. The histology examination of skin biopsies revealed acanthosis, considerable hyperkeratosis, and myceleal filaments invading the horny layer, the sweat glands and hair follicles. Abscesses and granulomas were also seen in the superficial dermis. Oral griseofulvin 1 g per day and topical applications with ketoconazole gave clear improvement. DISCUSSION: Dermatophytic disease is a chronic dermatophytosis observed mainly in North Africa. The locally high rate of consanguinous marriages would suggest autosomal recessive inheritance of a genetic anomaly possibly associated with deficient cellular immunity. The lesions are polymorphous and develop progressively, probably due to diminished cellular immunity. This case with giant cutaneous horns would be a new variant. Antifungals can provide definitive cure. The pathogenesis of this severe dermatophytosis remains to be established.     

Tuberculosis of the endocrine system

Tuberculosis now rarely affects the endocrine system. Adrenal tuberculosis is responsible for Addison's disease, but now fewer cases are affected. Although the symptoms and signs of Addison's disease appear when most of the adrenal glands have been functionally destroyed, adrenal tuberculosis results in not only chronic adrenal insufficiency but also acute adrenal failure. Dissemination of M. tuberculosis is responsible for adrenal tuberculosis, other tuberculous lesions (including the past lesions) should be evaluated. Bilateral adrenal calcification and/or enlargement which are often pointed out on abdominal CT, are important signs of adrenal tuberculosis. Thyroid gland is rarely affected, but thyroid function impairment is uncommon even if it is affected. Hypopituitarism due to intracranial tuberculoma or tuberculous meningitis are also reported. Tuberculosis of the endocrine system is a part of disseminated infection, so it should not be overlooked in miliary spread tuberculosis.     

Soft laser therapy in combination with tebonin i.v. in tinnitus

Lymph node tuberculosis is the most frequent tuberculous manifestation in the otorhinolaryngological area. In 13 patients with histologically verified tuberculous lymphadenitis cervical sonographic examinations revealed characteristic findings. The sonographic features typical for this disease were multiple, enlarged, conglomerating roundish and oval lymph nodes. These lymph nodes were hypoechoic, exhibited dorsal sound amplification and had sharp margins. With caseation, however, there were blurred borders. In cold abscesses an inhomogeneous texture with inhomogeneous shadows was found. Differential diagnosis included non-specific abscess-forming lymphadenitis, lymph node metastases and malignant lymphoma. A tentative diagnosis of cervical lymph node tuberculosis may be made due to the polymorphous sonographic pattern if history and clinical findings are taken into account. A proper histological and microbiological work-up is still essential for confirmation of the sonographic diagnosis.     

Leukemia cutis

Leukemia cutis is an uncommon manifestation of leukemia that is strongly associated with the presence of extramedullary disease at other sites. Patients usually present with leukemia cutis concomitantly with systemic leukemia or after leukemia has been diagnosed. Acute monocytic, myelomonocytic, and the T-cell leukemias show the highest incidence of leukemia cutis. The lesions show varied morphology and can be difficult to distinguish both clinically and histopathologically from nonspecific cutaneous lesions, which occur much more frequently. Immunohistochemistry is useful in making the distinction between them. The prognosis in leukemia cutis is generally poor; the best results have been achieved with a combination of systemic and local therapy.     

Primary gastric tuberculosis

Intestinal tuberculosis (TB) comprises 5% of all cases of TB and may be a major problem in immigrant communities, although the incidence of pulmonary TB is declining. Gastric TB is rare, constituting 0.1-2% of all cases of TB. Gastric TB usually develops secondary to other tuberculous lesions, most commonly pulmonary. On endoscopy antral infiltrative lesions are found. Primary gastric TB is very rare, only 8 cases having been reported in the English literature. We report a case of primary gastric TB in a 55-year-old woman who presented with abdominal pain and gastric outlet obstruction. The diagnosis was confirmed by endoscopic biopsies which showed granulomas, but no acid-fast bacilli. The Mantoux test was positive, acid-fast bacilli were found in the gastric juice, and a positive culture for TB was obtained on gastric lavage. There was an excellent response to antituberculous chemotherapy. With the relative rate of extra-pulmonary TB increasing, primary gastric TB should be taken into account in the differential diagnosis of infiltrative lesions of the antrum.     

Screening for idiopathic scoliosis. Comparison of 90 cases shows less surgery by early diagnosis

Cutis marmorata telangiectatica congenita (CMTC), a rare benign condition usually present at birth, is characterized by areas of cutaneous marbling that often become more pronounced with low temperatures. The skin lesions typically become less prominent with age, but may be associated with a variety of abnormalities. Reported are three patients with vivid cutis marmorata who had leg length discrepancies (LLD) which, unlike most limb discrepancies caused by vascular malformations, involved relative growth retardation of the affected leg.     

Tuberculous colitis mimicking Crohn's disease

Intestinal tuberculosis is a rare disease in western countries and may mimic a variety of gastrointestinal disorders. Here, we report the case of a 63-yr-old patient who presented with profuse bleeding from a deep rectal ulcer. Similar lesions were found in different parts of the colon. Multilocular colorectal carcinoma was suspected based on the macroscopic appearance. Histology, however, suggested Crohn's disease. Intestinal tuberculosis was initially ruled out by negative staining for acid-fast bacilli, mycobacterial culture, and polymerase chain reaction analysis. A treatment for Crohn's disease was started. Endoscopic reexamination revealed progressive disease with extensive ulcerations of the terminal ileum. Histopathological examination then revealed acid-fast bacilli in the colonic mucosa typical for mycobacterium tuberculosis infection. This case emphasizes the need to include intestinal tuberculosis in the initial differential diagnosis of ulcerative colorectal lesions also in the western population.     

The risk of treatment. A study of rheumatoid arthritis patients'' attitudes

Non-respiratory forms of tuberculosis are frequently described in immigrants from endemic countries and in immunocompromised patients. Among the extrapulmonary forms of tuberculous disease, peripheral lymph node involvements, generally cervical, are the most common. Interestingly, only a few cases of tuberculous inguinal adenitis have been reported in the literature during the last 15 years. We report 2 cases of isolated inguinal inflammatory lymph-adenitis observed in immigrant immunocompetent women. The diagnosis of tuberculosis was confirmed by culture obtained by needle aspiration of a lymph node. The lesions completely healed after standard antituberculous therapy.     

Treatment of multi drug resistant tuberculosis

Multi drug resistant pulmonary Tuberculosis (MDR-TB) are divided into two types. The one is primary drug resistance and the other is acquired drug resistance. Cases of acquired MDR-TB are more often. Chemotherapy of MDR-TB demands use in combination of three or more sensitive anti-tuberculosis drugs, but it is difficult to apply this combined treatment practically. In Japan, it is often effective to use in combination of sensitive anti-tuberculosis drugs added PZA, Newquinolon agents and Clarithromycin. When chemotherapy is not effective, surgical treatment should be performed. We experienced six operation cases of MDR-TB. Lobectomy were performed in five cases, and all cases were negative tuberculous bacilli after operation. One case of thoracic empyema with bronchial fistula was positive tuberculous bacilli after operation and died of MDR tuberculosis.     

Tuberculous pseudotumor causing biliary obstruction. Report of a case with diagnosis by fine needle aspiration biopsy and bile cytology

Hepatobiliary tuberculosis is a rare but distinct clinical entity. We report an unusual case of biliary tract obstruction due to localized hepatic tuberculosis with periportal tuberculous adenitis. The lesion mimicked a malignancy clinically and radiologically. Fine needle aspiration biopsy revealed granulomas, epithelioid histiocytes and Langhans' giant cells. The cytodiagnosis was confirmed by identification of acid-fast bacilli in the bile cytology and isolation of Mycobacterium tuberculosis by culture. The patient responded to antituberculosis therapy. The usefulness of bile cytology in the diagnostic management of biliary tract obstruction is illustrated.     

Tuberculosis in captive exotic birds

Avian tuberculosis was studied clinically and pathologically in 137 affected birds from the National Zoological Park during a 7-year period (1969-1975). Twelve of 22 orders exhibited were affected by the disease, and the highest annual mortality was 4% (in 1975). Antemortem diagnosis of early cases of the disease, based on tuberculin testing, and serologic, hematologic, and radiographic studies, was inconsistent and often not conclusive. Pathologically, the diseases primarily involved digestive organs and spleen. There was a spectrum of lesions consisting of nodules of large foamy histiocytes packed with acid-fast bacilli to giant cell-containing granulomas that were often caseous but not cavitated or calcified. Amyloidosis was seen in approximately 20% of the cases. Mycobacterium avium serotype 1 was isolated from 30 tuberculous birds cultured. There was no sex predilection, and most of the affected birds were adults ranging from 1 to 10 years of age.     

Erythromycin elicits opposite effects on antro-bulbar and duodenal motility: analysis in diabetics by cineradiography

Hodgkin's disease (HD) and non-Hodgkin's lymphoma (NHL) are infrequently associated with noninfectious granulomas in involved or noninvolved organs. Adult T-cell leukemia/lymphoma (ATLL) is an aggressive lymphoproliferative neoplasm associated with T-lymphotropic virus type 1 (HTLV-1). We describe a case of cutaneous type ATLL, affecting mainly the skin as a maculopapular eruption, in which some skin biopsies contained epithelioid cell granulomas in the lymphoma cutis (ATLL) lesion. These Lennert's-like epithelioid clusters were also present in lymph nodes, which showed some degree of invasion by the ATLL lymphocytes. Although prognosis of ATLL is generally poor, our patient has had a less aggressive course, with a survival time to date of 13 years. Our findings suggest that the presence of epithelioid granulomata in an ATLL patient may be a manifestation of a host response which confers some protection against the disease progression. To our knowledge, this is the first report of a case of ATLL with a noninfectious granuloma similar to a Lennert's lesion.     

Adenosine deaminase activity in serum and pleural effusions of tuberculous and non-tuberculous patients

In a retrospective study Adenosine deaminase (ADA), was assayed in 86 serum samples and 12 pleural fluid samples of patients with pulmonary tuberculosis. Serum and pleural fluid ADA levels were also examined in a group of 38 non-tuberculous patients with pleural effusion. Highly significant increases in both serum and pleural fluid ADA levels were noted in tuberculous patients when compared to both control enzyme cut-off values and non-tuberculous pleural effusion patients. Negative Ziehl-Nielsen staining for acid fast bacilli and Purified Protein Derivative skin test results were obtained in 32.3% and 11.1% of the examined patients respectively. All these patients showed significantly elevated serum or pleural fluid ADA levels. It is hereby suggested that serum and pleural fluid ADA levels can in conjunction with other tests, serve as a marker in patients of pulmonary tuberculosis.     

Ultrasound guided fine needle aspiration cytology in abdominal tuberculosis

Although barium studies and CT are useful in assessing abdominal pathology in tuberculosis, imaging findings are not always specific and a histopathological or bacteriological confirmation is often required. The aim of the present study was to evaluate the role of ultrasound (US) guided fine needle aspiration cytology (FNAC) in the diagnosis of abdominal tuberculosis in patients with non-palpable lesions detected on US/CT. FNAC was performed on 31 sites in 30 patients. The sites included enlarged lymph nodes (n = 14), focal lesions in liver (n = 2) and spleen (n = 8), and thickened bowel in the ileocaecal region (n = 7). The results were classified cytomorphologically into four groups: (1) definite evidence of tuberculosis; (2) presumptive evidence of tuberculosis; (3) suggestive of tuberculosis; and (4) negative for tuberculosis. 18 of the 31 FNACs (58%) revealed a positive diagnosis of tuberculosis (definite evidence in nine patients and presumptive evidence in nine patients). 13 of the 31 FNACs (42%) showed either necrosis alone (n = 4) or negative results (n = 9). Zeihl-Neelson staining for acid-fast bacilli on direct smear was positive in only nine patients (29%). Splenic and lymph nodal FNAC had a high sensitivity (87.5% and 78.6%, respectively) in the diagnosis of tuberculosis. None of the bowel and liver FNACs was diagnostic. No complications were encountered. US guided FNAC offers a safe and accurate method of achieving a diagnosis in patients with suspected abdominal tuberculosis who present with radiologically demonstrable but non-palpable lesions, especially those involving lymph nodes and spleen.     

T lymphocytes bearing the gamma/delta T-cell receptor in cutaneous lesions of dermatitis herpetiformis

T lymphocytes bearing the gamma/delta T-cell receptor are a rare component of normal human GI epithelium and skin. Recently, however, an unusually high percentage of T lymphocytes with gamma/delta receptors has been described in gastrointestinal biopsies from patients with dermatitis herpetiformis, implicating the gamma/delta T cell subset in the pathogenesis of this disease. We investigated a possible role for this subset of lymphocytes in the pathogenesis of the cutaneous lesions of dermatitis herpetiformis. Using a standard immunoperoxidase technique, we labelled perilesional skin biopsies from patients with dermatitis herpetiformis and other inflammatory dermatoses with monoclonal antibodies to CD3, CD4, CD8, alpha/beta T cell receptor, gamma/delta T cell receptor, and IL-2 receptor. We found no differences in the percentage of gamma/delta positive T lymphocytes in skin lesions of dermatitis herpetiformis as compared to other selected inflammatory conditions. These findings suggest that the pathogenesis of the cutaneous lesions of dermatitis herpetiformis is not mediated through gamma/delta T cells, and that the cutaneous lesions may develop through mechanisms different from those operative in the gastrointestinal tract.