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.     

Splenic sepsis in sickle cell disease

We describe two patients with sickle cell disease (SCD) who developed infections situated in the spleen. One patient had a splenic abscess and there was strong clinical evidence for an infected splenic infarct in the second patient. SCD predisposes to splenic infection because of functional hyposplenism, defective phagocyte function and splenic infarction. Splenic infections can occur in patients who might be considered to have an absent spleen and the diagnosis of splenic abscess should be considered in individuals with SCD who present with fever and abdominal pain.     

Adie syndrome as the initial sign of primary Sj?gren syndrome

PURPOSE: To report Adie syndrome as the initial sign of primary Sj?gren syndrome. METHODS: Case report. RESULTS: Adie syndrome was associated with necrotizing gingivitis and xerostomia. Antibodies against Ro (SS-A) were present. Prednisone and antimalarial drugs were ineffective in treating Adie syndrome but improved the necrotizing gingivitis. CONCLUSION: Search for Sj?gren syndrome is mandated in patients with Adie syndrome. The latter condition is likely related to ganglionitis, a mechanism responsible for peripheral nervous system involvement in primary Sj?gren syndrome.     

Long-term survival of an AIDS patient with a tuberculous cerebral abscess

Unlike other forms of tuberculosis, tuberculous cerebral abscess is a rare complication of human immunodeficiency virus (HIV) infection and usually presents at a late stage of the disease. This article describes a case of tuberculous cerebral abscess in an HIV-infected patient that was effectively treated with surgery and chemotherapy. The patient has survived more than 5 1/2 years since being diagnosed and remains in good health.     

Oesophageal tuberculosis mimicking secondary oesophageal involvement of mediastinal neoplasm

During the last decade the number of cases of abdominal tuberculosis diagnosed in Western countries has dramatically increased. There are many reasons, including the appearance of AIDS and the increased morbidity of people across the world due to the westward migration of many people coming from areas with a high incidence of tuberculosis. Oesophageal involvement is rare in tuberculosis, occurring mainly as an extension of the disease from the adjacent tuberculous lymph nodes. Fifty-eight cases of oesophageal tuberculosis have so far been reported. We describe a patient affected by oesophageal tuberculosis mimicking secondary oesophageal involvement of mediastinal malignancy.     

Disseminated tuberculosis of unusual locations

We report a case of disseminated tuberculosis involving the middle ear, the central nervous system, the spine and the lung. The tuberculous epidural abscess and otomastoiditis don't have any specific imaging features. But their coexistence with an other tuberculous involvement might suggest their tuberculous nature. The epidural abscess may result from direct extension from otomastoiditis.     

Tuberculous lymphadenitis

Tuberculous lymphadenitis is a common extrapulmonary tuberculosis. Its incidence is about 28%. Pulmonary hilar lymphadenitis and mediastinal lymphadenitis are often visible in the routine chest X-ray films during pulmonary tuberculosis. But abdominal lymphadenitis are difficult to detect on this method. Computed tomography is a useful tool to detect the tuberculous lymphadenitis both mediastinal and abdominal. The active tuberculous lymphadenitis shows characteristic findings with contrast enhanced CT, central low attenuation and peripheral rim enhancement were seen. On the contrary homogeneous without low attenuation area and with calcification were inactive tuberculosis. Bacterial diagnosis is difficult and PCR method is effective for detect the tuberculosis. Usual anti-tuberculous chemotherapy were performed for the tuberculous lymphadenitis and effective but on the fistula formation surgical procedure are also performed.     

AIDS-associated renal tuberculosis

In order to study the prevalence and the clinical features of renal tuberculosis associated with AIDS, we studied the renal tissue of the necropsies made in 46 AIDS patients under light microscopy. We found renal tuberculous granuloma in 11 (23%) patients (in 3 without previous diagnosis of renal or extrarenal tuberculosis) and only 4 of them presented moderate hematuria or pyuria sterile. As subclinical renal tuberculosis was frequent in this group of AIDS patients, the urine culture for Mycobacterium tuberculosis may be useful for diagnosing tuberculosis in AIDS patients.     

Pancreatic tuberculosis in non-immunocompromised patients: reports of two cases, and a literature review

We present two cases of biopsy proven tuberculosis of the pancreas in non-immunocompromised patients diagnosed and treated in our unit within the last 14 years. The first case presented with abdominal pain and fever, and the second with iron deficiency anaemia and severe weight loss. In both cases abdominal ultrasound and computed tomography suggested a pancreatic carcinoma. There was no pulmonary or intestinal tuberculosis. The tuberculin skin test was positive. Upon exploratory laparotomy the macroscopic appearance of the pancreas was that of an inoperable pancreatic carcinoma. Following the histological diagnosis of pancreatic tuberculosis, both patients were successfully treated with triple antituberculous therapy for 6 months. Isolated pancreatic tuberculosis is an extremely rare disease with only 41 cases in non-immunocompromised patients reported worldwide (1966-1997). It is a curable disease and should be considered in the differential diagnosis of a pancreatic mass or abscess shown on ultrasound or computed tomography, especially in developing countries, where tuberculosis is common.     

Tuberculous hepatosplenic abscess, human immunodeficiency virus infection and multiresistant tuberculosis

BACKGROUND: Tuberculosis (TB) with liver and/or spleen abscess (HSA) formation in HIV-positive patients is uncommon. PATIENTS AND METHODS: One hundred and thirty-seven HIV positive patients with TB were studied from January 93 to June 95. Patients with tuberculous HSA were enrolled in the study. Diagnosis was obtained by recovery of Mycobacterium tuberculosis in clinical specimens and the presence of hypoechogenic lesions in liver and/or spleen. RESULTS: M. tuberculosis isolates were resistant to some of the usual drugs in 51 patients. Twenty of these patients had HSA (39%) and in 18 patients the antibiotic sensitivity testing showed resistance to isoniazid, rifampin, ethambutol, and streptomycin. The remaining 86 patients had episodes of TB with drug-susceptible microorganism and only three patients had HSA (3%) (p < 0.001). The 23 patients with tuberculous HSA had a mean CD4+ lymphocyte count of 33 x 10(6) cells/L (2-111) and 7 had a previous episode of TB. The abdominal echography showed hepatosplenomegaly in all cases. Abscesses were located at the liver in 12 patients (52%), spleen in 18 (78%) and both organs in 7 (30%). In 16 cases a corticosteroid therapy was indicated. In the 3 patients with susceptible TB and HSA the clinical course was good. The 20 patients with resistant TB died. CONCLUSION: Abdominal TB in HIV-positive patients and HSA formation appears to be more common in severely immunosuppressed patients, with resistant TB and its mortality rate is high. The response to therapy with antituberculous drugs is slow and sometimes the administration of corticosteroids is necessary for the resolution of symptoms.     

The Danish prescription registries

An 18-month-old Caucasian female began with a high fever. She developed swelling in one finger and one toe. Abdominal ultrasound revealed multiple abscesses in her spleen. Multiple blood culture and splenic abscess aspirations grew no pathogens. She had transient response to multiple antibiotics and splenic abscess drainage, but fever returned along with subcutaneous nodules. Culture of splenic tissue from her second splenic drainage eventually grew one organism identified as Actinomyces naeslundii. Therapy with high dose penicillin followed by amoxicillin p.o. and total splenectomy led to complete recovery.     

Tuberculoma of the spleen: a rare but important clinical entity

Tuberculoma of the spleen has been an extremely rare entity during the last decades in the Western world. We describe a case in a young, HIV-negative woman who was evaluated for fever of unknown origin. The workup was initially negative, and she was treated successfully with steroids and nonsteroidal anti-inflammatory analgesics. Recurrence of the fever and an abnormal CT of the abdomen lead to an exploratory laparotomy, which revealed a subcapsular caseous material containing splenic abscess. The very few cases reported in the literature, and the increasing incidence of extrapulmonary tuberculosis due to the alarming numbers of immunodeficient patients that a surgeon may encounter are also discussed.     

Distribution and contrast enhanced CT appearance of abdominal tuberculous lymphadenopathy

PURPOSE: To clarify the contrast enhanced CT features and anatomic distribution of the disseminated vs non-disseminated tuberculosis (TB) involving abdominal lymph nodes. MATERIALS AND METHODS: The contrast enhanced CT findings of abdominal lymphadenopathy in 25 patients, including disseminated TB associated with miliary TB of the lung (n = 5) and non-disseminated TB (n = 20), were retrospectively evaluated in a blind review to assess our criteria of morphology, density and location of the involved lymphadenopathy. RESULTS: The enhancement patterns of disseminated TB were not different from those of non-disseminated TB. Ninety-six percent of the patients had peripheral rim enhancement, and 60% showed a multilocular appearance. The enlarged lymph nodes of TB were less than 4 cm in diameter. Lymphadenopathy caused by hematogenous dissemination often accompanied splenic involvement showing multiple low-density foci in the spleen. The predominant sites of lymphadenopathy of disseminated TB were hepatoduodenal ligamentous, hepatogastric ligamentous, mesenteric, and both upper and lower portions of the retroperitoneal lymph nodes, whereas non-disseminated TB mainly involved hepatoduodenal ligamentous, hepatogastric ligamentous, mesenteric and upper retroperitoneal lymph nodes, excluding the lower retroperitoneal lymph nodes. By combining contrast enhancement patterns and the anatomic distribution of lymphadenopathy shown on the contrast enhanced CT images, reviewers made a correct diagnoses of tuberculosis in 94%, of cases, with a specificity of 95% and sensitivity of 92%. CONCLUSION: Contrast enhanced CT patterns correlate well with the pathologic features of tuberculous lymphadenopathy. A different anatomic distribution between disseminated and non-disseminated TB involving the lower retropentoneal lymph nodes was recognized in this study.     

Abdominal wall hematoma]

We describe three case reports of hematomas in the abdominal wall muscles and discuss etiology, diagnostic findings and treatment. Abdominal wall hematomas are uncommon, and the condition is often misdiagnosed. One of our patients was laparotomised owing to suspected appendicitis, and one patient presented a tuberculous abscess that may have been an infected hematoma. Ultrasonographic examination or CT gives the correct diagnose. Conservative management is the treatment of choice unless bleeding is severe or the course is complicated by infection.     

Tuberculous abscess in retromammary region: CT findings

PURPOSE: Our goal was to evaluate CT findings of tuberculous abscess in the retromammary region of the breast. METHOD: Four patients with tuberculosis extending from the retromammary region to the pleura were examined by CT and the findings were evaluated. All cases were also examined with mammography and two cases were evaluated with sonography. Diagnosis was confirmed by acid-fast bacillus stain, culture, and histologic examination. RESULTS: Mammography showed relatively smoothly marginated, round mass density in two cases, nodular density in one, and focal bulging of the pectoral wall in one. A sonogram demonstrated in two cases a fistulous connection from the heterogeneous, fluid-containing lesion with floating internal debris in the retromammary region to the thoracic cavity. In all four cases, CT showed relatively smoothly marginated, inhomogeneous, hypodense lesions with surrounding rims of the cold abscess type. A direct fistulous connection from the retromammary lesion through the thoracic wall into the pleura was seen in two cases. Destroyed rib fragments within the abscess were noted in two cases. CONCLUSION: A tuberculous abscess in the retromammary region usually showed on CT a focal, smoothly marginated, inhomogeneous, hypodense lesion with a surrounding enhancing rim. A direct fistulous connection with the pleura or a destroyed rib fragment in the abscess as revealed by CT can be helpful in the differential diagnosis of other infectious types of retromammary abscess.     

Therapeutical approaches to transmissible spongiform encephalopathies (TSE): the case of amphotericin-B

Within 1987-1995 the authors observed 16 cases of tuberculosis in HIV-infected patients which accounted for 26.7% of AIDS patients treated by them. 14 cases were diagnosed intravitally, 2 postmortem. Infiltrative, generalized, cavernous, intrathoracic lymph node, intraabdominal lymph node tuberculosis and tuberculous pleurisy were identified in 5, 6, 2, 1, 1 and 1 patients, respectively. 6 patients from the above are still alive and are receiving treatment (5 of them with infiltrative tuberculosis), 10 died. Tuberculosis course and outcomes in HIV-infected subjects depended on the stage of their immunodeficiency. In moderate immunodeficiency (CD4-lymphocyte > 200/mm3) tuberculosis ran, as a rule, as local and infiltrative, sensitive to specific therapy. In severe damage to immune system (CD4 < 100/mm3) tuberculosis acquired a generalized course, sometimes fulminant, resistant to treatment. It is inferred that HIV-infected subjects with immunodeficiency need tuberculosis prophylaxis with isoniazide or rifampicin.     

Resurgence of a forgotten pathology: pylephlebitis caused by tuberculous adenopathies

The incidence of abdominal tuberculosis represents less than 1% of all forms of tuberculosis. We report the case of a portal vein thrombosis associated with tuberculous adenopathy of the hepatic hilum discovered in a young woman free of symptoms, without any risk factors, who had recovered from a cavity pulmonary tuberculosis after a classical anti-tuberculous treatment. This case suggests that abdominal tuberculosis often remains undiagnosed. Reemergence of tuberculosis is likely because of the increase in the incidence of the acquired immunodeficiency syndrome.     

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.     

MALT lymphoma of the parotid gland associated with Sj?gren syndrome. A case report and review of literature

Sj?gren syndrome (SS) is a chronic inflammatory process involving the exocrine glands. Its association with the development of lymphomas is well documented, and this risk has estimated to be 44 times that of the general population. A MALT lymphoma of the parotid gland in a patient with Sj?gren syndrome is reported. We review the literature and comment the clinical and histopathological features of these tumors.     

Craniocervical junction tuberculosis: a rare but dangerous disease

BACKGROUND: Mycobacterium tuberculosis of the cervical spine is a rare but dangerous manifestation of extra-pulmonary tuberculosis. The clinical picture ranges from early, nonspecific, insidious symptoms to severe neurological complications and death, attributed to craniocervical junction instability and cervicomedullary compression. The different lines of management include antituberculous medication with traction and external fixation or adjunctive surgery (debridement and stabilization) in patients with severe or persistent neurological complications and/or vertebral instability. METHODS: We describe two patients with advanced craniocervical junction tuberculosis. The early clinical picture was nonspecific in Case 1 and obscured by psychiatric illness in Case 2. The detailed clinical and radiological findings, and the management, will be described. Involvement of the occipital condyles and foramen magnum, which has not been reported previously, will be demonstrated. RESULTS: Both cases underwent transoral biopsy, aspiration, and debridement of retropharyngeal abscess (granuloma). Histological and tissue culture studies proved the abscesses were tuberculous and anti-tuberculous medications were started. Case 1 showed complete resolution of the clinical and radiological findings. Case 2 developed cardiorespiratory arrest while in a halo jacket. He was resuscitated but remained quadriplegic and semiconscious; he developed nosocomial gram negative pneumonia. He was referred back to his local hospital where he died 1 year later. CONCLUSIONS: Tuberculosis is an infrequent but notable cause of cervicomedullary compression. It should be suspected in patients with infective spondylitis who are immunocompromised or reside in an area highly endemic for tuberculosis. Management strategies include antituberculosis medication, transoral biopsy and drainage of the abscess, traction and external fixation, posterior decompression, and internal fixation, according to the clinical and radiological findings.