[Disseminated tuberculosis in non-immunocompromised host: three case reports]

INTRODUCTION

Disseminated tuberculosis, i.e., tuberculosis involving lung, liver, spleen, bone marrow and lymph nodes is rare (2.8%), particularly when immunocompromised diathesis is lacking.

EXEGESIS

We report three cases of disseminated tuberculosis confirmed by bacteriology or histology, which occurred in non-immunocompromised patients. Disease evolution under antituberculous treatment was favorable in two cases and fatal in the third one.

CONCLUSION

Disseminated tuberculosis must be suspected when miliary pulmonary lesions are associated with hematologic abnormalities, even in non-immunocompromised host. Early treatment is mandatory to avoid fatal outcome.

[Pathogenetic aspect of the diagnosis of tuberculous lymphadenitis]

Based on their own experimental (55 rabbits) and clinical (114 patients) findings, the authors propose a new immunopathogenetic approach to diagnosing tuberculous lymphadenitis under the present-day conditions by taking into account the environmental situation. They describe an original enzyme immunoassay for lymph nodal extracts, which has yielded positive results: 88% sensitivity, 92% specificity, and 90% diagnostic efficiency.

Isolated cervical tuberculosis in patients with HIV infection

OBJECTIVE

Tuberculosis isolated to the head and neck region is common in patients with HIV infection. However, the management of isolated head and neck tuberculosis has not been reported in the literature. This study was done to describe the characteristics of tuberculosis isolated to the head and neck region in patients infected with HIV and to detect differences in presentation and diagnostic management based on the status of HIV infection at presentation.

METHODS

A retrospective study was performed including 38 patients infected with HIV who were seen with tuberculosis isolated to the head and neck region at two tertiary care centers during a 10-year period. These patients were divided into two groups on the basis of the HIV status at presentation, which indirectly reflects the level of immunosuppression. Group 1 included 11 patients (29%) with AIDS at presentation. Group 2 included 27 patients (71%) with HIV infection but not AIDS.

RESULTS

The cervical lymphatics were the most common site for isolated head and neck tuberculosis (89%), with the supraclavicular nodes most often involved (53%). Extralymphatic involvement was less common (11%), but involved a variety of anatomic locations (skin, spinal cord, larynx, parotid). The presenting history and physical examination had a low sensitivity for tuberculosis in patients with HIV infection, mainly because of the presence of multiple confounding factors. Purified protein derivative testing was highly sensitive for tuberculosis in patients with HIV infection alone (61 %); however, its usefulness was diminished in patients with AIDS (14%; p=0.03). Fine-needle aspiration biopsy was 94% sensitive for diagnosing tuberculosis and was not affected by the status of HIV infection. Surgical biopsy was the gold standard for diagnosing tuberculosis but was associated with chronically draining fistulas in a significant number of cases (14%).

CONCLUSIONS

These data suggest that tuberculosis should be considered in the differential diagnosis of all head and neck lesions in patients infected with HIV, even in the absence of pulmonary involvement. Purified protein derivative testing should be done liberally in these patients, with realization that the sensitivity of purified protein derivative testing is reduced in patients with AIDS. Fine-needle aspiration biopsy should be the key diagnostic test in this patient population, with open surgical biopsy reserved for highly suspicious cases in which other measures were not diagnostic.

[Tuberculous lymphadenitis as a topical problem of phthisiology]

The paper presents the results of follow-up of 894 patients in 1983 - 1993. The increasing topicality for physiology and the potentialities of making the diagnosis of the disease better are defined, based on the data on the pathogenesis and pathomorphism of tuberculous lymphadenitis and on the results of testing new diagnostic techniques, including cytological and histological studies of sections and imprints, enzyme immunoassay, and polymerase chain reaction.

Surgical treatment of bacillus Calmette Guérin lymphadenitis

Although its protective effect is contested and the risk of contracting tuberculosis is rather low nowadays, BCG vaccination is frequently performed. Changes of strain repeatedly led to an increased complication rate. In Austria between 1990 and 1991, of 3386 newborn babies (Strain Pasteur) 116 developed lymphadenitis 3 to 28 weeks after vaccination. The affected children received four types of treatment: nothing specific, isoniazid, or surgery with and without isoniazid. Surgical treatment was found to be necessary in 96 cases. Bacilli were successfully grown in culture in 46% of cases up to week 20 after vaccination; but later than 20 weeks no culture became positive. All cultured bacteria were isoniazid-sensitive. From our data we drew the following conclusions: isoniazid therapy did not prove successful when inflamed lymph nodes exceeded a certain size. Suppurative lymphadenitis in lymph nodes exceeding 1.0 to 1.5 cm usually led to infiltration or even perforation of the skin. Surgery prevents these complications and significantly reduces healing time. Adjuvant isoniazid therapy cannot be recommended, except for generalized BCG tuberculosis.

Unusual presentations of extrapulmonary tuberculosis in three hemodialysis patients

We report three patients who received maintenance hemodialysis and suffered from extrapulmonary tuberculosis with unusual presentations. The first patient presented with fever of unknown origin. All studies showed negative findings except high erythrocyte sedimentation rate and high value of C-reactive protein. He failed to response to broad-spectrum antibiotics but showed a complete response to antituberculosis therapy. The second patient presented with right supraclavicular lymphadenopathy and weakness. Lymph node biopsy revealed caseating granuloma with positive acid-fast bacilli. The third patient presented with tumor mass of left sternoclavicular joint for which malignancy was suspected initially. Ultimately, tuberculosis was documented by histopathologic studies showing caseating granuloma. All three patients had normal findings of chest x-ray and did not have previous history of tuberculosis and diabetes mellitus.

Cervical tuberculous lymphadenitis in a frequent traveler to endemic areas of tuberculosis

Scrofula or cervical tuberculous lymphadenitis (CTBL) should be suspected in patients with a history of potential exposure to tuberculosis present with cervical lymphadenopathy. A 55 year-old frequent traveler to Philippine and Thailand developed swelling of the bilateral cervical lymph nodes, and positive conversion of purified protein derivative of tuberculin (PPD) without pulmonary manifestations. The excisional biopsy of the cervical lymph nodes was useful for prompt diagnosis of CTBL, and the patient was successfully treated with isoniazid (INH) and rifampicin (RFP).

Child's tuberculous lymphadenitis with fistula evoked by the BCG stem

Lymphadenitis with persisting fistualas in children is almost always conditioned by specific inflammation, tuberculosis, zoonoses, actinomycoses. Tuberculosis of the lymph nodes can either be primary or post-primary. In this case report we have dealt with a case of a rare primary lymph node tuberculosis that arose as a result of vaccination complications. Disturbance of cellular immunity was the reason for BCG lymphadenitis. In references, the reasons for BCG-itis as well as vaccination contra-indications have been described.

[Tuberculosis of the lymph nodes with esophageal-cutaneous fistula in a patient with AIDS]

A case of patient with the tuberculosis of lymph nodes and esophago-cutaneous fistula in the course of AIDS has been presented. A valve has been formed within fistula enabling to visualize a free passage only after an oral contrast administration. It is worth noting that tuberculosis frequently accompany severe course of AIDS.

[Tuberculosis in chronic renal failure patients with or without renal replacement therapy]

Tuberculosis developed in 40 out of 978 chronic renal failure (CRF) patients with or without renal replacement therapy during a five-year period. The incidence was 4.1% and was 10 times higher than that in the general population. The onset of symptoms was within 1 year after dialysis or kidney transplantation in 68% of the patients. 82.5% of them had predominantly extrapulmonary tuberculosis and most of these were lymph node infection. The diagnosis of tuberculosis in these patients was difficult; tuberculin sensitivity was present only in 6.4% of the patients and examination of sputum and other fluid for mycobacteria was usually unrewarding. Detecting serum anti-PPD-IgG level might be a valuable supplementary diagnostic method, because 85% of patients with active tuberculosis showed positive results. Measuring serous exudate and urine anti-PPD-IgG level by ELISA or M. Tuberculosis DNA by PCR might be helpful in the diagnosis of tuberculous serositis and urinary tract mycobacterial infection.

Tuberculosis caused by Mycobacterium africanum associated with involvement of the upper and lower respiratory tract, skin, and mucosa

Cutaneous tuberculosis is rarely seen in industrialized countries and is usually caused by Mycobacterium tuberculosis. We report a case of cutaneous tuberculosis with bilateral nodular scleritis, nasal sinus invasion, and nasal septum perforation (confirmed by computed tomography scans of the sinuses), associated with pulmonary infiltrates and mediastinal adenopathy, in an African woman. Mycobacterium africanum was recovered from the sputum after 8 weeks of culture in Löwenstein-Jensen medium. To our knowledge, this is the first description of M. africanum associated with cutaneous tuberculosis and nasal sinus invasion.

Bilateral inguinal scrofuloderma during steroid therapy in a patient with bullous pemphigoid

This report described a case of scrofuloderma that developed in the bilateral inguinal regions during treatment of bullous pemphigoid with systemic corticosteroid. Analysis of the literature on scrofuloderma between 1978-1993 disclosed that the number of cases with extracervical involvement are increasing. Immunosuppression could disseminate tuberculous focuses, resulting in extracervical involvement of SD connected with the underlying extrapulmonary tuberculous lesions.

Adverse reactions to BCG

In the post-war period the following BCG vaccines were successively in use for preventive vaccination in the Czech territory: (a) Copenhagen BCG, 1947-1950, (b) Prague BCG 725, 1951-1980, (c) Moscow BCG, 1981-1993, and (d) Behring BCG, from 1994 onwards. These BCG substrains can be now identified by modern methods of molecular genetics. Introducing the Moscow BCG brought about an elevated incidence of iatrogenic local and regional lymph node adverse reactions compared with the previous Prague BCG product and, as a new phenomenon, bone and joint involvements in children vaccinated at birth. The aim of this study was to analyze the incidence of postvaccination adverse reactions reported in the period from 1981 to 1993 as related to the Moscow BCG vaccine and, to demonstrate the effect of lower vaccination dosage on their frequency. The concentration of the Moscow BCG varied from 11 to 22.6 x 10(6) (average 16.2) CFU per 1 mg. In the period when full dose of BCG (0.05 mg per 0.1 ml) was applied to newborns 437 local and 195 regional lymph node complications were recorded, i.e. 0.08% of vaccinated were affected, demanding antituberculosis chemotherapy in 6.5% and surgical interventions in 24%. When the lowered vaccination dose (0.025 mg per 0.1 ml) was inoculated to newborns the local adverse reactions rose paradoxically affecting 0.1% of vaccinated but the regional lymph node reactions fell considerably to reach 0.01%; the demand for chemotherapy and surgery also fell down to 3.1 and 4.8% respectively. Bone and joint adverse involvements were recorded in 28 cases, i.e. in 3.7 per 10(5) of those vaccinated with the full dose.(ABSTRACT TRUNCATED AT 250 WORDS)

[Tuberculosis in Africans hospitalized in Paris. Impact of infection by the human immunodeficiency virus]

OBJECTIVES

Human immunodeficiency virus (HIV) infection has greatly modified the epidemiology and clinical course of tuberculosis. The aim of this study was to analyze the characteristics of tuberculosis in African patients hospitalized in Paris by comparing clinical features in patients with and without HIV infection.

METHODS

Hospital records of 71 patients from Africa hospitalized between 1989 and 1992 in Paris with a certain or probable diagnosis of tuberculosis were studied retrospectively.

RESULTS

There were 30 patients (42%) with HIV infection. In 12 of them (40%) HIV positivity was discovered at diagnosis of tuberculosis. Age, sex, and duration of residence in France before diagnosis were similar between HIV+ and HIV- patients. Pulmonary tuberculosis was found in 23 patients and extrapulmonary forms (mainly lymph node involvement) were seen in 34; both in 14 patients. There was no difference in localization between HIV+ and HIV- patients except for disseminated tuberculosis which was more frequent in HIV+ patients. Skin reactions to tuberculin were positive in 76% and 97% of the HIV- and HIV+ patients respectively (p < 0.02). Drug resistance was observed in 8 patients (6 HIV+): streptomycin (n = 6), pyrazinamide (n = 2), isoniazide (n = 2), ethambutol (n = 1) and rifampicin (n = 1). Drug therapy was successful in controlling the initial manifestations of tuberculosis in both HIV+ and HIV- patients.

CONCLUSION

Extrapulmonary forms of tuberculosis, especially lymph node infection was more frequent in Africans hospitalized in Paris, whether the patients were HIV positive or negative. HIV infection was associated with disseminated tuberculosis, non-excavated pulmonary tuberculosis and undesirable side effects of antituberculosis drugs.

[Periportal adenitis secondary to abdominal tuberculosis. A CT study]

Isolated periportal tuberculous adenitis is rare. Computed tomography (TC) is the primary modality for its detection and evaluation. Although not definitive, in the presence of an appropriate clinical history and a positive purified protein derivative test, a diagnosis of periportal tuberculous lymphadenopathy may be suggested by CT by the presence of low-density enlarged porta hepatis lymph nodes with immediate postcontrast peripheral rim enhancement.

Lichen scrofulosorum in a patient with AIDS

A patient with AIDs who presented with pulmonary tuberculosis and cervical scrofuloderma developed a widespread eruption of lichenoid papules shortly after commencing antituberculous therapy. The clinical and histological features in this case were consistent with lichen scrofulosorum even though the tuberculin test was negative. To our knowledge this is the first reported case of lichen scrofulosorum in an HIV positive patient. The lesions cleared following 8 weeks of antituberculous therapy.

[Findings of bile duct ultrasonography in 100 patients with AIDS in black Africa]

A systematic study of bile ducts by abdominal echotomography on 100 African patients affected by AIDS disease has showed 11 bile ducts abnormalities (7 alithiasic cholecystitis and 6 inflammatory cholangitis, associated in 2 cases). The patients studies showed several associated infections, particularly a pulmonary tuberculosis and/or extra-pulmonary. The etiology of bile ducts attack has not been formally specified: lack of Cryptosporidium at the stools parasitologic exam, but presence of several opportunistic germs, or no, in the several samples (blood, cerebrospinal fluid, stools, expectoration).

Infection with Mycobacterium bovis in a patient with AIDS: a late complication of BCG vaccination

We present a 28-year-old HIV-infected man with a 2-year delayed complication of BCG immunization. When immunized the man was healthy, with an unknown HIV status, but 2 years later he was diagnosed with AIDS because of a Pneumocystis carinii pneumonia. He was successfully treated and discharged in a state of good health. A few months later he presented with an enlarged lymph node and Mycobacterium bovis, BCG strain, was cultured. No sign of dissemination was found. We discuss the indications for BCG vaccination in adults, especially in areas and in populations with a high prevalence of HIV.

[A case report on tuberculosis with remittent fever after tonsillectomy in a patient under CAPD]

This report pertains to a case of chronic renal failure with remittent fever after tonsillectomy. The patient was 45-year-old female who had been undergoing continuous ambulatory peritoneal dialysis (CAPD) for five years. She was admitted to our hospital after being diagnosed as having pyrexia with tonsillitis. A tonsillectomy was performed. Although several symptoms and signs, such as fever, positive CRP and accelerated ESR, improved transiently by the seventh postoperative day, remittent fever and cervical lymph node swelling suddenly recurred after the eighth postoperative day. In spite of the antibiotic therapy, the fever continued for two weeks thereafter. A culture to check for acid-fast bacilli was negative, but on epithelioid cell granuloma with a small central abscess was found in the biopsy specimen of the lymph node. INH was prescribed to her. After three days of INH administration, the patient became afebrile. Patients with long-term dialysis are known to be very susceptible to tuberculous diseases. However, to date, there has been no report of tuberculosis being accompanied by a fever after a tonsillectomy. As it might be difficult to make a tubercular diagnosis on such a febrile patient, early antituberculous chemotherapy is recommended for patients with antibiotic-refractory fever.

The re-emergence of scrofula with HIV infection: a review of epidemiology, pathogenesis, diagnosis and treatment

Scrofula has been called "The Dangerous Masquerader" because of its propensity to mimic other diseases. Scrofula has been mistaken for metastatic carcinoma, regional neoplasms, thyroglossal duct cysts, fungal disease, toxoplasmosis, lymphoma, osteosarcoma, chondrosarcoma, bacterial adenitis, and collagen vascular disease. Because of the enormous number of infectious and neoplastic diseases acquired by the HIV positive population, the diagnosis of scrofula may be further delayed in some patients. In these patients the early diagnosis of scrofula might allow the early identification of HIV infection and the early institution of anti-retroviral therapy. The recommended duration of anti-tuberculosis therapy is also different in HIV positive patients. Therefore, to ensure the patient of the most beneficial therapy, the physician must always consider scrofula in the differential diagnosis of a neck mass, and particularly because of the increases incidence of intrapulmonary tuberculosis in AIDS patients, he must consider the possibility of HIV infection.

[Abdominal tuberculosis in patients with acquired immunodeficiency syndrome]

BACKGROUND

In individuals with HIV infection, extrapulmonary forms of tuberculosis are considered as opportunistic infections and are included in the diagnosis of AIDS. They often have atypical clinical features. Abdominal participation is uncommon and its diagnosis may be difficult.

METHODS

The clinical, radiological and pathological features of patients with a diagnosis of AIDS with abdominal tuberculosis in a series of 254 AIDS cases in a general hospital from 1984 to October 1990 were reviewed.

RESULTS

Tuberculosis developed in 104 (41%) of AIDS patients. In 25 (24%) the disease was exclusively pleuropulmonary and in 79 (76%) extrapulmonary tuberculosis was present, either alone or in association. Extrapulmonary tuberculosis was the first opportunistic infection in 66 AIDS cases (26%). The abdominal participation was demonstrated in 19 patients, with the following localizations: lymph nodes (9), liver (8), spleen (5), ileum (1) and peritoneum (1). Four patients with splenic tuberculosis also had multifocal nodular lesions.

CONCLUSIONS

Abdominal participation was found in 19 of the 104 AIDS patients with tuberculosis (18%). Lymph node involvement was the most common type. Hepatosplenic tuberculosis had a miliary form or showed multifocal images in echography or computed tomography.

[Tuberculous hilar lymphadenopathy: a survey of recent cases. Study of the variations in clinical manifestations and the mode of onset]

Forty-eight cases of tuberculous hilar lymphadenopathy were studied comparatively between the groups experienced before and after 1975. We found the following characteristics in the clinical manifestations and in the mode of onset among the recent cases as against the classical ones. (1) Age distribution of cases shifted from younger to elderly groups. (2) Roentgenologically, typical primary complex has been decreasing, while the atypical patterns such as solitary mediastinal lymphadenopathy or those associated with healed pulmonary lesions have increased. (3) Since the introduction of RFP to the treatment of tuberculosis, cases of hilar lymphadenopathy incidentally diagnosed with the early exacerbation due to RFP has been increasing. (4) Of the total of 48 cases, 10 were presumed not being originated from the primary infection, but from reactivation. (5) Relative increase of such cases may partly explain the shift of hilar lymphadenopathy to elderly group.

[BCG-induced inflammation during childhood and in pregnancy. Additionally a contribution to BCG-induced necrotising cerebral arteritis]

In the third year of life of a girl vaccinated neonatally against tuberculosis an abscess of the associated lymph nodes appeared which contained acid-fast bacilli. After extirpation of the lymph nodes weeks later an intestinal BCG-dissemination was observed which seemed to be cured under a brief tuberculostatic therapy. At the age of 22 years a left sided hemiplegia due to aneurysms and thrombosis of 2 cerebral arteries was seen. At autopsy in the adventitia of the arteria basilaris macrophages were discovered which showed intracellular acid-fast bacilli. A paralysis of the oculomotor nerve appearing later was also caused by this brain lesion. Towards the end of a pregnancy a serious BCG-dissemination in the intestines relapsed. A healthy premature child was born. Massive tuberculostatic therapy was inefficient. The woman died in her 27th year of life. A defective function of the macrophages is suggested for the immunological abnormality.

[Esophagobronchial fistula of tuberculous origin]

We present the case of an asymptomatic male in whom bilateral hilar and right paratracheal lymph node enlargement was a casual finding. An esophagogram was performed to evaluate possible mediastinal nodes and an esophagobronchial fistula was discovered. In view of the coexistence of lymph node enlargement and esophagobronchial fistula, the case was presumed to be tuberculosis, as was confirmed by sputum culture positive for Mycobacterium tuberculosis. After tuberculostatic treatment, the course was favorable. Closure of the fistula was confirmed in a later follow-up.

Intrathoracic lymphadenopathy in postprimary tuberculosis

In the past, hilar or mediastinal lymphadenopathy was considered by many to be a feature of only the primary or first infection with Mycobacterium tuberculosis, and to exclude the diagnosis of reactivation or postprimary tuberculosis. In a series of 56 adult patients with documented postprimary disease due to M tuberculosis, we found hilar or mediastinal lymphadenopathy in three cases (5%). Although intrathoracic lymphadenopathy was more common in primary tuberculosis, we do not believe that intrathoracic lymphadenopathy is as specific for primary tuberculosis, particularly in the adult, as was once thought. For this reason, we believe that the roentgenographic demonstration of intrathoracic lymphadenopathy should not be used as a definitive research or clinical criterion for primary tuberculosis in an adult.

Secondary tuberculosis of the skin. Clinical features and problems in laboratory diagnosis

One hundred patients with secondary skin tuberculosis--59 with lupus vulgaris (LV), 27 with scrofuloderma (SD), and 14 with tuberculosis verrucosa cutis (TVC)-were included in this study. The buttocks and lower limbs were seen to be important sites of involvement in LV, besides the occurrence over the face. An active focus of tuberculosis was present in 18, a past history of pulmonary tuberculosis in 8, and intrafamilial tuberculous infections in 21. Histopathology and culture for Mycobacterium tuberculosis were done in all the cases. Guinea pig inoculation was done in 11. The poor results of these investigations have been highlighted and discussed with reference to studies done in the past by other workers. The need for improvement in laboratory techniques is suggested.

Abdominal CT findings of disseminated Mycobacterium avium-intracellulare in AIDS

Disseminated infection from Mycobacterium avium-intracellulare (MAI) has recently been recognized as a common and serious complication of the acquired immunodeficiency syndrome (AIDS). The authors report the computed tomographic (CT) findings of 17 patients with AIDS and disseminated MAI referred for abdominal CT examination. Multiple large retroperitoneal and mesenteric lymph nodes were demonstrated in 14 patients (82%). MAI involvement was confirmed within abdominal lymph nodes in six patients by fine-needle percutaneous aspiration (five patients) or postmortem examination (one patient) and within enlarged peripheral lymph nodes in two other patients. The authors concluded that large, bulky, intraabdominal adenopathy in AIDS patients should suggest the diagnosis of MAI infection as well as other known causes of adenopathy, including lymphoma and metastatic Kaposi sarcoma. The authors recommend percutaneous aspiration of enlarged intraabdominal lymph nodes to establish the correct diagnosis.

Actinomycetales infection in the acquired immunodeficiency syndrome

Four parenteral drug abusers with the acquired immunodeficiency syndrome had nonmycobacterial actinomycetales infections. Three patients had nocardiosis and one developed a streptomyces lymphadenitis. There was pericardial involvement in two patients, and two patients died. Presumptive diagnoses were often incorrect, highlighting the risks of empiric therapy in these patients. Four of the nine patients with the acquired immunodeficiency syndrome and nocardia or streptomyces infections whose cases were reported to the Centers for Disease Control also had mycobacterial disease. A common susceptibility to these agents may exist in these immunosuppressed patients.