Clinical Characteristics and Etiologies of Miliary Nodules in the US: A Single-Center Study

Rare Case of Lower Gastrointestinal Bleeding Secondary to Miliary Tuberculosis in the United States

Tuberculosis (TB) remains a significant global health challenge. Miliary TB is a rare manifestation of TB that involves systemic lymphohematogenous dissemination of infection and presents diagnostic challenges due to its often asymptomatic or non-specific nature. This case report documents a rare occurrence of gastrointestinal (GI) bleeding secondary to miliary TB without pulmonary symptoms in an 81-year-old Filipino-American male living in the United States. Extensive imaging studies revealed a mass in the right colon with multiple bleeding vessels draped around it; it was not amendable to treatment with embolization and required right hemicolectomy with end ileostomy. The pathology report of the excised mass demonstrated miliary TB with necrotizing granulomas and granulomatous lymphadenopathy involving 23 lymph nodes. The patient was started on anti-tuberculosis medical management; however, the patient remained clinically unstable and expired on postoperative day 39. This case highlights the importance of the heightened clinical awareness required during times of globalization and in regions with dense immigrant populations. We aim to delineate the clinical understanding of gastrointestinal TB (GITB) and review possible indications for surgical management. We aim to help reduce diagnostic delay, therefore improving patient outcomes and limiting the spread of disease.

Deep learning for precise diagnosis and subtype triage of drug-resistant tuberculosis on chest computed tomography

Deep learning, transforming input data into target prediction through intricate network structures, has inspired novel exploration in automated diagnosis based on medical images. The distinct morphological characteristics of chest abnormalities between drug-resistant tuberculosis (DR-TB) and drug-sensitive tuberculosis (DS-TB) on chest computed tomography (CT) are of potential value in differential diagnosis, which is challenging in the clinic. Hence, based on 1176 chest CT volumes from the equal number of patients with tuberculosis (TB), we presented a Deep learning-based system for TB drug resistance identification and subtype classification (DeepTB), which could automatically diagnose DR-TB and classify crucial subtypes, including rifampicin-resistant tuberculosis, multidrug-resistant tuberculosis, and extensively drug-resistant tuberculosis. Moreover, chest lesions were manually annotated to endow the model with robust power to assist radiologists in image interpretation and the Circos revealed the relationship between chest abnormalities and specific types of DR-TB. Finally, DeepTB achieved an area under the curve (AUC) up to 0.930 for thoracic abnormality detection and 0.943 for DR-TB diagnosis. Notably, the system demonstrated instructive value in DR-TB subtype classification with AUCs ranging from 0.880 to 0.928. Meanwhile, class activation maps were generated to express a human-understandable visual concept. Together, showing a prominent performance, DeepTB would be impactful in clinical decision-making for DR-TB.

Examining Miliary Disease Etiology in a Coccidioides-Endemic Center: A Retrospective Cohort Study

Background: A miliary pattern on chest imaging is often attributed to tuberculosis (TB) infection. However, a myriad of conditions can cause a miliary pattern, many of which are imminently life-threatening. Research Question: The primary aim of our study is to elucidate the potential causes of miliary chest imaging patterns to improve workup and empiric therapy selection. The secondary aims are to discern the predictors of miliary disease etiology and to determine whether appropriate empiric antimicrobial therapies were given. Study Design and Methods: In this retrospective cohort study, we searched a radiology database for patients with chest imaging studies described by the word "miliary". Subjects were excluded if they were under 18 years of age and if there were insufficient objective data to support a miliary disease etiology. A radiologist independently reviewed all imaging studies, and studies that did not appear to have a true miliary pattern were excluded. The collected data include patient demographics, immunocompromising risk factors, conditions associated with miliary disease, β-D-glucan levels, serum eosinophil count, and empiric therapies received. Results: From our 41-patient cohort, 22 patients (53.7%) were clinically diagnosed with coccidioidomycosis, 8 (19.5%) with TB, 7 (17.1%) with metastatic solid cancer, 1 (2.4%) with lymphoma, 1 (2.4%) with other (Mycobacterium simiae), and 3 (7.3%) with unknown diseases (the sum equals 42 patients because one individual was diagnosed with both coccidioidomycosis and TB). All six patients with greater than 500 eosinophils/μL were diagnosed with coccidioidomycosis. Of the 22 patients diagnosed with coccidioidomycosis, 20 (90.91%) were empirically treated with an antifungal regimen. Of the eight patients with TB, six were empirically treated for TB. Interpretation: Based on our data from a Coccidioides-endemic region with close proximity to tuberculosis-endemic areas, the leading cause of miliary disease is coccidioidomycosis, although TB and cancer are also common etiologies. Serum eosinophilia and elevated β-D-glucan levels were strongly predictive of coccidioidomycosis in our patient cohort with a miliary chest imaging pattern.

Pulmonary Histoplasmosis in People Living with Human Immunodeficiency Virus in French Guiana: Clinical Epidemiology, Medical Imaging and Prognostic

BACKGROUND

Histoplasmosis is mainly described as a disseminated disease in people living with HIV (PLHIV). Compared to historical descriptions in immunocompetent individuals, knowledge is lacking on the detailed clinical and radiological findings and outcomes of pulmonary histoplasmosis (PH). Overlooked or misdiagnosed with other AIDS-defining condition, prognostic of PLHIV may be at risk because of inappropriate care.

METHODS

A retrospective multicentric study was conducted in PLHIV from French Guiana between January 1988 and October 2019. Proven PH were documented through mycological direct examination, culture, or histology. Patients with concomitant respiratory infections were excluded.

RESULTS

Among 65 patients, sex ratio M:F was 2.4 with a median age of 39 years [IQR 25-75%: 34-44]. Median CD4 count was 24 cells/mm3 [11-71], with histoplasmosis as the AIDS-defining condition in 88% and concomitant AIDS-defining conditions in 29%. Clinical findings were fever (89%), cough (58%), dyspnea (35%), expectoration (14%), and hemoptysis (5%). Sixty-one X-rays and 24 CT-scans were performed. On X-rays, an interstitial lung disease was mainly found (77%). On CT-scans, a nodular pattern was predominant (83%): mostly miliary disease (63%), but also excavated nodules (35%). Consolidations were present in 46%, associated with miliary disease in 21%. Thoracic lymphadenopathies were found in 58%, mainly hilar and symmetric (33%). Despite antifungal treatment, case-fatality rate at one month was 22%.

CONCLUSION

When faced with an interstitial lung disease on X-rays or a miliary pattern on CT-scans in advanced PLHIV, physicians in endemic areas, apart from tuberculosis or pneumocystosis, should include histoplasmosis as part of their differential diagnoses.

Factors related to mortality in critically ill histoplasmosis: a multicenter retrospective study in Guadeloupe and French Guyana

PURPOSE

To describe clinical and biological features and the outcomes of patients admitted for histoplasmosis in two intensive care units (ICU) in French Guyana and in the French West Indies (Guadeloupe).

METHODS

All patients admitted to these two ICUs for culture-proven histoplasmosis between January 2014 to August 2022 were included in the study. Using univariate and multivariate analysis, we assessed risk factors at ICU admission that were associated with death.

RESULTS

Forty patients were included (65% men). Median age was 56 years and simplified acute physiologic score (SAPS) II was 65. HIV was found in 58%, another immunodeficiency was identified in 28%, and no underlying immunodeficiency could be identified in 14% of patients. Within the first 24 h of ICU admission, 85% of patients had acute respiratory failure, 78% had shock, 30% had coma, and 48% had hemophagocytic lymphohistiocytosis. Mechanical ventilation was instituted in 78% of patients and renal replacement therapy in 55%. The 30-day mortality was 53%. By multivariate analysis, factors independently associated with 30-day mortality were SOFA score (odds ratio [OR] 1.5, 95% confidence interval [CI] [1.1-2.1]), time between symptom onset and treatment per day (OR 1.1, 95% CI 1.0-1.1), and hemophagocytic lymphohistiocytosis (OR 6.4, 95% CI 1.1-47.5).

CONCLUSION

Histoplasmosis requiring ICU admission is a protean disease with multiple and severe organ involvement. Immunodeficiency is found in most patients. The prognosis remains severe despite appropriate treatment and is worsened by late treatment initiation.

Case Report: Recombinant Human Endostatin Plus Chemotherapy for Epidermal Growth Factor Receptor-Negative Miliary Lung Adenocarcinoma

Except for the traditional chemotherapy, few treatments strategy about miliary intrapulmonary carcinomatosis (MIPC) have been reported in the existing literature. In this report, we primarily discussed the possible etiology and the potentially effective treatment options for a patient with MIPC who benefited from combined treatment. A nonsmoking woman was diagnosed with MIPC at an advanced stage. Gene detection showed an EGFR negative status. She accepted first-line chemotherapy with pemetrexed and cisplatin, and the tumor progressed. Next, PD-1 inhibitors plus pemetrexed and cisplatin were administered, and the tumor remained uncontrolled. After two cycles of recombinant human endostatin plus second-line chemotherapy, the numerous pulmonary nodules had all nearly completely disappeared, while an accentuated decrease in the primary tumor volume was observed. Moreover, biochemical markers, including the patient’s tumor markers, also trended toward normal. This report describes the first case of a MIPC patient who significantly responded to antiangiogenic therapy combined with chemotherapy. Anti-angiogenic therapy may be a possible strategy for the EGFR-negative lung adenocarcinoma population.

The development and validation of a diagnostic scoring system to differentiate pulmonary tuberculosis from non-tuberculosis pulmonary infections in HIV-infected patients with severe immune suppression

Background

It remains challenging to differentiate tuberculosis (TB) from non-TB pulmonary infections in HIV-infected patients. Herein, we developed a scoring system aimed to rapidly determine the likelihood of TB or non-TB pathology in HIV-infected patients presenting with pulmonary infections.

Methods

We collected and collated data of hospitalized HIV-infected patients with pulmonary infections, followed by univariate and multivariate data analyses to determine risk variables that were significantly different between HIV/TB patients and HIV/non-TB patients. Subsequently, a regression coefficient was calculated for each variable, and a score was assigned to each variable in line with its regression coefficient. The sum of the scores for each variable in our scoring model was used to predict the likelihood of TB or non-TB pulmonary infection in each patient. Finally, we tested the diagnostic accuracy of the scoring system in our retrospective cohort, as well as in a prospective cohort.

Results

A total of 598 HIV-infected patients were enrolled in our retrospective cohort, among whom 288 had TB and 310 had non-TB pulmonary infections. Eight variables, including fever, highest body temperature, erythrocyte sedimentation rate (ESR), cervical lymphadenopathy, hilar and/or mediastinum lymphadenopathy, pulmonary cavitation, pleural effusion, and miliary nodules, were found to be mathematically significantly different via univariate analysis and multivariate logistic regression analysis. After regression coefficient calculation followed by score assignment, a receiver operating characteristic (ROC) curve was plotted, and the area under the curve (AUC) was calculated to be 0.902. When the total score for a patient is > 12, the sensitivity and specificity for TB prediction using our scoring system were 76.4% and 87.7% respectively in the retrospective cohort, and its diagnostic accuracy was 82.7% in the prospective cohort.

Conclusions

Our results demonstrate that our proposed diagnostic scoring system could be helpful in differentiating pulmonary TB from non-TB pulmonary infections in HIV-infected patients.

Artificial Intelligence System Application in Miliary Lung Metastasis: Experience from a Rare Case

Introduction

Miliary intrapulmonary carcinomatosis (MIPC) is very rare in the existing literature. We reported a lung adenocarcinoma patient presented with over 200 uniform size pulmonary nodules in all lung lobes at the initial examination. The application of artificial intelligence (AI) in lung cancer has been gradually reported, but not yet reported in MIPC. The application of AI in this rare disease is worth exploring.

Patient Information

A 57-year-old woman received chest computed tomography (CT) scan because of dry cough, intermittent chest wall and back pain for 3 weeks. CT imaging found over 200 uniform size pulmonary nodules in an evenly dispersed pattern at bilateral lungs with a 38×45mm new creature at the dorsal segment of the lower lobe of the left lung. However, as a very reliable diagnostic assistant system in CT imaging of lung cancer, AI can only identify 18 nodules in such classic metastatic lung cancer case.

Conclusion

This case provides classical imaging figures as textbook-like, even though there is no such classic imaging of lung metastases in the existing textbooks. This medical imaging material will impress medical students and help them learn about the disease deeply. This medical imaging material can warn patients to recognize the horror of lung cancer metastasis and has good popularization of science. This medical imaging material presents a new challenge for AI.

The Great Italian Masquerade

Tuberculosis and sarcoidosis are both granulomatous diseases centered on the lung but capable of myriad extrapulmonary manifestations. Because of substantial similarity in their presentations, these two entities can be notoriously challenging to differentiate. This can be particularly true of countries in which tuberculosis is rarely encountered because of a reflexive tendency to ascribe granulomatous inflammation in the lung to sarcoidosis, especially if the granulomas are non-necrotizing. However, as our case from a non-endemic country reminds, sarcoidosis can be comfortably diagnosed only after convincing exclusion of infectious causes of granulomas. Distinguishing these two diseases is of utmost importance as, despite their overlapping presentations, they have completely non-overlapping treatments which can lead to harm if erroneously applied. At the end of our discussion, we summarize the clinical features favoring one diagnosis over the other.

Sarcoidosis and Cancer: A Complex Relationship

Sarcoidosis is a systemic disease of unknown etiology, characterized by the presence of non-caseating granulomas in various organs, mainly the lungs, and the lymphatic system. Since the individualization of sarcoidosis-lymphoma association by Brincker et al., the relationship between sarcoidosis or granulomatous syndromes and malignancies has been clarified through observational studies worldwide. Two recent meta-analyses showed an increased risk of neoplasia in sarcoidosis. The granulomatosis can also reveal malignancy, either solid or hematological, defining paraneoplastic sarcoidosis. Recent cancer immunotherapies, including immune checkpoint inhibitors (targeting PD-1, PD-L1, or CTLA-4) and BRAF or MEK inhibitors were also reported as possible inducers of sarcoidosis-like reactions. Sarcoidosis and neoplasia, especially lymphoma, can show overlapping presentations, thus making the diagnosis and treatment harder to deal with. There are currently no formal recommendations to guide the differential diagnosis workup between the evolution of lymphoma or a solid cancer and a granulomatous reaction associated with neoplasia. Thus, in atypical presentations (e.g., deeply impaired condition, compressive lymphadenopathy, atypical localization, unexplained worsening lymphadenopathy, or splenomegaly), and treatment-resistant disease, targeted biopsies on suspect localizations with histological examination could help the clinician to differentiate neoplasia from sarcoidosis. Pathological diagnosis could sometimes be challenging since very few tumor cells may be surrounded by massive granulomatous reaction. The sensitization of currently available diagnostic tools should improve the diagnostic accuracy, such as the use of more “cancer-specific” radioactive tracers coupled with Positron Emission Tomography scan.

Diffuse Lung Metastases in EGFR-Mutant Non-Small Cell Lung Cancer

Diffuse lung metastases have been reported in non-small cell lung cancer (NSCLC) harboring epidermal growth factor receptor (EGFR) mutations. The purpose of our study was to compare the incidence of diffuse lung metastases in EGFR-mutant NSCLC and EGFR-wild type NSCLC and to assess other imaging features that may be associated with diffuse lung metastases in EGFR-mutant NSCLC. Two radiologists retrospectively reviewed pre-treatment imaging of metastatic NSCLC cases with known EGFR mutation status. We assessed the imaging features of the primary tumor and patterns of metastases. The cohort consisted of 217 patients (117 EGFR-mutant, 100 EGFR wild-type). Diffuse lung metastasis was significantly more common in EGFR-mutant NSCLC compared with wild-type (18% vs. 3%, p < 0.01). Among the EGFR-mutant group, diffuse lung metastases were inversely correlated with the presence of a nodule greater than 6 mm other than the primary lung lesion (OR: 0.13, 95% CI: 0.04–0.41, p < 0.01). EGFR mutations in NSCLC are associated with increased frequency of diffuse lung metastases. The presence of diffuse lung metastases in EGFR-mutant NSCLC is also associated with a decreased presence of other larger discrete lung metastases. EGFR mutations in NSCLC should be suspected in the setting of a dominant primary lung mass associated with diffuse lung metastases.

Histoplasmosis and Tuberculosis Co-Occurrence in People with Advanced HIV

Distinguishing between histoplasmosis, tuberculosis (TB), and co-occurrence of disease is a frequent dilemma for clinical staff treating people with advanced Human Immunodeficiency Virus (HIV) infection. This problem is most frequently observed in clinical settings in countries where both diseases are endemic. It is also a challenge outside these endemic countries in HIV clinics that take care of patients coming from countries with endemic histoplasmosis and TB. The gold standard for diagnosis of both of these diseases is based on conventional laboratory tests (culture, histopathology and special stains). These tests have several limitations, such as lack of laboratory infrastructure for handling isolates (biosafety level 3), shortage of laboratory staff who have appropriate training and experience, variable analytical performance of tests and long turn-around time. Recently, novel rapid assays for the diagnosis of histoplasmosis and TB became available. However, this technology is not yet widely used. Mortality in immunocompromised patients, such as people with advanced HIV, is directly linked with the ability to rapidly diagnose opportunistic diseases. The aim of this review is to synthesize the main aspects of epidemiology, clinical characteristics, diagnosis and treatment of histoplasmosis/TB co-occurrence in people with advanced HIV.

Factors for the Early Revision of Misdiagnosed Tuberculosis to Lung Cancer: A Multicenter Study in A Tuberculosis-Prevalent Area

Background: Lung cancer misdiagnosed as tuberculosis (TB) is not rare, but the factors associated with early diagnosis revision remain unclear. Methods: We screened the cases with TB notification from 2007 to 2018 and reviewed those with misdiagnosis with a revised diagnosis to lung cancer. We analyzed the factors associated with early diagnosis revision (≤1 months) and early obtained pathology (≤1 months) using multivariable Cox regression. Results: During the study period, 45 (0.7%) of 6683 patients were initially notified as having TB, but later diagnosed with lung cancer. The reasons for the original impression of TB were mostly due to image suspicion (51%) and positive sputum acid-fast stain (AFS) (27%). Using multivariable Cox proportional regression, early diagnosis revision was associated with obtaining the pathology early, lack of anti-TB treatment, and negative sputum AFS. Furthermore, the predictors for early obtained pathology included large lesion size (>3 cm), presence of a miliary radiological pattern, no anti-TB treatment, and a culture-negative result when testing for nontuberculous mycobacteria (NTM) using multivariable Cox regression. Conclusion: In patients who are suspected to have TB but no mycobacterial evidence is present, lung cancer should be kept in mind and pathology needs to be obtained early, especially for those with small lesions, radiological findings other than the miliary pattern, and a culture positive for NTM.