Inflammatory pseudotumor associated with Mycobacterium tuberculosis infection

An outcome-based composite approach for the diagnosis of intestinal tuberculosis: a pilot study from a tertiary care centre in South India

BACKGROUND

The diagnosis of intestinal TB (ITB) is challenging because of its overlapping features with Crohn's disease. This outcome-based study evaluated the combination of colonoscopy, histopathology, Xpert MTB/RIF and TB culture for best sensitivity and specificity.

METHOD

This was a four-year retrospective, observational study of 426 clinically suspected patients who underwent colonoscopy with biopsies for histopathology, Xpert MTB/RIF and TB culture. ITB was diagnosed using the composite reference standard (CRS), which comprised either histological features or culture or Xpert MTB/RIF positivity, and positive response to anti-tuberculous treatment on follow up.

RESULTS

35 (8.2%) patients were diagnosed with ITB. Histopathology had the highest sensitivity (91.4%) and negative predictive value (99.2%), MTB/RIF had the highest specificity (100%) and positive predictive value (100%). A combinatorial approach with Xpert MTB/RIF and histopathology had optimal diagnostic value (97%), approaching 100% sensitivity with culture. 40% of cases were diagnosed within 12 hours with Xpert MTB/RIF and 97% cases within three days.

CONCLUSION

This combinatorial diagnostic model provides rapid and reliable diagnosis of ITB which may be useful in endemic areas.

Non-neoplastic Soft Tissue Tumors and Tumor-like Lesions

Clinicians are commonly faced with patients presenting with a solitary palpable soft tissue mass. Most soft tissue lesions are benign, and not every mass is due to a neoplastic process. Many pathologies can mimic a malignant tumor. Despite appropriate clinicoradiologic assessment, these lesions can be mistaken for a soft tissue sarcoma and can lead to multiple investigations or an intervention, inconveniencing patients and leading to an increased health care cost. With the relevant clinical history, clinical examination, and specific imaging characteristics, the diagnosis can be narrowed. We present a pictorial review of soft tissue sarcoma mimics with guidance on appropriate differential diagnoses.

Disseminated Tuberculosis Mimicking Lung Cancer with Multiple Bone Metastasis: A Case Report

Tuberculosis (TB) is a contagious infectious disease caused by Mycobacterium tuberculosis (Mtb) of which attacking various organs particularly the lungs. Tuberculosis can occur together with malignancy or manifest as malignancy. Lung tuberculosis may appear in a variety of clinical and radiological manifestations caused by other diseases including tumors. These tumors are called pseudo-tumors. TB pseudo-tumor is a rare manifestation that can occur in immunocompetent patients in both primary and post-primary TB. The clinical presentation of TB pseudo-tumor is nonspecific and the clinical suspicion must be increased to diagnose related diseases. Radiological features can also be challenging to be distinguished from actual tumors. The classic manifestations of pulmonary TB are generally easy to diagnose due to the distinctive clinical and radiological characteristics nonetheless some pulmonary TB symptoms are also often found in patients with lung cancer. Infection patients resemble malignancies most were asymptomatic (> 27%) and the remaining 27% showed symptoms that varied with the average symptoms experienced about 1 month earlier. Clinical presentations that require a lot of misdiagnosis result in delayed treatment and unnecessary procedures. Establishing a diagnosis in cases of tuberculosis that causes malignancy is very important since the management and outcomes of the infection and malignancy process are quite different. Consequently we report a 24-year-old man with tuberculosis possible lung cancer with multiple bone metastase. Extrapulmonary tuberculosis which attacks bones and joints constitutes 10% to 20% of all TB cases. The location of bone and joint TB generally develops in the lumbar or thoracic vertebrae

Kidney inflammatory myofibroblastic tumor masquerading as metastatic malignancy: A case report and literature review

BACKGROUND

Inflammatory myofibroblastic tumor (IMT) is a rare mesenchymal tumor that is characterized by spindle cells differentiated from muscle fibroblasts and infiltration of various types of inflammatory cells. IMT can occur at any age and at any anatomic site. The most common location of IMT is the bladder in the genitourinary tract. Only scarce cases of kidney IMT have been reported in the literature.

CASE SUMMARY

A 77-year-old woman, with a history of bilateral renal calculus for 15 years, was admitted to the Department of Urology of our hospital complaining of recurrent painless gross hematuria for one month. The treatment with cephalosporin was ineffective. Computed tomography imaging showed a mixed density and slightly heterogeneously enhanced lesion in the middle pole of the left kidney and ipsilateral adrenal enlargement. The patient underwent surgical treatment by retroperitoneoscopic left radical nephrectomy plus adrenalectomy. A large number of typical spindle cells surrounded by plasma cells and lymphocytes were observed microscopically. Immunohistochemical analyses indicated that these spindle cells were positive for vimentin, cytokeratin (CK), Ki-67, CK7, CD34, and CD31 and were focally positive for CD10 and anaplastic lymphoma kinase (ALK-1). Thus, a diagnosis of IMT was made definitively. The patient recovered well after operation, and no recurrence or metastasis was noted during the 22-mo follow-up.

CONCLUSION

Since kidney IMT is very rare and lacks characteristic clinical manifestation, it is easily misdiagnosed as a malignant tumor before operation. Surgery remains the best choice for diagnosis and treatment, and such cases must be followed carefully because of the uncertain biological behavior of this tumor. This report suggests that renal calculus may be one of the causes of IMT, but further investigation is necessary to prove it.

Differentiating Crohn's disease from intestinal tuberculosis

Differentiating Crohn's disease (CD) and intestinal tuberculosis (ITB) has remained a dilemma for most of the clinicians in the developing world, which are endemic for ITB, and where the disease burden of inflammatory bowel disease is on the rise. Although, there are certain clinical (diarrhea/hematochezia/perianal disease common in CD; fever/night sweats common in ITB), endoscopic (longitudinal/aphthous ulcers common in CD; transverse ulcers/patulous ileocaecal valve common in ITB), histologic (caseating/confluent/large granuloma common in ITB; microgranuloma common in CD), microbiologic (positive stain/culture for acid fast-bacillus in ITB), radiologic (long segment involvement/comb sign/skip lesions common in CD; necrotic lymph node/contiguous ileocaecal involvement common in ITB), and serologic differences between CD and ITB, the only exclusive features are caseation necrosis on biopsy, positive smear for acid-fast bacillus (AFB) and/or AFB culture, and necrotic lymph node on cross-sectional imaging in ITB. However, these exclusive features are limited by poor sensitivity, and this has led to the development of multiple multi-parametric predictive models. These models are also limited by complex formulae, small sample size and lack of validation across other populations. Several new parameters have come up including the latest Bayesian meta-analysis, enumeration of peripheral blood T-regulatory cells, and updated computed tomography based predictive score. However, therapeutic anti-tubercular therapy (ATT) trial, and subsequent clinical and endoscopic response to ATT is still required in a significant proportion of patients to establish the diagnosis. Therapeutic ATT trial is associated with a delay in the diagnosis of CD, and there is a need for better modalities for improved differentiation and reduction in the need for ATT trial.

Mycobacterial spindle cell pseudotumour: epidemiology and clinical outcomes

INTRODUCTION

Mycobacterial spindle cell pseudotumour (MSP) is a rare disease characterised by tumour-like local proliferation of spindle-shaped histiocytes containing acid-fast positive mycobacteria. The aim of this literature review is to describe the clinical parameters and treatment outcomes of patients with MSP.

METHODS

A literature search was conducted using the search terms related to mycobacteria and spindle cell tumours. A previously unreported stem cell transplant recipient from our institution diagnosed with MSP was also included. Demographics, comorbidities, site of infection, treatment and clinical outcomes were analysed.

RESULTS

Fifty-one patients were analysed. Twenty-six (51%) had HIV infection. Mycobacterium avium complex was the most frequent organism isolated in 24 (47.1%) followed by Mycobacterium tuberculosis complex in eight (16%) cases. Lymph nodes were the most common site of infection (45.1%). Twenty (39.2%) patients received antimycobacterial agents, 12 (23.5%) underwent surgical resection and six (11.8%) received antimycobacterial agents plus surgery. Treatment was successful in 24 (47.1%) patients and failed in 15 (29.4%); 13 of these 15 patients died. Antimycobacterial therapy was significantly associated with successful outcome compared with surgical resection or no treatment (P<0.001).

CONCLUSION

MSP is a rare condition associated primarily with immunodeficiencies. Antimycobacterial therapy is significantly associated with successful outcome.

Pseudotumor presentation of renal tuberculosis mimicking renal cell carcinoma: A rare entity

Tuberculosis can involve any part of the body. Urogenital tuberculosis is a fairly common extra-pulmonary manifestation of tuberculosis and renal tuberculosis is the most common form of urogenital tuberculosis. Renal tuberculosis seldom presents as a mass, usually due to hydronephrosis of the involved kidney. However in extremely rare cases it may present as an inflammatory pseudotumor which may mimic renal cell carcinoma. We present a case of a 65- year- old male who was provisionally diagnosed as renal cell carcinoma based on clinical and radiological findings and managed accordingly but was finally diagnosed as renal tuberculosis based on histopathological examination of surgical specimen.

Mycobacterium avium-Intracellulare Complex (MAC) Producing a Periportal Pseudotumor in a Patient With HIV and a Normal CD4 Count

Mycobacterium avium-intracellulare complex (MAC) is an opportunistic infection typically associated with profound immunosuppression, such as AIDS. The presentation of disseminated MAC can be subtle and mimic systemic symptoms associated with lymphoma; abdominal pseudotumor is an exceptionally rare presentation. In the era of highly active anti-retroviral therapy (HAART), opportunistic infections are increasingly rare, and secondary prophylaxis for MAC may be discontinued after adequate therapy and immune reconstitution. Recurrence of disseminated MAC after adequate therapy may be due to macrolide resistance, but with an adequate CD4 T-cell count and undetectable HIV viral load, recurrence raises questions of more subtle immune dysregulation.

Diseases masking and delaying the diagnosis of urogenital tuberculosis

As urogenital tuberculosis (UGTB) has no specific clinical features, it is often overlooked. To identify some of the reasons for misdiagnosing UGTB we performed a systematic review. We searched in Medline/PubMed papers with keywords 'urogenital tuberculosis, rare' and 'urogenital tuberculosis, unusual'. 'Urogenital tuberculosis, rare' presented 230 articles and 'urogenital tuberculosis, unusual' presented 81 articles only, a total of 311 papers. A total of 34 papers were duplicated and so were excluded from the review. In addition, we excluded from the analysis 33 papers on epidemiological studies and literature reviews, papers describing non-TB cases and cases of TB another than urogenital organs (48 articles), cases of congenital TB (three articles), UGTB as a case of concomitant disease (16 articles), and UGTB as a complication of BCG-therapy (eight articles). We also excluded 22 articles dedicated to complications of the therapy, which made a total of 164 articles. Among the remaining 147 articles we selected 43 which described really unusual, difficult to diagnose cases. We also included in our review a WHO report from 2014, and one scientific monograph on TB urology. The most frequent reasons for delayed diagnosis were absence typical clinical features of UGTB, and the tendency of UGTB to hide behind the mask of another disease. We can conclude that actually UGTB is not rare disease, but it is often an overlooked disease. The main reasons for delayed diagnosis are vague, atypical clinical features and a low index of suspicion.

Inflammatory myofibroblastic tumor of renal pelvis presenting with iterative hematuria and abdominal pain: A case report

Inflammatory myofibroblastic tumor (IMT) is a rare type of mesenchymal tumor, which may affect various organs. The preferential site for IMT in the genitourinary system is the urinary bladder, while the presence of IMT in the kidney, and particularly in the renal pelvis, is rare. In the present report, the case of a 43-year-old man who was admitted to the Department of Urology of The Second Xiangya Hospital of Central South University (Changsha, China) in July 2012, with complaints of iterative gross hematuria and abdominal pain unresponsive to antibiotics is described. Computed tomography and magnetic resonance imaging indicated a slightly enhanced mass in the left renal pelvis of 1.5 cm in diameter. On request of the patient, a left nephrectomy was then performed, based on a suspected diagnosis of renal pelvic carcinoma. However, analysis of the intraoperative fast-frozen section exhibited proliferation of compact spindle cells, suggesting IMT. Therefore, further ureterectomy was avoided, and the patient remained in healthy condition thereafter.

Pulmonary mycobacterial spindle cell pseudotumor in a lung transplant patient: progression without therapy and response to therapy

Mycobacterial spindle cell pseudotumor (MSP) represents a rare, non-malignant, mass-forming reaction to various mycobacterial infections, typically occurring in immunocompromised patients. It is characterized by the proliferation of spindle-shaped fibrohistiocytic cells without the formation of epithelioid granulomas. Without staining for acid-fast bacilli, histological distinction from other spindle cell lesions, including malignancy, can be difficult. Most of the MSP cases reported in the literature have involved lymph nodes, skin, spleen, or bone marrow, but rarely involve the lung. MSP predominately occurs in patients who are immunosuppressed. We present a patient with MSP of the transplanted lung caused by non-tuberculous mycobacteria, in whom both the natural course of the untreated pseudotumor as well as the response to antimycobacterial treatments were observed.

Neonatal tuberculosis and cardiac inflammatory myofibroblastic tumor

A 1-month-old neonate was admitted in respiratory distress. Two-dimensional echocardiography and computed tomography scan showed a mass anterior to the left ventricle and right ventricular outflow tract. A biopsy revealed an inflammatory myofibroblastic tumor. A tuberculin test showed an 18-mm diameter induration. Three of the 6 household contacts were also positive for pulmonary tuberculosis. Antituberculosis medication was started. After 1 year, echocardiography and computed tomography scan showed complete resolution of the mass.

Tumor miofibroblástico inflamatório da bexiga em criança: relato de caso

Tumores miofibroblásticos inflamatórios raramente acometem vias urinárias ou crianças, comumente mimetizando neoplasias malignas nos exames de imagem. Foram descritos apenas 35 casos desses tumores na bexiga de crianças, segundo a literatura recente. Os autores apresentam o caso de uma criança com um tumor miofibroblástico vesical que evoluiu favoravelmente após ressecção cirúrgica completa.

Etiology analysis and computed tomography imaging of a tonsillar inflammatory myofibroblastic tumor: report of an immunocompetent patient and brief review

Objectives

The etiology of Inflammatory myofibroblastic tumor(IMT) is contentious. In this study, we used computed tomography (CT) to examine tonsillar IMT and further analyzed the etiology of this entity.

Methodology

We presented CT features of left tonsillar IMT and reviewed the English-language literature published between 1984 and 2011.

Results

To our knowledge, there are only six published cases of tonsillar IMT including the present case. Two patients were asymptomatic at initial presentation. Two patients were taking immunosuppressants, and one was pregnant and in an immunomodulated state. CT of our patient revealed a 2.6 × 1.8 cm irregular soft tissue mass between the left tonsil and the base of the tongue. It did not invade surrounding structures and was not enhanced on contrast-enhanced imaging.

Conclusions

Tonsillar IMT may be a benign tumor. We suggest that preoperative recognition of tonsillar IMT by CT may be important to avoid unnecessary expanded surgery.

Myocbacterium-avium intracellulare associated inflammatory pseudotumor of the anterior nasal cavity

In this case report, we describe an unusual case of mycobacterial associated inflammatory pseudotumor that occurred in a patient with a previous history of cocaine abuse. We discuss inflammatory pseudotumor (IPT) in general and emphasize the rare entity where an associated mycobacterial infection is seen. The histogenesis is not yet completely understood. The lesion can pose challenges for practicing pathologists and a misdiagnosis of malignancy can occur at multiple facets. A discussion about the differential diagnosis and clues to make the distinction is presented. In addition to spindle cell proliferation, the presence of a background of mixed inflammatory cell infiltrate and foamy macrophages are clues to make the diagnosis. In the case of mycobacteria associated IPT, Acid Fast Bacilli (AFB) stains will easily highlight the organisms confirming the diagnosis.