Fatal mycobacteremia caused by Mycobacterium tuberculosis in a patient with acute leukemia

Differentiation between tuberculosis and leukemia in abdominal and pelvic lymph nodes: evaluation with contrast-enhanced multidetector computed tomography

PURPOSE

To compare the characteristics of tubercular vs. leukemic involvement of abdominopelvic lymph nodes using multidetector computed tomography (CT).

MATERIALS AND METHODS

We retrospectively reviewed multidetector computed tomography features including lymph node size, shape, enhancement patterns, and anatomical distribution, in 106 consecutive patients with newly diagnosed, untreated tuberculosis (55 patients; 52%) or leukemia (51 patients; 48%). In patients with leukemia, 32 (62.7%) had chronic lymphocytic leukemia, and 19 (37.3%) had acute leukemias; of these, 10 (19.6%) had acute myeloid leukemia, and 9 (17.6%) had acute lymphocytic leukemia.

RESULTS

The lower para-aortic (30.9% for tuberculosis, 63.2% for acute leukemias and 87.5% for chronic lymphocytic leukemia) and inguinal (9.1% for tuberculosis, 57.9% for acute leukemias and 53.1% for chronic lymphocytic leukemia) lymph nodes were involved more frequently in the three types of leukemia than in tuberculosis (both with p <0.017). Tuberculosis showed peripheral enhancement, frequently with a multilocular appearance, in 43 (78.2%) patients, whereas patients with leukemia (78.9% for acute myeloid leukemia and acute lymphocytic leukemia, 87.5% for chronic lymphocytic leukemia) demonstrated predominantly homogeneous enhancement (both with p <0.017). For the diagnosis of tuberculosis, the analysis showed that a peripheral enhancement pattern had a sensitivity of 78.2%, a specificity of 100%, and an accuracy of 88.7%. For the diagnosis of leukemia, the analysis showed that a homogeneous enhancement pattern was associated with a sensitivity of 84.3%, a specificity of 94.5%, and an accuracy of 89.6%.

CONCLUSION

Our findings indicate that the anatomical distribution and enhancement patterns of lymphadenopathy seen on multidetector computed tomography are useful for differentiating between untreated tuberculosis and leukemia of the abdominopelvic lymph nodes.

Clinical characteristics and outcomes of Mycobacterium tuberculosis disease in adult patients with hematological malignancies

BACKGROUND

Diseases caused by Mycobacterium tuberculosis (TB) among adult patients with hematological malignancies have rarely been investigated.

METHODS

Adult patients with hematological malignancies at National Taiwan University Hospital between 1996 and 2009 were retrospectively reviewed. Patients with positive serology for HIV were excluded. TB disease is diagnosed by positive culture(s) in the presence of compatible symptoms and signs. The demographics, laboratory and, microbiological features, were analyzed in the context of clinical outcomes.

RESULTS

Fifty-three of 2984 patients (1.78%) were diagnosed with TB disease. The estimated incidence was 120 per 100,000 adult patients with hematological malignancies. Patients with acute myeloid leukemia had a significantly higher incidence of TB disease than other subtypes of hematological malignancies (2.87% vs. 1.21%, p = 0.002, odds ratio, 2.40; 95% confidence interval, 1.39-4.41). Thirty-eight patients (72%) with non-disseminated pulmonary TB disease presented typically with mediastinal lymphadenopathy (53%), pleural effusion (47%) and fibrocalcific lesions (43%) on chest imaging. The 15 (28%) patients with extra-pulmonary disease had lower rates of defervescence within 72 h of empirical antimicrobial therapy (13% vs 45%, p = 0.03) and a higher 30-day in-hospital mortality (20% vs. 0%, p = 0.004) compared to those with disease confined to the lungs.

CONCLUSIONS

TB disease is not uncommon among patients with hematological malignancies in Taiwan. Patients who received a diagnosis of extra-pulmonary TB suffered higher mortality than those with pulmonary TB alone. Clinicians should consider TB in the differential diagnoses of prolonged fever in patients with hematological malignancies, particularly in regions of high endemicity.

Tuberculosis in acute leukemia: a clinico-hematological profile

We studied 130 consecutive cases of acute leukemia over a 2-year period and identified 9 cases (6.9%) with active tuberculosis (TB). Eight patients with TB had acute myeloid leukemia (AML). Patients with AML were more likely to develop TB as compared to patients with acute lymphoblastic leukemia (ALL) despite the wider use of steroids and radiotherapy in ALL protocols {OR 4.41 (CI 0.53-36.44)}. Only 1 patient died of disseminated TB during post induction neutropenia. All other patients were successfully managed using current anti-tuberculous therapy (ATT). On the whole, TB did not cause any undue delay in chemotherapy and did not flare up during subsequent chemotherapy cycles. However it is not a commonly described infection in acute leukemia and a high index of suspicion is warranted especially in areas endemic for TB.

Mycobacterium tuberculosis Bacteremia in HIV-negative Patients

BACKGROUND/PURPOSE

Limited information exists about the epidemiologic characteristics of HIV-negative patients with Mycobacterium tuberculosis bacteremia (MTB).

METHODS

We retrospectively surveyed tuberculosis (TB) cases reported at National Taiwan University Hospital between 1997 and 2003. Demographic data, underlying diseases or conditions, clinical, microbiologic and radiologic findings and therapy were collected. Long-term outcome was evaluated at 1 year after initiation of anti-TB agents.

RESULTS

During the study period the incidence of MTB bacteremia in HIV-negative patients and HIV-positive patients were 0.024 and 6.2 per 1000 discharges, respectively (p<0.01). All 11 HIV-negative patients were males and eight (73%) were more than 50 years old. The most common underlying diseases/conditions were immunosuppressive therapy (64%) and heart disease (55%). Fever (80%), lymphopenia (75%) and pulmonary symptoms (58%) were the most common presentations. Ten patients were septic, two had septic shock and two had acute respiratory distress syndrome on admission. The median interval between admission and initiation of therapy for those who were cured was 6 days. Six (55%) died of TB and/or their underlying diseases. Of the six patients who died, the median survival after collection of positive blood culture was 19 days for three treated patients and 7 days for three untreated patients (p=0.01).

CONCLUSION

This case series demonstrates the wide spectrum of the initial presentation of HIV-negative patients with MTB bacteremia. The case fatality rate was high and was likely due to immunocompromised status and no anti-TB treatment prior to death. A high index of suspicion for TB and blood culture for MTB provides an additional simple and noninvasive diagnostic method to detect disseminated TB in endemic areas.