Brief Report: Tuberculosis Sepsis and Activated Protein C

Clinical features, treatment outcomes and mortality risk of tuberculosis sepsis in HIV-negative patients: a systematic review and meta-analysis of case reports

Purpose

Tuberculosis sepsis (TBS) is sepsis due to the Mycobacterium species causing tuberculosis (TB). It seems to be rare in HIV-negative patients and mainly individual case reports have been reported. This systematic review summarizes the epidemiology, clinical features, and treatment outcomes of TBS in HIV-negative patients.

Methods

An electronic search of PubMed, Embase, Web of Science, and Google Scholar was performed to identify published case reports of TBS between January 1991 and September 2022.

Results

Twenty-five articles reported 28 cases of TBS in HIV-negative patients, among which 54% (15/28) were women; with 50% (14/28) of patients not having reported predisposing factors. A total of 64% (18/28) of patients died, and the diagnosis was obtained for many of them only post-mortem. Two of the reports mentioned the BCG vaccination status. A higher proportion of deaths occurred in patients with delayed diagnosis of sepsis. The probability of survival of patients diagnosed with tuberculosis sepsis was 68% on day 10; 41% on day 20; and 33% on day 30 after admission.

Conclusions

Our review showed TBS occurred in HIV-negative patients and some of them have no known immunocompromised underlying co-morbidity. TBS might not be rare as clinicians thought but might be prone to be missed. In endemic settings, M. tuberculosis etiology of sepsis should be accounted for early, irrespective of HIV infection status.

Coccidioidomycosis of the Vocal Cords Presenting in Sepsis: A Case Report and Literature Review

Coccidioidomycosis is a predominantly pulmonary disease caused by species of Coccidioides, a fungus endemic to the American Southwest. Most cases involve exclusively pulmonary manifestations while less than one percent present with disseminated infection, usually with meningeal or skin involvement. In this case, a patient with a history of odynophagia, sore throat, productive cough, weight loss, and abnormalities on chest radiograph presented with sepsis and diabetic ketoacidosis. During admission, the patient underwent bronchoscopy with resulting tissue and bronchoalveolar lavage samples positive for Coccidioides immitis, later supported by confirmatory serum studies. This case illustrates a rare presentation of vocal fold involvement without direct invasion from a continuous site and highlights the importance of a high index of suspicion for disseminated coccidioidomycosis with prompt antifungal treatment in order to avoid the very high morbidity and mortality in such cases.

Mycobacterial Sepsis and Multiorgan Failure Syndrome

Tuberculosis (TB) is a global disease with high prevalence in developing countries. According to the World Health Organization (WHO) fact sheet 2009, more than 2 billion (equal to one third of world’s population) people are infected with TB bacilli. Of the cases detected, 5 % were cases of multi-drug resistant TB. Admission to a critical care unit is not required in the majority of cases. However, TB sepsis is a rapidly fatal disease that requires intensive care unit (ICU) admission and management and represents a big diagnostic and therapeutic challenge.

Acute forms of tuberculosis in adults

Although typically considered a chronic disease, tuberculosis (TB) has protean acute manifestations, the major forms of which are reviewed in this article. The pathogenesis of acute TB, although still incompletely understood, may be related to both epidemiologic and genetic host factors. Miliary TB manifests as a nonspecific clinical syndrome with a high mortality rate. The most well-known form of acute TB is meningitis, characterized by fever, nuchal rigidity, and a lymphocytic pleocytosis of the cerebrospinal fluid. Acute abdominal TB may present with obstruction or less commonly as perforated viscus or peritonitis. Critically ill patients may have acute respiratory distress syndrome, shock, or disseminated intravascular coagulopathy. The spectrum of disease makes diagnosis of acute TB difficult unless clinical suspicion of disease is high, but the high mortality mandates its consideration. Early initiation of therapy is crucial to optimize clinical outcome.

Fever of unknown origin caused by tuberculosis

Tuberculosis is an important cause of fever of unknown origin. Travel, age, dialysis, diabetes, birth in a country with a high prevalence of tuberculosis, and immunoincompetence are among the most salient risks. Associated physical findings, radiologic evaluation, and hematologic and endocrinologic abnormalities may provide clues to the diagnosis. Both noninvasive and invasive diagnostic modalities are reviewed. Because diagnosis may be elusive, therapeutic and diagnostic trials of antituberculous therapy should be considered in all patients with fever of unknown origin who defy diagnosis.