Upper Respiratory Tract Tuberculosis

Primary Tuberculosis of the Pharynx in an HIV Context: A Case Report

Pharyngeal tuberculosis without pulmonary involvement is very rare and may be confused with malignant lesions. We present a 45-year-old female patient with a history of HIV presenting with a history of cough, sore throat, and oral ulcers with chronic use of antibiotics. The evolution would indicate a probable malignant tumor, but the biopsy was consistent with Pharyngeal TB. The patient initiated anti-tuberculosis therapy and demonstrated improved conditions and remission of ulcers. In the context of HIV, this treatment could be a major contributor to the underdiagnosis of the disease and may lead to alternative diagnoses. Therefore, it is vital to consider this condition in patients who do not respond to antibiotics.

Isolated laryngeal tuberculosis complex infection: expect the unexpected

Laryngeal tuberculosis (LT), a rare but possible manifestation of extrapulmonary tuberculosis (TBC) and the most frequent granulomatous disease of the larynx, is slowly resurfacing due to the worldwide recrudescence of TBC. We present the case of a 59 y-o Caucasian woman, non-smoker, with no history of recent travels in endemic areas, affected by pulmonary sarcoidosis, that presented with a symptomatic vegetating lesion involving the left free margin of the epiglottic and a small, ulcerated lesion over the right arytenoid mucosa. While the patient's profile would not lead to a primary suspect of laryngeal TBC, the diagnostic workup and histological examination confirmed the unusual finding, and the patient was started on standard antitubercular therapy, with a complete laryngeal response. Although isolated laryngeal tuberculosis is still a rare finding, it should be kept into consideration also in non-endemic areas, especially in patients with chronic disease requiring immunosuppressive drugs.

Clinical characteristics and prognosis of laryngeal tuberculosis combined with respiratory tuberculosis

PURPOSE

To investigate the clinical characteristics, diagnosis and prognosis of patients with laryngeal tuberculosis (LTB) combined with respiratory tuberculosis.

MATERIALS AND METHODS

A retrospective analysis was conducted on 134 patients who underwent endoscopy and were eventually diagnosed with LTB. The patients' demographic characteristics, clinical manifestations, endoscopic features, auxiliary examination, imaging examination and prognostic characteristics were analyzed.

RESULTS

LTB patients had a median age of 45.5 years (range from 12 to 87 years) and a median course of 3.0 months (range from 0.1 to 72 months). The patients' symptoms mainly presented as hoarseness (97.0 %), abnormal sensation of pharyngeal (49.3 %), cough and sputum (41.0 %), pharyngalgia (39.6 %), dysphagia (10.4 %) and dyspnea (8.2 %). The positive rate of tuberculous symptoms was 25.4 %. Endoscopic features showed that the lesions mainly involved the glottis (87.3 %), presenting as unilateral lesions (66.7 %), near-full-length involvement (88.0 %), with mucosal waves significantly reduced (86.3 %), followed by supraglottis (43.3 %), subglottis (24.6 %) and the pharynx (15.7 %). The lesions may present as granulomatous proliferation (66.4 %), ulceration (65.7 %) or swelling and exudation (51.5 %). A total of 75 patients (56.0 %) were finally diagnosed with combined pulmonary tuberculosis (PTB), with a positive chest X-ray rate of 25.6 % and a positive chest CT rate of 71.2 %. A total of 42 patients who received anti-tuberculosis treatment were followed up, and 73.8 % of patients had significant improvement in symptoms. The morphology of the pharyngeal and laryngeal mucosa returned to basically normal (59.4 %) or scar-like (34.4 %).

CONCLUSIONS

LTB is usually found in middle-aged men, and patients' symptoms are mainly hoarseness, abnormal sensation of pharyngeal, pharyngalgia, cough and sputum, and can be combined with tuberculous symptoms. These lesions mainly involve multiple subregions, mainly in the glottis, and can be combined with pharyngeal involvement. There were various types of lesions. Half of the patients were complicated with PTB, and chest CT was superior to X-ray in the detection of pulmonary lesions. After regular anti-tuberculosis treatment, the symptoms and morphology of the pharyngeal and laryngeal mucosa of most patients were significantly improved.

Primary Laryngeal Tuberculosis Manifesting as Irregular Vocal Fold Lesion

Laryngeal tuberculosis is rare despite its close anatomical and physiological proximity to the lungs. It constitutes less than 1% of extrapulmonary tuberculosis. The symptoms of laryngeal tuberculosis are non-specific and mimic other laryngeal pathologies. The recent evolving and atypical endoscopic laryngeal features cause a diagnostic dilemma and delay in treatment. In this report, we presented three patients with distinct age and medical history, and hoarseness. Flexible videolaryngoscopy showed similar findings in the three cases, with irregular mucosa involving the entire length of the vocal fold, unilaterally in two cases and bilaterally in one. Mucosal waves were typically absent on laryngostroboscopy examination. The routine workup for pulmonary tuberculosis was unremarkable. The usage of Mycobacterium tuberculosis complex (MTBC) and rifampicin resistance (Xpert MTB/RIF) assay that detects Mycobacterium tuberculosis in the tissue biopsy specimens has helped in the rapid diagnosis of primary laryngeal tuberculosis and timely commencement of anti-tuberculous therapy. The clinical course and response to treatment were diverse in which two cases showed good response whilst the third developed disseminated tuberculosis despite optimal therapy.

Primary tonsillar tuberculosis in a pediatric patient: Case report and literature review

RATIONALE

Tuberculosis is an entity that usually affects the lungs, although extrapulmonary sites can also be involved. Tonsils are rarely affected, especially in the absence of pulmonary disease, primary tonsillar tuberculosis being a diagnostic challenge for the clinician.

PATIENT CONCERNS

We present the case of a 14-year-old female teenager, presented to our Pediatric Service with a 14-day history of dysphagia, odynophagia and left reflex otalgia associated with a 5 kg weight loss. Clinical examination revealed mild pharyngeal erythema, marked enlargement of the left tonsil infiltrating the lateral pharyngeal wall and the uvula and painful, mobile, nonadherent to deep bilateral latero-cervical adenopathy.

DIAGNOSIS

Positive interferon-gamma release assay (QuantiFERON-TB gold). Mantoux test reading was 16 mm.

INTERVENTIONS

During hospitalization, the patient received Clindamycin and Gentamicin for 3 days i.v., with discrete relief of symptoms and inflammatory markers. On the 4th day of hospitalization, treatment with Imipenem/Cilastin is started for 7 days in micro-perfusion, with tonsil hypertrophy decrease in size and favorable clinical evolution.

OUTCOME

Tonsil hypertrophy decreased in size and patient had a favorable clinical evolution. At discharge, the patient was given a 6-month course of anti-tuberculous drug.

LESSONS

The particularity of this case is represented by the rarity of primary tuberculosis of tonsils in children, with unilateral involvement, displaying at the same time a common issue encountered in the current practice: the limitations and the difficult course of setting the diagnosis due to the involvement of relatives in the medical act.

A rare case of coexistence of Wegener's granulomatosis and pulmonary tuberculosis with subsequent development of thrombosis of the cerebral veins

BACKGROUND

Granulomatosis with polyangiitis (GPA), also known as Wegener's granulomatosis, is an idiopathic systemic disease typically affecting the lungs, although other organs may also be involved.

CASE PRESENTATION

A 28-year-old male was admitted to Baqiyatallah university hospital in Teheran (Iran) after a 3-week history of fever and productive cough. The patient gradually developed fatigue, arthralgia, hematuria, nausea, vomiting, dyspnea, hemoptysis, weight loss, oliguria and then anuria. Chest-X-ray (CXR) and computerized tomography scan revealed cavitating nodular opacities in the right lung lobe. Furthermore, plasma creatinine increased from 2.2 to 4 mg/dl in a few days. Histopathological examination of kidney biopsy revealed peri-glomerular and peri-vascular inflammation, degeneration and necrosis of the tubular epithelial lining, red blood cell casts, distorted glomerular structure, fibrin thrombi, segmental breaks of the glomerular basal membrane, disruption of Bowman's capsular membrane and crescent formation of the affected glomeruli. An abnormal CXR, an abnormal urinary sediment and a typical kidney histology were used as criteria to diagnose glomerulonefritis with poliangiitis (GPA). Bronchoalveolar lavage smear and PCR turned out positive for mycobacterium tuberculosis. After 3 months of treatment for (GPA) and tuberculosis the patient developed headache and seizure. Cerebral Magnetic Resonance Venography revealed cerebral venous thrombosis of the sinus transverse and sigmoid.

CONCLUSIONS

Tuberculosis may coexist with GPA, as it occurred in our patient. Since a crescentic glomerulonephritis can progress to renal failure, clinicians should always be aware of potential multiple conditions when considering differential diagnoses.

Protein and Microbial Biomarkers in Sputum Discern Acute and Latent Tuberculosis in Investigation of Pastoral Ethiopian Cohort

Differential diagnosis of tuberculosis (TB) and latent TB infection (LTBI) remains a public health priority in high TB burden countries. Pulmonary TB is diagnosed by sputum smear microscopy, chest X-rays, and PCR tests for distinct Mycobacterium tuberculosis (Mtb) genes. Clinical tests to diagnose LTBI rely on immune cell stimulation in blood plasma with TB-specific antigens followed by measurements of interferon-γ concentrations. The latter is an important cytokine for cellular immune responses against Mtb in infected lung tissues. Sputum smear microscopy and chest X-rays are not sufficiently sensitive while both PCR and interferon-γ release assays are expensive. Alternative biomarkers for the development of diagnostic tests to discern TB disease states are desirable. This study's objective was to discover sputum diagnostic biomarker candidates from the analysis of samples from 161 human subjects including TB patients, individuals with LTBI, negative community controls (NCC) from the province South Omo, a pastoral region in Ethiopia. We analyzed 16S rRNA gene-based bacterial taxonomies and proteomic profiles. The sputum microbiota did not reveal statistically significant differences in α-diversity comparing the cohorts. The genus Mycobacterium, representing Mtb, was only identified for the TB group which also featured reduced abundance of the genus Rothia in comparison with the LTBI and NCC groups. Rothia is a respiratory tract commensal and may be sensitive to the inflammatory milieu generated by infection with Mtb. Proteomic data supported innate immune responses against the pathogen in subjects with pulmonary TB. Ferritin, an iron storage protein released by damaged host cells, was markedly increased in abundance in TB sputum compared to the LTBI and NCC groups, along with the α-1-acid glycoproteins ORM1 and ORM2. These proteins are acute phase reactants and inhibit excessive neutrophil activation. Proteomic data highlight the effector roles of neutrophils in the anti-Mtb response which was not observed for LTBI cases. Less abundant in the sputum of the LTBI group, compared to the NCC group, were two immunomodulatory proteins, mitochondrial TSPO and the extracellular ribonuclease T2. If validated, these proteins are of interest as new biomarkers for diagnosis of LTBI.

Appearance and morphologic features of laryngeal tuberculosis using laryngoscopy: A retrospective cross-sectional study

Laryngeal tuberculosis (LTB) is highly contagious and can cause permanent laryngeal damage. Therefore, correctly identifying laryngoscopic LTB lesion locations, sizes, and morphologic features are essential for LTB diagnoses. This study aimed to explore the appearance and morphologic features of LTB and correlated these features with clinical symptoms.We retrospectively analysed 39 LTB patients in our hospital between January 2013 and December 2019. Medical records, including clinical presentation, lesion appearance (locations, sizes, and morphology), complementary examination results, and histopathologic features were summarized and analysed.In this patient cohort, dysphonia and sore throat were the two most common clinical symptoms. In LTB patients with extensive lesions, ulcerative lesions were most common, and the proportion of cases with concurrent pulmonary tuberculosis (86.4%, P = .033) infection was higher, as were the positive rates of sputum smears (72.7%, P = .011) and cultures (86.4%, P = .002) than patients without concurrent pulmonary TB and with more localized and exophytic lesions. The histopathologic features of LTB-related ulcerative lesions included fewer granulomas and more areas with caseous necrosis. These lesions were more likely to have acid-fast bacilli detected with a Ziehl-Neelsen stain than exophytic lesions that rarely showed detectable bacilli.A complete knowledge regarding the visual and morphologic features of LTB on laryngoscopy is needed for the early detection and diagnosis of LTB. Our study revealed the lesion sites, sizes, and morphologic features of LTB. These parameters were also correlated with patient clinical symptoms. Future studies are needed to support and expand the results of this retrospective study.

Diagnosis of laryngeal tuberculosis in a high TB burden area

PURPOSE

The larynx is the second most commonly affected site in the head and neck region in patients with extrapulmonary tuberculosis (TB). Despite this, the prevalence of laryngeal TB is largely unknown, particularly in areas with a high TB burden. The laboratory diagnosis of TB includes microscopy, culture and molecular testing. The aims of this study were to determine the prevalence of laryngeal TB in patients presenting with laryngeal pathology in a region with a high TB burden and to determine the optimal diagnostic methods for the diagnosis of laryngeal TB.

METHODS

This was a prospective descriptive study of 80 adult patients undergoing direct laryngoscopy and biopsy for laryngeal pathology in the Department of Otorhinolaryngology, Universitas Academic Hospital, Bloemfontein, South Africa over a 1 year period. Histopathological and microbiological investigations (microscopy, Xpert MTB/RIF, and TB culture) were performed on all laryngeal biopsies.

RESULTS

Five (6.25%) out of 80 patients were diagnosed with laryngeal TB. In one patient, the Xpert MTB/RIF assay was positive on the laryngeal tissue and histology showed granulomas. Two patients had granulomas on histology although the microbiological tests on the tissue were negative. Two patients had only positive tissue cultures for Mycobacterium tuberculosis. None of the biopsies had positive Ziehl-Neelsen stains.

CONCLUSION

The results suggest that the diagnosis of laryngeal TB required a combination of histopathology, culture and PCR and that the Xpert MTB/RIF assay is not a sensitive test for the diagnosis of laryngeal TB.

Laryngeal tuberculosis: a rare cause of critical airway obstruction

Laryngeal tuberculosis (TB) is a rare condition, occurring in less than 1% of patients infected with pulmonary TB. We present a case of a 57-year-old male patient, who presented in extremis with audible stridor, increased work of breathing and cyanosis. In addition, the patient had a complex medical history, including a recent diagnosis of congenital malformation of the epiglottis. Emergency intervention was required to secure the airway, and after initial attempts at intubation were unsuccessful, an emergency tracheostomy was performed. Four days after initial presentation, his sputum tested positive for acid-fast bacilli, and a subsequent CT chest revealed pulmonary as well as laryngeal TB, which was confirmed on biopsy of the larynx. The patient was commenced on a 24-week course of anti-tuberculous treatment and was successfully decannulated 6 months after the emergency airway was established.