1
|
Chen WT, Liu ZC, Li MS, Zhou Y, Liang SJ, Yang Y. Tuberculosis-associated hemophagocytic lymphohistiocytosis misdiagnosed as systemic lupus erythematosus: A case report. World J Clin Cases 2022; 10:3178-3187. [PMID: 35647112 PMCID: PMC9082715 DOI: 10.12998/wjcc.v10.i10.3178] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/10/2021] [Accepted: 02/23/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a rare disorder with rapid progression and high mortality. HLH occurs mostly due to infection, malignant tumors, and immune disorders. Among infections that cause HLH, viral infections, especially Epstein-Barr virus infections, are common, whereas tuberculosis is rare. Tuberculosis-associated HLH has a wide range of serological and clinical manifestations that are similar to those of systemic lupus erythematosus (SLE).
CASE SUMMARY This study describes a case of tuberculosis-associated HLH misdiagnosed as SLE because of antinuclear antibody (ANA), Smith (Sm) antibody and lupus anticoagulant positivity; leukopenia; thrombocytopenia; pleural effusion; decreased C3, quantitatively increased 24 h urinary protein and fever. The patient was initially treated with glucocorticoids, which resulted in peripheral blood cytopenia and symptom recurrence. Then, caseating granulomas and hemophagocytosis were observed in her bone marrow. She was successfully treated with conventional category 1 antituberculous drugs. In addition, we reviewed the literature on tuberculosis-associated HLH documented in PubMed, including all full-text articles published in English from December 2009 to December 2019, and summarized the key points, including the epidemiology, clinical manifestations, diagnosis, and treatment of tuberculosis-associated HLH and the differences of the present case from previous reports.
CONCLUSION Tuberculosis should be considered in patients with fever or respiratory symptoms. Antituberculous drugs are important for treating tuberculosis-associated HLH.
Collapse
Affiliation(s)
- Wen-Ting Chen
- Department of Rheumatology and Clinical Immunology, Army Medical Center, Army Medical University, Chongqing 400000, China
| | - Zhi-Cheng Liu
- Southwest Hospital, Army Medical University, Chongqing 400000, China
| | - Meng-Shan Li
- Department of Rheumatology and Clinical Immunology, Army Medical Center, Army Medical University, Chongqing 400000, China
| | - Ying Zhou
- Department of Rheumatology and Clinical Immunology, Army Medical Center, Army Medical University, Chongqing 400000, China
| | - Shen-Ju Liang
- Department of Rheumatology and Clinical Immunology, Army Medical Center, Army Medical University, Chongqing 400000, China
| | - Yi Yang
- Department of Rheumatology and Clinical Immunology, Army Medical Center, Army Medical University, Chongqing 400000, China
| |
Collapse
|
2
|
Pörner D, Von Vietinghoff S, Nattermann J, Strassburg CP, Lutz P. Advances in the pharmacological management of bacterial peritonitis. Expert Opin Pharmacother 2021; 22:1567-1578. [PMID: 33878993 DOI: 10.1080/14656566.2021.1915288] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Bacterial peritonitis is an infection with high mortality if not treated immediately. In the absence of an intraabdominal source of infection, bacterial peritonitis may arise in patients with liver cirrhosis, in patients on peritoneal dialysis (PD) for end-stage renal disease or in patients with tuberculosis. In patients with cirrhosis, bacterial peritonitis may trigger acute on chronic liver failure with substantial mortality despite optimal treatment. In patients on PD, peritonitis may make continuation of PD impossible, necessitating the switch to hemodialysis.Areas covered: Recovery from peritonitis and prevention of complications depend on timely pharmacological management. Challenges are the broad microbiological spectrum with growing rates of antimicrobial resistance, the underlying chronic liver or kidney failure and high rates of relapse. The authors provide a review of predisposing conditions, diagnosis, and prevention of bacterial peritonitis with a particular focus on the pharmacological management.Expert opinion: Diagnosis of the type of bacterial peritonitis is essential to pharmacological management. In patients with spontaneous bacterial peritonitis, broad-spectrum antibiotics should be given intravenously in conjunction with albumin. In patients on PD, antibiotic therapy should be preferably applied intraperitoneally with empirical coverage of gram-positive and gram-negative bacteria. Secondary peritonitis usually requires surgical or interventional treatment.
Collapse
Affiliation(s)
- Daniel Pörner
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, Bonn, Germany
| | - Sibylle Von Vietinghoff
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, Bonn, Germany
| | - Jacob Nattermann
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, Bonn, Germany
- German Center for Infection Research (DZIF), University Hospital Bonn, Venusberg-Campus 1, Bonn, Germany
| | - Christian P Strassburg
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, Bonn, Germany
- German Center for Infection Research (DZIF), University Hospital Bonn, Venusberg-Campus 1, Bonn, Germany
| | - Philipp Lutz
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, Bonn, Germany
- German Center for Infection Research (DZIF), University Hospital Bonn, Venusberg-Campus 1, Bonn, Germany
| |
Collapse
|
3
|
Krishna S, Moorthy A, Bachalli P, Gaikwad R, Bhat P, Hegde S. Report of a Case of Tuberculosis of Mandibular Condyle in a Patient on Haemodialysis. J Maxillofac Oral Surg 2020; 19:517-519. [PMID: 33071497 DOI: 10.1007/s12663-019-01254-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 06/07/2019] [Indexed: 11/29/2022] Open
Affiliation(s)
- Shreya Krishna
- Department of Head and Neck Surgery, Rangadore Memorial Hospital, 1st Cross Rd, Shankarapuram, Basavanagudi, Bengaluru, Karnataka 560004 India
| | - Aditya Moorthy
- Department of Head and Neck Surgery, Rangadore Memorial Hospital, 1st Cross Rd, Shankarapuram, Basavanagudi, Bengaluru, Karnataka 560004 India
| | - Prithvi Bachalli
- Department of Head and Neck Surgery, Rangadore Memorial Hospital, 1st Cross Rd, Shankarapuram, Basavanagudi, Bengaluru, Karnataka 560004 India
| | - Rohith Gaikwad
- Department of Oral and Maxillofacial Surgery, St. James Hospital, Dublin, Ireland
| | - Prashanth Bhat
- Department of Head and Neck Surgery, Rangadore Memorial Hospital, 1st Cross Rd, Shankarapuram, Basavanagudi, Bengaluru, Karnataka 560004 India
| | - Shobha Hegde
- Department of Head and Neck Surgery, Rangadore Memorial Hospital, 1st Cross Rd, Shankarapuram, Basavanagudi, Bengaluru, Karnataka 560004 India
| |
Collapse
|
4
|
Lee IH, Kim SG, Kwon JG, Yang CS, Kang S, Kim MK, Ahn DJ. Intestinal tuberculosis in a patient with end-stage renal disease on hemodialysis: A case report. Medicine (Baltimore) 2020; 99:e21641. [PMID: 32769931 PMCID: PMC7593056 DOI: 10.1097/md.0000000000021641] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
RATIONALE Intestinal tuberculosis (TB) is rarely seen in patients with end-stage renal disease (ESRD). We report an intestinal TB case with a clinical presentation similar to that of colon cancer in a patient with ESRD on hemodialysis. PATIENT CONCERNS A 49-year-old man presented with a 3-month history of general weakness and anorexia. He had been treated for stage 5 chronic kidney disease (CKD) due to diabetic nephropathy for the last 3 years. His blood urea nitrogen and serum creatinine levels were 96.9 and 8.1 mg/dL, respectively, at the time of admission; azotemia was accompanied by severe anemia, hypoalbuminemia, hyperkalemia, and metabolic acidosis. Hemodialysis was initiated for suspected exacerbation of uremia; however, intermittent fever, night sweats, and abdominal discomfort persisted. DIAGNOSES Abdominal computed tomography (CT) and whole-body F-fluorodeoxyglucose positron emission tomography were indicative of ascending colon cancer with lymph node metastases. However, colonoscopy with biopsy revealed the formation of submucosal caseating granuloma and acid-fast bacillus. INTERVENTIONS We initiated quadruple therapy with isoniazid, rifampicin, pyrazinamide, and ethambutol. The patient continued the quadruple regimen for the first 2 months before switching to dual therapy and received anti-TB medications for a total of 12 months. OUTCOMES After 9 months of standard anti-TB chemotherapy, polypoid residual lesions were noted during follow-up colonoscopy. Laparoscopy-assisted ileocecal resection was performed. No findings suggestive of recurrence of colonic TB were observed on follow-up abdominal CT at 6 months after discontinuation of anti-TB medications. LESSONS If non-specific uremic symptoms persist in patients with advanced CKD, the possibility of extrapulmonary TB such as intestinal TB must be considered. Also, in patients with radiologic suspicion of colon cancer, endoscopy with biopsy should be performed promptly to exclude colonic TB with similar clinical manifestations.
Collapse
Affiliation(s)
| | | | | | | | - Sungmin Kang
- Department of Nuclear Medicine, Daegu Catholic University School of Medicine, Daegu
| | - Min-Kyung Kim
- Department of Pathology, Dongguk University College of Medicine, Gyeongju
| | - Dong Jik Ahn
- Department of Internal Medicine, HANSUNG Union Internal Medicine Clinic and Dialysis Center, Daegu, Republic of Korea
| |
Collapse
|
5
|
Podder S, Fleckenstein K, Gaudiano Z. A case of extrapulmonary tuberculosis in a patient with end-stage renal disease with elevated parathyroid hormone-related protein. SAGE Open Med Case Rep 2020; 8:2050313X20926421. [PMID: 32547759 PMCID: PMC7273542 DOI: 10.1177/2050313x20926421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 04/21/2020] [Indexed: 01/20/2023] Open
Abstract
The diagnosis of extrapulmonary tuberculosis in patients with end-stage renal disease can be challenging as the signs and symptoms are often non-specific. In this study, we present a case of extrapulmonary tuberculosis in an Ethiopian woman with end-stage renal disease who had subcarinal and right hilar lymphadenopathy, moderate sized right pleural effusion, hypercalcemia, and elevated parathyroid hormone–related protein in the setting of an elevated 1,25-dihydroxyvitamin D. After being started on appropriate tuberculosis treatment, patient’s parathyroid hormone–related protein level decreased and calcium level normalized. Our literature review showed that the elevation of parathyroid hormone–related protein in extrapulmonary tuberculosis has not been well studied, and it is our aim to explore the role of parathyroid hormone–related protein in extrapulmonary tuberculosis.
Collapse
Affiliation(s)
- Shreya Podder
- Department of Internal Medicine, Inova Fairfax Medical Campus, Falls Church, VA, USA
| | | | - Zehra Gaudiano
- Department of Internal Medicine, Inova Fairfax Medical Campus, Falls Church, VA, USA
| |
Collapse
|
6
|
Zhou ZF, Jiang L, Zhao Q, Wang Y, Zhou J, Chen QK, Lv JL. Roles of pattern recognition receptors in diabetic nephropathy. J Zhejiang Univ Sci B 2020; 21:192-203. [PMID: 32133797 DOI: 10.1631/jzus.b1900490] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Diabetic nephropathy (DN) is currently the most common complication of diabetes. It is considered to be one of the leading causes of end-stage renal disease (ESRD) and affects many diabetic patients. The pathogenesis of DN is extremely complex and has not yet been clarified; however, in recent years, increasing evidence has shown the important role of innate immunity in DN pathogenesis. Pattern recognition receptors (PRRs) are important components of the innate immune system and have a significant impact on the occurrence and development of DN. In this review, we classify PRRs into secretory, endocytic, and signal transduction PRRs according to the relationship between the PRRs and subcellular compartments. PRRs can recognize related pathogen-associated molecular patterns (PAMPs) and danger-associated molecular patterns (DAMPs), thus triggering a series of inflammatory responses, promoting renal fibrosis, and finally causing renal impairment. In this review, we describe the proposed role of each type of PRRs in the development and progression of DN.
Collapse
Affiliation(s)
- Zhi-Feng Zhou
- The First Clinical Medical College of Nanchang University, Nanchang 330006, China
| | - Lei Jiang
- Department of Nephrology, the First Affiliated Hospital of Nanchang University, Institute of Molecular Immunology of Kidney Disease of Nanchang University, Nanchang 330006, China
| | - Qing Zhao
- Department of Nephrology, the First Affiliated Hospital of Nanchang University, Institute of Molecular Immunology of Kidney Disease of Nanchang University, Nanchang 330006, China
| | - Yu Wang
- Department of Nephrology, the First Affiliated Hospital of Nanchang University, Institute of Molecular Immunology of Kidney Disease of Nanchang University, Nanchang 330006, China
| | - Jing Zhou
- Department of Nephrology, the First Affiliated Hospital of Nanchang University, Institute of Molecular Immunology of Kidney Disease of Nanchang University, Nanchang 330006, China
| | - Qin-Kai Chen
- Department of Nephrology, the First Affiliated Hospital of Nanchang University, Institute of Molecular Immunology of Kidney Disease of Nanchang University, Nanchang 330006, China
| | - Jin-Lei Lv
- Department of Nephrology, the First Affiliated Hospital of Nanchang University, Institute of Molecular Immunology of Kidney Disease of Nanchang University, Nanchang 330006, China
| |
Collapse
|
7
|
Shima H, Nishitani M, Tashiro M, Inoue T, Kawahara K, Okada K, Minakuchi J, Kawashima S. Pulmonary sarcoidosis as a cause of intermittent fever of unknown origin in a hemodialysis patient with renal cell carcinoma: A case report and literature review. Hemodial Int 2019; 23:E53-E58. [PMID: 30729655 DOI: 10.1111/hdi.12695] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 07/14/2018] [Indexed: 11/28/2022]
Abstract
Hemodialysis patients have weakened immune systems and can exhibit fever due to various causes. Herein, we describe the case of a 61-year-old hemodialysis patient who exhibited intermittent low-grade fever after a pacemaker had been implanted 2 months before due to sick sinus syndrome. She had a medical history of subcutaneous sarcoidosis and uveitis. Active pulmonary sarcoidosis was diagnosed based on elevated soluble interleukin-2 receptor, elevated lysozyme level, and gallium-67 scintigraphy uptake in hilar and mediastinal lymph nodes. She was also diagnosed with renal cell carcinoma via contrast computed tomography. However, because her C-reactive protein level remained normal, the possibility of neoplastic fever was considered low. After the initiation of prednisolone administration, her fever gradually disappeared. Her serum soluble interleukin-2 receptor and lysozyme level improved in parallel with the enlargement of the mediastinal lymph node and gallium-67 scintigraphy uptake.
Collapse
Affiliation(s)
- Hisato Shima
- Department of Kidney Disease, Kawashima Hospital, 1-39 Kitasakoichiban-cho, Tokushima, 770-0011, Japan
| | - Masaaki Nishitani
- Department of Urology, Kawashima Hospital, 1-39 Kitasakoichiban-cho, Tokushima, 770-0011, Japan
| | - Manabu Tashiro
- Department of Kidney Disease, Kawashima Hospital, 1-39 Kitasakoichiban-cho, Tokushima, 770-0011, Japan
| | - Tomoko Inoue
- Department of Kidney Disease, Kawashima Hospital, 1-39 Kitasakoichiban-cho, Tokushima, 770-0011, Japan
| | - Kazuhiko Kawahara
- Kamojima-Kawashima Clinic, 396-3 Iioazahukui, Kamojima-cho, Yoshinogawa, Tokushima, 776-0033, Japan
| | - Kazuyoshi Okada
- Department of Kidney Disease, Kawashima Hospital, 1-39 Kitasakoichiban-cho, Tokushima, 770-0011, Japan
| | - Jun Minakuchi
- Department of Kidney Disease, Kawashima Hospital, 1-39 Kitasakoichiban-cho, Tokushima, 770-0011, Japan
| | - Shu Kawashima
- Department of Kidney Disease, Kawashima Hospital, 1-39 Kitasakoichiban-cho, Tokushima, 770-0011, Japan
| |
Collapse
|
8
|
Vikrant S. Tuberculosis in dialysis: Clinical spectrum and outcome from an endemic region. Hemodial Int 2018; 23:88-92. [PMID: 30289617 DOI: 10.1111/hdi.12693] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 08/05/2018] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Tuberculosis (TB) is a significant health problem in developing countries. There are limited data on TB among end stage renal disease (ESRD) patients on maintenance dialysis in India. Clinical profile and outcome of TB in dialysis were studied. METHODS Retrospective study of ESRD patients who were on maintenance dialysis (either peritoneal dialysis [PD] or hemodialysis (HD]) and diagnosed to have TB over a period of 11 years. FINDINGS Thirty-two patients had a diagnosis of TB. Mean age of the patients was 50.3 ±13.9 years. The majority (56.2%) of the patients were female. The modality of dialysis was HD in 53.1% and PD in 46.9%. Mean duration of dialysis at the diagnosis of TB was 15.1 ± 13.9 months. Over three-quarter of the patients had an extrapulmonary involvement. Pleuro-pulmonary (40.6%), peritoneum (34.4%), and lymph node (15.6%) were the most common sites for TB. About 6.3%patients had disseminated TB, and 3.1% had pericardial TB. The clinical presentation of TB was: fever/pyrexia of unknown origin 28.1%, constitutional symptoms of anorexia, fever, night sweats and weight loss 34.4%, abnormal chest radiograph 37.5%, ascites/peritonitis 34.4%, pleural effusion 25%, lymphadenopathy 18.8%, meningoencephalitis 6.3%, and pericardial effusion 3.1%. Peritoneal TB presented as nonresolving peritonitis in PD and ascites in HD. The diagnosis was a microbiological/histological in 50% and rest 50% only on clinical grounds. Nine (29%) patients had adverse effects of anti-TB drugs. Four patients of TB peritonitis had a poor gastrointestinal tolerance of anti-TB drugs and defaulted on the treatment and had an adverse outcome. About 53.1% of the patients survived, and 46.9% died. DISCUSSION TB in dialysis is mostly extrapulmonary. Early diagnosis is difficult, and the adverse effects of anti-TB medications complicate the treatment. TB in dialysis carries high morbidity and mortality. TB peritonitis has a poor prognosis.
Collapse
Affiliation(s)
- Sanjay Vikrant
- Department of Nephrology, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
| |
Collapse
|
9
|
Hamadah AM, Beaulieu LM, Wilson JW, Aksamit TR, Gregoire JR, Williams AW, Dillon JJ, Albright RC, Onuigbo M, Iyer VK, Hickson LJ. Tolerability and Healthcare Utilization in Maintenance Hemodialysis Patients Undergoing Treatment for Tuberculosis-Related Conditions. Nephron Clin Pract 2016; 132:198-206. [PMID: 26859893 DOI: 10.1159/000444148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 01/19/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The incidence of tuberculosis (TB) in end-stage renal disease is significantly higher than that in the general population. Among those with kidney dysfunction, anti-TB treatment is associated with increased side effects, but the effect on healthcare utilization is unknown. Methods/Aim: To assess patient-reported symptoms, adverse effects and describe changes in healthcare utilization patterns during treatment for TB, we conducted a case series (n = 12) of patients receiving maintenance hemodialysis (HD) from Mayo Clinic Dialysis Services and concurrent drug therapy for TB from January 2002 through May 2014. Healthcare utilization (hospitalizations and emergency department (ED) visits independent of hospital admission) was compared before and during treatment. RESULTS Patients were treated for latent (n = 7) or active (n = 5) TB. The majority of patients with latent disease were treated with isoniazid (n = 5, 71%), while active-disease patients received a 4-drug regimen. Adverse effects were reported in 83% of patients. Compared to measurements prior to drug initiation, serum albumin and dialysis weights were similar at 3 months. Commonly reported anti-TB drug toxicities were described. More than half (58%) of the patients were hospitalized at least once. No ED or hospital admissions occurred in the period prior to drug therapy, but healthcare utilization increased during treatment in the latent disease group (hospitalization rate per person-month: pre 0 vs. post 1). CONCLUSIONS Among HD patients, anti-TB therapy is associated with frequently reported symptoms and increased healthcare utilization. Among this subset, patients receiving treatment for latent disease may be those with greatest increase in healthcare use. Careful monitoring and early complication detection may help optimize medication adherence and minimize hospitalizations.
Collapse
Affiliation(s)
- Abdurrahman M Hamadah
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minn., USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|