Enigma of Extrapulmonary Tuberculosis: Where Do We Stand?

Acute acalculous cholecystitis as a rare gastroenterological association of COVID-19: a case series and systematic review

Background and Aim

Acute acalculous cholecystitis (AAC) is an acute inflammatory disease of the gallbladder in the absence of cholecystolithiasis. It is a serious clinicopathologic entity, with a high mortality rate of 30-50%. A number of etiologies have been identified that can potentially trigger AAC. However, clinical evidence on its occurrence following COVID-19 remains scarce. We aim to evaluate the association between COVID-19 and AAC.

Methods

We report our clinical experience based on 3 patients who were diagnosed with AAC secondary to COVID-19. A systematic review of the MEDLINE, Google Scholar, Scopus, and Embase databases was conducted for English-only studies. The latest search date was December 20, 2022. Specific search terms were used regarding AAC and COVID-19, with all associated permutations. Articles that fulfilled the inclusion criteria were screened, and 23 studies were selected for a quantitative analysis.

Results

A total of 31 case reports (level of clinical evidence: IV) of AAC related to COVID-19 were included. The mean age of patients was 64.7 ± 14.8 years, with a male-to-female ratio of 2.1:1. Major clinical presentations included fever 18 (58.0%), abdominal pain 16 (51.6%), and cough 6 (19.3%). Hypertension 17 (54.8%), diabetes mellitus 5 (16.1%), and cardiac disease 5 (16.1%) were among the common comorbid conditions. COVID-19 pneumonia was encountered before, after, or concurrently with AAC in 17 (54.8%), 10 (32.2%), and 4 (12.9%) patients, respectively. Coagulopathy was noted in 9 (29.0%) patients. Imaging studies for AAC included computed tomography scan and ultrasonography in 21 (67.7%) and 8 (25.8%) cases, respectively. Based on the Tokyo Guidelines 2018 criteria for severity, 22 (70.9%) had grade II and 9 (29.0%) patients had grade I cholecystitis. Treatment included surgical intervention in 17 (54.8%), conservative management alone in 8 (25.8%), and percutaneous transhepatic gallbladder drainage in 6 (19.3%) patients. Clinical recovery was achieved in 29 (93.5%) patients. Gallbladder perforation was encountered as a sequela in 4 (12.9%) patients. The mortality rate in patients with AAC following COVID-19 was 6.5%.

Conclusions

We report AAC as an uncommon but important gastroenterological complication following COVID-19. Clinicians should remain vigilant for COVID-19 as a possible trigger of AAC. Early diagnosis and appropriate treatment can potentially save patients from morbidity and mortality.

Relevance for Patients

AAC can occur in association with COVID-19. If left undiagnosed, it may adversely impact the clinical course and outcomes of patients. Therefore, it should be considered among the differential diagnoses of the right upper abdominal pain in these patients. Gangrenous cholecystitis can often be encountered in this setting, necessitating an aggressive treatment approach. Our results point out the clinical importance of raising awareness about this biliary complication of COVID-19, which will aid in early diagnosis and appropriate clinical management.

Isolated Colonic Histoplasmosis in Patients Undergoing Immunomodulator Therapy: A Systematic Review

Gastrointestinal histoplasmosis remains an inconspicuous clinicopathologic entity. It is predominantly considered a protean manifestation of disseminated disease. We hereby delineate a unique case of biopsy-proven isolated colonic histoplasmosis in a patient undergoing methotrexate therapy. Furthermore, we present the first systematic review of the MEDLINE, Google Scholar, Embase, and Scopus databases regarding isolated colonic histoplasmosis in adult patients receiving immunomodulator therapy (IMT). A total of 13 case reports (level of clinical evidence: IV) were identified. The mean age was 55.6 ± 11.1 years, with 9 (69.2%) cases reported in women. Patients with subclinical disease (5, 38.5%) were often incidentally diagnosed by screening colonoscopy. Symptomatic individuals predominantly presented with diarrhea (4, 30.8%), weight loss (3, 23.1%), and/or abdominal pain (3, 23.1%). IMT was mainly administered for liver transplant (4, 30.8%), renal transplant (4, 30.8%), and ulcerative colitis (2, 15.4%). Common colonoscopy features included colonic ulcerations (7, 53.8%), polyps or pseudopolyps (3, 23.1%), and/or mass-like lesions (3, 23.1%). Diagnosis was made by histology of colonic biopsy in 11 (84.6%) and resected specimens in 2 (15.4%) patients. Treatment consisted of a combination of amphotericin B with oral itraconazole in 6 (46.2%), oral itraconazole alone in 5 (38.5%), and amphotericin B alone in 2 (15.4%) patients. Complete clinical recovery was achieved in all patients. This article illustrates that isolated colonic involvement can be the only clinical presentation of histoplasmosis. It may masquerade as other bowel disorders, presenting diagnostic and therapeutic conundrums. Gastroenterologists should rule out colonic histoplasmosis in IMT recipients who develop unexplained colitis symptoms.

Extrapulmonary tuberculosis: mimicking metastases in a patient with melanoma in a high TB-burden country; case report

This is a case report that includes an analysis about extrapulmonary tuberculosis and his singularities, cause can be confused with cancer. Our patient an 83-year-old woman from Pasto-Colombia presents a mimicking metastasis with melanoma. This guides us to understand that extrapulmonary tuberculosis is a rare pathology, but it should be considered as a potential differential diagnosis of any osteolytic lesion. That is the reasons for to be one of the great imitators in medicine, we come up with are totally necessary in a differential diagnosis with malignancies, a high index of suspicion.

Acute Mesenteric Tuberculous Lymphadenitis: A Comparative Analysis of Twenty-one Cases

Tuberculosis (TB) remains a major public health concern. Atypical extrapulmonary presentations of this infection may significantly delay its diagnosis and management. Tuberculous lymphadenitis (TL) is an extrapulmonary manifestation of a Mycobacterium tuberculosis infection. It is characterized by necrotizing mycobacterial infection of the lymph nodes. The clinical presentation of this disease ranges from fever and malaise to cervical lymphadenopathy and fistula formation. Herein, we present a comprehensive review of the previously reported cases of mesenteric lymphadenitis. The purpose of this study is to acquaint physicians to identify this disease in a timely manner. Furthermore, this review also highlights the rare presentation and management of TL.

Extensive Multisystemic Disseminated Tuberculosis in an Immunocompetent Patient

Extrapulmonary tuberculosis is uncommon and has an insidious onset with slow evolution and a paucibacillary nature. Here, we present a case of disseminated tuberculosis in an adult immunocompetent man presenting with morphologically different types of cutaneous lesions (i.e., multiple subcutaneous abcesses and multiple noduloulcerative lesions with discharging sinuses with seropurulent fluid). Extensive screening in the form of routine blood investigations, serologies, skin biopsy, Montoux test, sputum examination, chest and skull roentgenogram, noncontrast computed tomography chest and abdomen, contrast-enhanced computed tomography of the skull, and magnetic resonance imaging of lumbosacral spine with screening of the whole spine revealed extensive involvement of the skin, subcutaneous tissue, lungs, lymph nodes, skull bone, mandible, ribs, scapula, pelvis and Pott's spine, and thyroid.

Tuberculosis treatment failure in AIDS: vengeance with renal and ocular manifestations

Tuberculosis treatment failure is not uncommon in patients with AIDS. Treatment failure is defined as a positive sputum smear or culture at month 5 or later in the course of the treatment. The clinical presentations in these patients show remarkable heterogeneity. In this report, we chronicle the case of a patient with treatment failure presenting as the disseminated disease, specifically ocular and renal tuberculosis. Additionally, we undertake here a brief literature review highlighting the increased resistance to tuberculosis treatment in patients with AIDS, the rarity of ocular tuberculosis and the importance of tailoring drug regimens on an individual basis in these coinfected patients.