Bacteriologically Determined De Novo Tuberculosis during Tumor Necrosis Factor-α Inhibitor Therapy

A 58-year-old man with Crohn's disease received adalimumab for 13 months after screening results for tuberculosis were found to be negative. He was diagnosed with de novo mediastinal lymph-node tuberculosis, which was proved to be bacteriologically identical to that of an individual with smear positive lung tuberculosis by a variable number of tandem repeat analyses. After initiating anti-tuberculosis therapy, the patient developed immune reconstitution syndrome, which was improved by the re-administration of adalimumab. Even in countries with an intermediate tuberculosis burden, including Japan, we need to be alert for de novo tuberculosis as well as its reactivation during tumor necrosis factor-α inhibitor therapy.

A case report of granulomatous polyangiitis complicated by tuberculous lymphadenitis

RATIONAL

Granulomatous polyangiitis (GPA) is a type of vasculitis involving medium and small arteries, typically affecting the upper and lower respiratory tract with coexisting glomerulonephritis. GPA is also characterized by necrotizing granulomatous inflammation and the presence of antineutrophil cytoplasm antibodies (ANCA). So far, various infections have lead to elevation of titers of serum ANCA, making it difficult to diagnose.

PATIENT CONCERNS

We report a 50-year-old woman who was diagnosed as tuberculous lymphadenitis. During the treatment by anti-tuberculosis (TB) drugs, rapidly progressive renal failure and pleurisy had appeared with elevated titer of PR3-ANCA. Renal biopsy revealed crescentic glomerulonephritis.

DIAGNOSIS

Renal biopsy revealed crescentic glomerulonephritis and diagnosis of GPA was made.

INTERVENTIONS

Steroid therapy had been started with continuation of anti-TB drugs.

OUTCOMES

Renal dysfunction had gradually recovered and pleurisy had disappeared with decreasing titer of PR3-ANCA.

LESSONS

This is the first report of GPA complicated by TB infection. When we encounter a case with rapidly progressive renal failure during the TB infection, complication of GPA should be suspected as 1 of the different diagnosis.

Lymph node tuberculosis after melanoma treatment - sometimes the patient is lucky

Tuberculosis (TB) is considered a pulmonary disease that can however disseminate to other organs through hematogenous dissemination following primary TB infection. Evolution of the disease can either be precocious, before healing of the primary infection, or late after primary infection, due to reactivation of initial lesions usually because of simultaneous immunosuppressive factors such as diabetes, renal disease, hepatic disease or different type of immunosuppressing treatments. Rare cases when tuberculosis and cancer are diagnosed at the same time create diagnostic difficulties and therapeutic challenges. We present the case of an asymptomatic 52-year-old female that was diagnosed "by chance, at the right moment" with a form of skin melanoma on the right forearm, for which she received a rather well tolerated cytostatic treatment. At the end of this treatment, she was also investigated for a breast mass that proved to be benign; however, enlarged lymph nodes were discovered in the right armpit were discovered upon further investigation. One of the lymph nodes was surgically removed, as first suspicion was of a metastasis from the skin melanoma. However, it was lymph node tuberculosis therefore anti-tuberculosis treatment was initiated. The patient tolerated the treatment with minor side effects. On few occasions, a patient can be diagnosed with incipient stages of skin melanoma and even more rarely the same patient is diagnosed and treated prematurely for lymph node tuberculosis. Sometimes, a successful outcome needs an organized and well-educated patient and a little luck.

Tuberculosis lymphadenitis in a well managed case of sarcoidosis

Differentiation between tuberculosis (TB) and sarcoidoisis is sometimes extremely difficult. Sequential occurrence of sarcoidosis and TB in the same patient is uncommon. We present the case of a young man, with a proven diagnosis of sarcoidosis who later developed TB after completion of treatment for sarcoidosis. A 32-year-old male patient presented with low-grade fever since two months. Physical examination revealed cervical lymphadenopathy. Initial fine needle aspiration cytology (FNAC) of the cervical lymph node was suggestive of granulomatous inflammation; the chest radiograph was normal. Repeat FNAC from the same lymph node was suggestive of reactive lymphoid hyperplasia. The patient was treated with antibiotics and followed-up. He again presented with persistence of fever and lymphadenopathy and blurring of vision. Ophthalmological examination revealed uveitis, possibly due to a granulomatous cause. His repeat Mantoux test again was non-reactive; serum angiotensin converting enzyme (ACE) levels were raised. This time an excision biopsy of the lymph node was done which revealed discrete, non-caseating, reticulin rich granulomatous inflammation suggestive of sarcoidosis. The patient was treated with oral prednisolone and imporved symptomatically. Subsequently, nearly nine months after completion of corticosteroid treatment, he presented with low-grade, intermittent fever and a lymph node enlargement in the right parotid region. FNAC from this lymph node showed caseating granulomatous inflammation and the stain for acid-fast bacilli was positive. He was treated with Category I DOTS under the Revised National Tuberculosis Control Programme and improved significantly. The present case highlights the need for further research into the aetiology of TB and sarcoidosis.

[Development of cervical tuberculous lymphadenitis in a patient with Crohn's disease receiving infliximab despite of chemoprophylaxis with isoniazid]

We herein report a case of a 41-year-old female with a 14-year history of Crohn's disease who had been treated with diet and mesalazine. Because of inadequate control, therapy with infliximab was planned. She had a positive result on the interferon-gamma release assay (QuantiFERON TB). After active tuberculosis was ruled out by chest x-ray and computed tomography, she was started on a six-month course of isoniazid 7 weeks prior to starting infliximab. After 10 doses of infliximab (15 months of therapy), she presented with pain of cervical lymphadenopathy. A biopsy of the lymph nodes revealed Langhans giant cells from granulomas and a positive result of polylmerase chain reaction for Mycobacterium tuberculosis. The treatment with infliximab was discontinued and anti-tuberculosis therapy was started. Although treatment for latent tuberculosis infection lowers the risk of reactivation of tuberculosis due to tumor necrosis factor alpha-blockers, it cannot completely inactivate tuberculosis. Despite the completion of chemoprophylaxis, patients receiving such agents should be instructed to watch out for any symptoms associated with pulmonary and extrapulmonary tuberculosis such as fever, cough, malaise, body weight loss, night sweating and lymphadenopathy, and they should also be closely followed up.

Bacillus Calmette-Guerins vaccination at birth causing tuberculous granulomatous lymphadenitis

A rare but severe complication of Bacillus Calmette-Guerin (BCG) vaccination is the development of BCG disease, which can result in necrotizing granulomatous lymphadenitis. Symptoms can present as late as several months following the BCG vaccination. The key finding in BCG disease is the formation of caseating granulomas in draining lymph nodes; detection of BCG organisms from tissue samples are evident.

[THE CURRENT ASPECTS OF DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS OF COMPLICATIONS AFTER BCG VACCINATION]

Whether the diagnosis of BCG complications might be verified by molecular genetic methods, such as polymerase chain reaction (PCR) and sequencing, was studied. PCR could identify Mycobacterium tuberculosis as M. bovis strain BCG and increase the detection rate of M. tuberculosis by 38% as compared with traditional microbiological assays, which provides a means of recommending the method to verify the diagnosis of BCG complications.

[Intestinal tuberculosis of the terminal ileum causing obstructive ileus and tuberculous peritonitis and presenting numerous peritoneal small red nodules: a case report]

A 38-year-old woman suffering from lower abdominal pain was referred to our hospital. Abdominal computed tomography showed marked thickening of the terminal ileum to the cecum, localized collection of ascites, and multiple mesenteric lymphadenopathy. A barium contrast small bowel series showed solitary severe stenosis of the terminal ileum with marked swelling of the ileocecal valve, where colonoscopy could not pass through, suggesting that ileal stenosis was caused by intestinal tuberculosis. She also showed strongly positive tuberculin skin test. Laparoscopy-assisted ileocecal resection was performed for confirmation of diagnosis and removal of the stenotic intestinal lesion. Laparoscopically, numerous small red nodules scattered on the stenotic ileal serosa, peritoneum, and mesenterium. Histopathological examination revealed ileal tuberculosis causing ulcerative stricture, and mesenteric tuberculous lymphadenitis. The small red nodules were formed of hemorrhagic tuberculous nodules.

Histopathologic diagnosis of lymph node biopsies

This is a retrospective study of biopsies of lymph nodes received in the department of pathology, Nepal Medical College (NMC), from January 2004 to December 2005. Total number of lymph node biopsies during the two year period was 55, out of which 56.0% cases were females and 44.0% were males with M:F 1:1.29. Most common cause of lymphadenopathy was tuberculosis and most common group of lymph node was cervical lymph nodes. Metastatic deposits were seen in only six cases. So, like other developing countries, in our country also, tuberculosis is the leading cause for lymphadenopathy.

Tuberculous lymphadenitis in patients undergoing continuous ambulatory peritoneal dialysis

The aim of this study was to review the clinical features of tuberculous (TB) lymphadenitis in patients undergoing continuous ambulatory peritoneal dialysis (CAPD). Nine cases of TB lymphadenitis were diagnosed among 910 patients over a period of 10 years. There were five men and four women with a mean age of 51 +/- 15.5 years. The TB lymphadenitis involved the cervical lymph nodes in six patients, supraclavicular lymph nodes in two patients and mediastinal lymph nodes in one patient. Six patients presented with clinically enlarged lymph nodes of whom four also had fever. Three other patients were incidentally found to have enlarged lymph nodes on routine chest X-ray or ultrasound examination of the neck. Diagnosis of TB lymphadenitis was made by demonstrating caseating granulomata with or without positive acid-fast bacilli on excisional lymph node biopsy. All patients were cured with standard anti-tuberculosis drugs for 12 months. No recurrence of the TB lymphadenitis was observed after a mean follow-up of 59 +/- 30 months. We conclude that TB lymphadenitis is not uncommon among patients on CAPD. A high index of suspicion is needed for early diagnosis of this condition. Prompt initiation of anti-tuberculosis treatment is associated with good prognosis.

Aetiology of peripheral lymphadenopathy in adults: analysis of 1724 cases seen at a tertiary care teaching hospital in southern India

BACKGROUND

In patients presenting with peripheral lymphadenopathy, excision biopsy of the most accessible lymph node provides material to establish an early diagnosis, and is important in the management of these patients.

METHODS

A retrospective study was done of 1724 lymph node biopsy specimens obtained from adult patients and submitted for histopathological examination over a 12-year period.

RESULTS

About one-third (n = 614; 35.6%) of these patients had non-specific lymphadenitis. This included a heterogeneous group of disorders comprising benign follicular hyperplasia, reactive hyperplasia, marked follicular hyperplasia and reactive sinus histiocytosis. Tuberculosis lymphadenitis (n = 540; 31.3%) and malignancy (n = 447; 25.9%) were the other common causes. Of the 540 patients with tuberculosis lymphadenitis, the human immunodeficiency virus (HIV) status was tested in 424 (78.5%) patients; of these, 34 patients (8%) were HIV-seropositive. Epithelioid granulomas with caseation necrosis were more frequently seen in HIV-seronegative patients compared with HIV-seropositive ones (chi2 = 54.66; p < 0.001 ). In HIV-seropositive patients, multiple sites of lymph node involvement (chi2 = 40.597; p < 0.001), suppurative type with adjacent necrosis and panniculitis (chi2 = 68.128; p < 0.001), and non-reactive histological types (chi2 = 109.234; p < 0.001) were more commonly seen compared with HIV-seronegative patients. Kikuchi-Fujimoto disease (n = 36), Kimura disease (n = 7), Rosai-Dorfman disease (n = 6), were rare aetiological causes that have been infrequently reported from India.

CONCLUSION

Awareness of the characteristic histopathological findings and uncommon aetiological causes of peripheral lymphadenopathy may spare patients from unnecessary evaluation and treatment. In HIV-positive patients, lymph node tuberculosis may be histopathologically unusual and may be suppurative or non-reactive in nearly one-third of patients.

Value of sonography for follow-up of mediastinal lymphadenopathy in children with tuberculosis

PURPOSE

To assess the clinical value of sonography for the follow-up of mediastinal lymphadenopathy in children diagnosed with pulmonary tuberculosis (TB).

METHODS

We conducted a retrospective review of the medical records of 21 children (9 boys, 12 girls) with a mean age of 6 years (range, 7.4 months to 18 years) who had a positive intradermal tuberculin skin test. All patients underwent thorough history-taking, physical examination, frontal and lateral chest radiographs, and sonographic study of the mediastinum. The mediastinum was accessed through the suprasternal and left parasternal approaches. The presence of 1 or more masses with an ovoid or round shape and hypoechoic appearance in the anterior or middle mediastinum was recorded. A comparison was made between the results of the sonographic examination of the mediastinum before administration of anti-TB agents and after 3 months of treatment.

RESULTS

Pulmonary radiographic findings were suggestive of TB in 17 patients and were uncertain in 4 patients. Sonographic examination, however, detected mediastinal lymphadenopathy in all patients. A comparison of pretreatment mediastinal sonograms with those obtained after 3 months of anti-TB treatment showed a marked reduction of lymph node involvement in 17 patients (80.9%). In the remaining 4 patients, mediastinal lymphadenopathy was still present.

CONCLUSION

Mediastinal sonography appears to be a valuable tool for the diagnosis of TB and in the monitoring of response to treatment in children.

[Case of disseminated tuberculosis complicated with tuberculous meningitis while investigating an abdominal lymphadenopathy]

In February 2005, a 33-year-old man visited A hospital complaining of fever. The blood screening test revealed the liver dysfunction, then computed tomography showed swelling of abdominal lymph nodes. In April, headache and disorientation appeared. He was diagnosed as disseminated tuberculosis and tuberculous meningitis based on chest X-ray and computed tomography findings and examination of cerebrospinal fluid. After admission to our hospital, anti-tuberculous drugs were prescribed, but the cerebral infarction happened. The disturbance of consciousness and the left half of his body paralysis appeared. They did not improve and hydrocephalus was complicated in August, though he was treated by steroids. He needed all helps because of the left half of his body paralysis and an advanced sequelae was left. It was thought that the abdominal lymph adenopathy preceded as one of symptoms of the disseminated tuberculosis in this case. It is said to be rare that abdominal lymph node swelling is seen in the early stage of disseminated tuberculosis. But, we think that it is necessary to keep in mind that the possibility of disseminated tuberculosis as one of the diseases in differential diagnosis, when we examine enlargement of abdominal lymph nodes with symptoms suggesting the presence of infection such as fever.

Submandibular tuberculous lymphadenitis after endodontic treatment of the mandibular first premolar tooth: report of a case

Cervical tuberculous lymphadenitis (scrofula) is an infectious granulomatous disease that requires a precise diagnosis. The differential diagnosis involves mainly the pathologic conditions involving the regional lymph nodes and the submandibulary salivary glands. Although tuberculous lesions generally develop secondary to pulmonary disease, clinical manifestations are occasionally seen with no evidence of involvement of the lungs. In this report, a case of tuberculous submandibular lymphadenitis developing after endodontic treatment of the mandibular first premolar tooth is described.

[Transient worsening of chest radiograph and development of lymphadenopathy during chemotherapy for miliary tuberculosis]

A-37-year old woman was referred to our hospital because of bilateral pulmonary micronodular shadows on chest X-ray. Prednisolone was reported to be administered for her coughs and dyspnea more than a month, but was discontinued recently. Under the diagnosis as miliary tuberculosis, we started to treat her with the combined use of pyrazinamide, isoniazid, rifampicin, and ethambutol. Then her symptoms subsided gradually. Two months later, however, high fever developed, followed by exacerbation of the radiographic shadows, and marked cervical and mediastinal lymphadenopathy. We considered them so-called paradoxical worsening, and continued the antituberculosis therapy unchanged. Those clinical manifestations began to subside about 4 months after the initiation of the treatment. Paradoxical worsening has been described as a relatively rare manifestation, and seem to be attributable to prompt recovery of the immunity to mycobacterial antigens after the use of antituberculous therapy. We considered that, in this case, disseminated tuberculosis and firstly administered steroid that might suppress immune function, and discontinuation of steroid therapy followed by the bactericidal antituberculous chemotherapy were associated with the development of the paradoxical reactions, by analogy with immune reconstitution syndrome frequently reported in HIV-related tuberculosis patients.

A boy undergoing maintenance hemodialysis who developed mediastinal lymph node tuberculosis

The incidence of tuberculosis (TBC) in patients undergoing maintenance hemodialysis is reported to be higher than that in the general population. We report an 8-year-old boy receiving such treatment for chronic renal failure who developed mediastinal lymph node TBC. He showed only intermittent fever, recurring every 2 weeks, with no other symptoms suggesting TBC. Although staining and culture of pharyngeal swab and gastric juice specimens failed to provide evidence of TBC, a lymph node biopsy specimen disclosed typical pathologic findings of tuberculoma, including caseating granulomas. Antituberculous therapy with isoniazid (INH), rifampicin, pyrazinamide, and ethambutol was given for 12 months, resulting in complete resolution of the TBC, with no subsequent recurrence. To our knowledge, mediastinal lymph node localization of TBC is relatively rare, in a patient on maintenance hemodialysis, especially in a child.

Impact of sawdust and wood shavings in bedding on pig tuberculous lesions in lymph nodes, and IS1245 RFLP analysis of Mycobacterium avium subsp. hominissuis of serotypes 6 and 8 isolated from pigs and environment

Among 25,027 slaughter pigs raised in two farms, tuberculous lesions were detected in the lymph nodes of 898 (3.6%) of them. Tuberculous lesions were most commonly found in the mesenteric (601; 2.4%) and head (451; 1.8%) lymph nodes. Mycobacteria were isolated from 49 of 120 randomly selected mesenteric, head and bronchial lymph nodes with diagnosed tuberculosis originating from both farms. Forty six Mycobacterium avium subsp. hominissuis, one M. chelonae and two M. fortuitum isolates were found in the lymph nodes of pigs. No statistically significant difference was detected between farms A and B for isolation rates of mycobacteria from the lymph nodes of pigs and their species composition. To investigate the source of the pigs' infections, culture examinations of 117 samples from the external environment were performed. Mycobacteria were isolated from 25 samples from the external environment (21.4%). Mycobacterial isolates were also detected in eleven (91.7%) and two (16.7%) of 12 used sawdust and 12 of non-used (fresh) sawdust samples, respectively. None of 12 wood shavings was culture-positive. Twelve of 13 sawdust isolates were classified as M. a. hominissuis of serotypes 6 and 8 and genotype IS901- and IS1245+; the remaining isolate was classified as species M. fortuitum. Other conditionally pathogenic mycobacteria were only isolated from 12 of the remaining 81 samples from the external environment (excluding bedding). A total of eight isolates (two pig and six sawdust samples originating from farms A and B) were examined by IS1245 restriction fragment length polymorphism (IS1245 RFLP) analysis. These isolates produced five distinct IS1245 RFLP types with more than 20 bands. Based on identical IS1245 RFLP types of one pig isolate and two isolates of used sawdust from farm A, we have concluded that contaminated sawdust was the source of mycobacterial infection for pigs in our study.

Extrapulmonary tuberculosis in immunocompetent adults

Tuberculosis continues to be a significant cause of morbidity and mortality. Although tuberculosis usually attacks the lungs, other organs can also be affected, leading to extrapulmonary tuberculosis (EPT) or disseminated tuberculosis. This study retrospectively analysed the incidence, clinical sites and risk factors for EPT in 252 patients with EPT between 1 January 1991 and 30 June 2003. EPT was defined as clinical, laboratory, imaging, and/or histopathological evidence of mycobacterial infection in a site other than hilar lymph nodes or lung parenchyma. In our study group, tuberculous lymphadenitis (36.5%) was found to be the most common clinical presentation of EPT. 119 (47.2%) patients developed the severe form of EPT, according to the WHO report, and 133 (52.8%) patients developed the less severe form. A case history of pulmonary tuberculosis was found to be a risk factor for the development of EPT (p <0.05). The study showed that EPT is still a public health problem. These findings suggested that pulmonary tuberculosis may play a critical role in the development of EPT. 12-month therapy may be chosen in patients with EPT considering acceptable adverse effects without relapses.

CT scanning for the detection of tuberculous mediastinal and hilar lymphadenopathy in children

BACKGROUND

The diagnosis of primary pulmonary tuberculosis (PTB) in children relies heavily on the radiographic demonstration of mediastinal lymphadenopathy. Plain radiographs may be unreliable and CT is the current 'gold standard' for demonstrating this. Only two previous studies have described the CT findings of mediastinal adenopathy exclusively in children.

OBJECTIVE

To determine the prevalence, distribution, characteristics and effect on the bronchial tree of mediastinal lymphadenopathy using modern CT techniques, in children suspected of PTB.

MATERIALS AND METHODS

One hundred children (54 boys, 46 girls) with clinically suspected PTB were prospectively recruited from an overnight admission ward if they met the WHO criteria for suspected PTB. CT scans were evaluated by a panel of radiologists with regard to a predetermined set of criteria.

RESULTS

Lymph nodes were present in 92 patients, and nodes greater than 1 cm were present in 46 patients. Enhancement of lymph nodes was present in 67 patients and was almost invariably 'ghost-like' ring enhancement. Calcification was present in only 9 patients. The most common location for lymphadenopathy was the subcarinal position ( n=90), followed by the hila ( n=85; left 74, right 72, bilateral 61), the anterior mediastinum ( n=79), the precarinal position ( n=64) and the right paratracheal position ( n=63). Multiple sites of involvement were present in 88 patients, and a single site for lymphadenopathy (subcarinal) was present in only 4 patients. Bronchial compression was identified in 29 patients. Most commonly, the left main bronchus was involved ( n=21), followed by the right main bronchus ( n=14) and the bronchus intermedius ( n=8), 16 right-sided compressions in total.

CONCLUSIONS

Lymphadenopathy was common, but only 46 patients had lymph nodes greater than 1 cm. Enhancement characteristics of tuberculous adenopathy differ from that described previously. Typical enhancement was 'ghost-like' rather than discreet ring enhancing with a low-density centre. The site most frequently involved by nodes also differs from previous studies. The subcarinal region should be the site receiving most attention for the identification of lymphadenopathy, as this is most frequently involved and is also the site of the largest lymph-node masses. The presence of lymph-node groups at other recognised sites adds confidence when there is doubt, as multifocal involvement is common. Approximately one-quarter of patients with hilar adenopathy may have bronchial compression in childhood.

[Cervico-facial and ENT symptoms due to HIV infection in tropical area. About 253 Congolese cases]

In human immunodeficiency virus infection as well as in related syndromes, cervico-facial and otorhino-laryngologic manifestations are current. A retrospective study in Oto-Rhino-Laryngology service of Brazzaville University Hospital from December 1995 to November 2001 has been reported. 253 patients were selected from a total of 1352 consultations. The study population is young (average age: 34 +/- 4.8 years), and most of the patients are 30 to 49 years old (75.9%). Men represent 51% and women 49%. Although sexual multipartnership (59.7%) is the main risk factor, traditional practices (22.8%) are not neglictible in Africa. Among all cases, human immunodeficiency virus type 1 is found in 72.3% of cases. The affections are located in the neck (40.5%), ear (24.9%), pharynx (17.3%), rhinosinus (13.3%), oral cavity and vestibule (2.7%) and larynx (1.3%). These main affections are represented by: parotidosis (20.1%), peripheric facial paralysis (15.4%), pharyngeal candidiasis (14.6%), sinusitis (14.2%) and ganglial tuberculosis (11.5%). Lymphoma (7 cases), kaposi's sarcoma (7 cases) and epidermoid carcinoma (1 case) are the malignant affections identified in 15 cases (6%). The diagnosis of some affections like cystic parotiditis (11%), noma (1.6%), African histoplasmosis (0.4%) and rhinoscleroma (0.4%) constitutes this study particularity The Oto-rhino-laryngologist's role is important in early diagnosis of HIV infection as well as in the followed-up of patients.

[A case of pulmonary tuberculosis complicated with tuberculosis of bilateral cervical lymph nodes and exacerbated pericostal abscess]

A 23-year-old man was admitted to our hospital because of cough and sputum in April 2001. A chest roentgenogram revealed infiltrative shadow with cavity formation in the bilateral lung fields. He was treated with sensitive antituberculous drugs. After starting the antituberculous therapy with INH, RFP, EB and PZA, bilateral cervical lymphadenopathy developed. Three months later, pericostal abscess appeared in the left anterior chest wall. Microscopic examination of the specimen obtained by needle aspiration biopsy disclosed positive for acid-fast bacilli. Smears of the pus showed acidfast bacilli identified as Mycobacterium tuberculosis by DNA-DNA PCR method. He developed tuberculous bilateral cervical lymphadenopathy and pericostal abscess during the course of antituberculosis chemotherapy. Drug sensitivity test revealed that tubercle bacilli in this case were sensitive. One year after the administration of chemotherapy, cervical lymphadenopathy and pericostal abscess were improved. Both masses were discontinuous with pulmonary tuberculosis and the possibility of lymphogenous spread of organism was speculated as its etiology. We assumed that both masses were due to paradoxical response to the antituberculosis chemotherapy.

[Management of paediatric neck masses]

OBJECTIVES

The present study was designed to demonstrate the regional distribution prevalence and management differences of certain pediatric neck masses in this region of the country.

PATIENTS AND METHODS

Fifty-five patients with pediatric neck masses, who were diagnosed and treated surgically were retrospectively analyzed.

RESULTS

Analysis of 55 patients showed that congenital neck masses were the most common pathology in pediatric neck masses (47%), followed by infectious and tuberculous lymphadenopathies (24%).

CONCLUSION

It can be concluded from the study that besides the age group and the characteristics of the neck mass, life standards of the region is also an important factor to be considered.

[Surgical therapy of pulmonary tuberculosis]

In individual cases of tuberculosis surgical therapy is part of an interdisciplinary therapeutic concept. Identifying the optimal point of time for surgery has a strong impact on the further course of the healing process and thus on the prognosis. Indications for surgical therapy are: 1. multi-drug-resistant pulmonary tuberculosis (MDR-TB), 2. late-onset complications (apergilloma, tuberculosis of the tracheobronchial tree or of mediastinal or hilar lymph nodes), 3. tuberculosis of the pleura. In MDR-TB an individual concept for therapy based on all chemotherapeutic options as well as thorough planning of the surgical procedure must be provided. Resections in tuberculotic late-onset complications should be performed in patients with persisting cavernous pulmonary tuberculosis as well as in patients with post tuberculosis complex; main goal is the prevention of tuberculotic relapse. Surgical strategies for tuberculosis of the pleura include the debridement of the pleural cavity in video assisted surgical technique, decortication, partial thoracoplasty with musculoplasty or chest fenestration.

Diagnosis of tuberculosis lymphadenitis using a polymerase chain reaction on peripheral blood mononuclear cells

Providing prompt and precise laboratory confirmation of a clinical diagnosis of tuberculous lymphadenitis is difficult given the paucibacillary nature of lymph node specimens. In this study carried out in Karachi, Pakistan, a polymerase chain reaction (PCR) assay aimed at detecting Mycobacterium tuberculosis DNA in peripheral blood mononuclear cells (PBMC-PCR) was standardized and compared with standard M. tuberculosis diagnostic techniques or a lymph node PCR (LN-PCR) for the diagnosis of tuberculosis lymphadenitis. Thirty-seven (77%) specimens from 48 patients with clinical or diagnosis of tuberculosis lymphadenitis were positive by cytology [17/48 (35%) with no acid fast bacilli (AFB) (suggestive), and 20/48 (42%) with AFB (positive) in direct smears], 30 (63%) by PBMC-PCR, 16 (33%) by LN-PCR, and 13 (27%) by culture. All controls were negative, with the exception of one false-positive LN-PCR. These data suggest the PBMC-PCR may be helpful in the diagnosis of tuberculous lymphadenitis.

[A case of Poncet's disease (tuberculous rheumatism) in a patient with chronic renal failure undergoing hemodialysis therapy]

A 78-year-old man who was undergoing hemodialysis therapy was admitted to our hospital because of sore throat, remittent cervical lymphadenopathy, and polyarthritis over the preceding 4 weeks. On admission, he had bilateral cervical lymphadenopathy. He complained of arthralgia associated with tenderness, warmth and swelling of both elbows, left side wrist and left shoulder joint. The C-reactive protein level on admission was 15.3 mg/dl. Rheumatoid factor, antinuclear antibodies, tuberculin skin test and blood culture were negative. Joint fluid was not aspirated. Radiographs of the joints did not reveal any abnormalities. Acid-fast bacilli were demonstrated in the smear of the cervical lymph node with a fluorochrome rhodamine-auramine stain. Mycobacterium tuberculosis DNA was identified by polymerase chain reaction. We found the presence of caseating granuloma on the biopsy specimens and M.tuberculosis was detected from culture. At that point, we diagnosed this patient as having tuberculous lymphadenitis. His general symptoms resolved rapidly after starting with a three-drug regimen consisting of isoniazid, rifampin and pyrazinamide. His polyarthritis also improved dramatically. Finally we considered that his polyarthritis was tuberculous rheumatism, also called Poncet's disease. Poncet's disease is characterized by sterile polyarthritis during active tuberculosis infection. It is considered a reactive arthritis, which is a different entity from tuberculous arthritis. Although this is a rare disease, we should be aware of it in hemodialysis patient clinics, because the incidence of tuberculosis infection has been reported to be increasing in patients with end-stage renal failure.

Tuberculous parotitis

Tuberculosis, though rare, should be considered in the differential diagnosis of a diffuse swelling of the parotid with enlarged cervical glands, particularly in young, feverish adults.

Extrapulmonary tuberculosis in high prevalence of tuberculosis and low prevalence of HIV

The authors' data show a higher rate of pleural and meningeal involvement among extrapulmonary TB cases than expected by previous works. Special attention should be given to tuberculous meningitis cases among all extrapulmonary TB cases because of its high mortality rate. The most common extrapulmonary involvement is pleural. Pleural involvement is most common among the young male military service personnel. These data underscore the importance of determining pleural involvement among extrapulmonary TB cases and emphasize the need to consider clinic and epidemiologic differences in the diagnosis and evaluation of extrapulmonary TB. Finally, it seems unlikely that HIV infection currently has a role in the cause of extrapulmonary TB in the authors' region.

[Mediastinal tuberculous lymphadenitis in a chronic renal failure patient with elevated serum pro-GRP level]

A 56-year-old man treated by peritoneal dialysis was admitted to our hospital because of abnormal shadows on chest radiographs. Chest CT revealed enlarged paraaortic lymph nodes (30 mm x 40 mm) and a tuberculoma in the left upper lobe. The serum level of pro-GRP was significantly above the cutoff value, but tuberculous mediastinal lymphadenopathy was identified from mediastinal lymph node biopsy specimens. We concluded that the elevation of the serum pro-GRP concentration was due to decreased renal clearance resulting from the chronic renal failure.

[Cervical tuberculous lymphadenopathy--a rare complication of myelodysplastic syndrome]

Patients with myelodysplasia are susceptible to infections due to their compromised immunity. If presenting with a cervical lymphadenopathy patients must, in addition to other causes, be evaluated for tuberculosis, especially if they show a concurrent erythema nodosum.

Mycobacterium tuberculosis infection of bilateral cervical lymph nodes after renal transplantation

We report the case of a 52-year-old man who underwent a renal transplantation and subsequently developed extrapulmonary tuberculosis. The immunosuppressive agent was intravenously administered continuously together with antituberculosis drugs. The tuberculosis improved and renal function has been well preserved for more than 3 years post transplantation.

Fine-needle aspiration cytology of postvaccinial disseminated bacillus Calmette-Guerin infection

Nine patients with primary immunodeficiency who received bacillus Calmette-Guerin (BCG) vaccine at birth developed disseminated BCG lesions and presented clinically with generalized skin rash and skin nodules. Fine-needle aspiration biopsy of the skin nodules and/or enlarged lymph nodes was performed in all patients. The most common cytologic pattern encountered was cellular smears showing a large number of histiocytes with abundant streaked cytoplasm in a background of neutrophils and debris. No granulomas were noted. Ziehl-Neelsen (ZN) stain for acid-fast bacilli showed a large number of these bacilli within the cytoplasm of the histiocytes, and extracellularly. This pattern was seen in 6 patients. The cytologic smears from 3 patients showed epithelioid granulomas in a background of neutrophils and debris. ZN stain for acid-fast bacilli showed fewer numbers of these bacilli compared to the first cytologic pattern. In conclusion, the most common cytologic pattern of postvaccinial disseminated BCG lesions in immunocompromised patients is a large number of histiocytes with abundant streaked cytoplasm in a background of neutrophils and debris. No epithelioid granulomas are seen in this pattern. A less frequent pattern is also encountered which shows epithelioid granuloma in a neutrophilic background. In both cytologic patterns, ZN stain for acid-fast bacilli is positive. However, in the first and most common pattern, the number of acid-fast bacilli is much larger than that seen in the second pattern. The different cytologic patterns might be related to the status of immunity of patients at the time of biopsy.

Tuberculosis among allogeneic bone marrow transplant recipients in India

Allogeneic bone marrow transplant recipients have severe impairment of cell-mediated immunity and hence a higher incidence of mycobacterial infections might be expected in regions where tuberculosis is common. We reviewed the case records of 217 patients who underwent allogeneic bone marrow transplantation during the period 1986-1999 at our center in India. Mycobacterial infections were diagnosed in three patients (1.38%). All patients presented with extrapulmonary disease. Two patients had disseminated tuberculosis with one of these being diagnosed on autopsy studies. The third patient had tuberculosis involving the cervical lymph node and dorsal spine. Two patients treated with antituberculous therapy are well. Infection with Mycobacterium tuberculosis is not a common problem in allogeneic bone marrow recipients even in an endemic area, but when it occurs, it is usually disseminated with predominantly extrapulmonary involvement.

Wegener's granulomatosis: pitfalls in the management of pulmonary disease: A case of Wegener's granulomatosis with a hilar mass

Wegener's granulomatosis (WG) is a systemic, granulomatous vasculitis that typically affects the upper airways, lungs, and, in most cases, the kidneys. Lung involvement occurs in 85% of patients. A classic feature of WG is multiple pulmonary nodules, which frequently cavitate. Hilar adenopathy or mediastinal masses are rare. These atypical pulmonary findings should raise suspicion of diseases other than WG and lead to biopsy with cultures, even when the diagnosis of WG appears to be certain. These guidelines proved to be reliable in a patient with WG in whom a hilar mass was associated with tuberculosis.

Reactivation of tuberculosis after conversion from azathioprine to mycophenolate mofetil 16 years after renal transplantation

The incidence of tuberculosis among transplant recipients is greater than in the general population. Mycophenolate mofetil (MMF) is a potent immunosuppressive agent that has become part of most standard immunosuppressive protocols after renal transplantation. We have recently shown that conversion from azathioprine (AZA) to MMF in patients with chronic allograft dysfunction may be beneficial. Here, we report a patient with a history of pulmonary tuberculosis during his childhood. This patient was converted from AZA to MMF therapy 16 years after allogenic renal transplantation because of chronic allograft dysfunction. Two months later, he developed axillary lymph node tuberculosis caused by Mycobacterium tuberculosis. Because he denied contact with infectious persons, we diagnosed reactivation of old dormant tuberculosis. After surgical extirpation, quadruple antituberculous therapy was administered for 3 months (isoniazid, rifampicin, ethambutol, and pyrazinamide), followed by dual therapy for 3 months (isoniazid and rifampicin), and monotherapy for another 3 months (isoniazid). In the follow-up period, he remained asymptomatic with stable graft function. We conclude that MMF therapy in renal allograft recipients may cause reactivation of old dormant tuberculosis, even in the very late posttransplantation period. In these patients, close monitoring and isoniazid prophylaxis may be useful.