Ultrasonographic diagnosis in abdominal tuberculosis

Sonographic findings were retrospectively analysed in 39 patients with proven abdominal tuberculosis (TB). The patients were treated over 15 years at a major teaching hospital, Mubarak Al-Kabber Hospital, in Kuwait. The findings included clear or complex ascites with fine strands, loculations and debris. The other findings were lymphadenopathy, bowel wall thickening, omental mass, focal lesions in the liver and spleen and psoas abscess. The sonographic findings in abdominal TB are not specific but may give valuable information to prevent unnecessary laparotomy.     

Cerebral hemorrhage due to tuberculosis meningitis: a rare case report and literature review

Tuberculosis (TB) is a common disease to threaten human health. TB of the central nervous system (CNS) is rare but the most serious type of systemic TB because of its high mortality rate, serious neurological complications and sequelae. In this case report, we describe a woman who presented with walking instability, intracerebral hemorrhage and leptomeningeal enhancement due to tuberculosis meningitis. The patient had no significant medical history and the initial clinical symptoms were walking instability. On analysis, the cerebrospinal fluid was colorless and transparent, the pressure was more than 400 mm H₂O, there was lymphocytic pleocytosis, increased protein, and decreased glucose levels present. No tuberculosis or other bacteria were detected. The patient''s brain computed tomography image showed intra-cerebral hemorrhage (ICH) and contrast magnetic resonance imaging showed ICH in the right frontal lob, and leptomeningeal enhancement. CNS TB is rare but has a high mortality rate. As this disease has no unique characteristics at first presentation such as epidemiology and obvious clinical manifestation, a diagnosis of CNS TB remains difficult.     

Monoclonal antibodies against a Mycobacterium tuberculosis Ag85B-Hsp16.3 fusion protein

The secreted Mycobacterium tuberculosis (MTB) proteins, Ag85B and Hsp16.3, have been the focus of intensive research in recent years. These proteins have high sensitivity in bacterium-negative tuberculosis (TB) patients, and are valuable for the rapid diagnosis of bacterium-negative TB. Fusion proteins including multiple antigens such as Ag85B and Hsp16.3 provide improved sensitivity and specificity for serological diagnosis of active TB compared with a single antigen. Many studies have shown that the production of MAbs recognizing a specific repertoire of M. tuberculosis antigens and the tests based on monoclonal antibodies have been found to be valuable in positive detection of TB, particularly for smear-positive pulmonary TB. A number of MAbs are currently used for serodiagnosis of TB. Therefore, an Ag85B-Hsp16.3 fusion protein was expressed and purified using an E. coli system in this study. Three Ag85B-Hsp16.3 fusion protein-specific MAbs were generated by routine murine hybridoma techniques. The titer, specificity, and relative affinity of all three MAbs were determined by ELISA and the serological responses were analyzed. The levels of antigens in a proportion of TB patients were shown to be significantly higher than those in healthy controls. The sensitivity and specificity of the currently available detection systems is likely to be improved by the employment of a combination of these MAbs with others that are already in use.     

Imaging of tuberculosis of the breast: 21 cases and a review of the literature

This study was conducted to assess the mammographic and sonographic features of tuberculosis (TB) of the breast seen at the Helen Joseph Hospital, Johannesburg, South Africa. The study is a retrospective review of patients who presented to the mammography department with breast symptoms subsequently diagnosed as TB or 'highly suspicious for TB'. The search of records extended over a period of 6 years (2002-2008). The search identified 21 patients who met the criteria. Patient characteristics, clinical presentation and radiological features have been analysed. The most common presentation of TB of the breast was an oedematous breast secondary to enlarged unilateral axillary lymph nodes. Only 33% of the patients presented with a palpable breast mass as the primary complaint. The significance of TB associated breast disease lies in recognising the disease entity as it can mimic breast cancer or pyogenic breast abscess.     

A Study of Manifestations of Extrapulmonary Tuberculosis in the ENT Region

Though tuberculosis (TB) primarily affects lungs, extra pulmonary tuberculosis (EPTB) is also common, especially in high disease load areas and mainly manifests in ENT region. To study the different manifestations of tuberculosis in ENT region in terms of presentation, disease process, treatment and outcome. Records of patients diagnosed and treated for TB in the ENT region at our institute’s DOTS centre for a two and half year period were analysed for presenting complaints, examination findings, diagnostic features, treatment modes and outcome. Out of 3750 cases diagnosed as TB, 230 had EPTB. 211 cases had ENT manifestations. Majority of the cases were male and in the fourth decade of life. Commonest manifestation was cervical lymphadenopathy with 201 cases. Fine needle aspiration cytology was mostly diagnostic and category I anti TB treatment (AKT) achieved cure. The six cases of TB otitis media presented with ear discharge, sometimes bloody and had varied tympanic membrane findings and facial palsy in two cases with different types and degrees of hearing loss. Diagnosis was confirmed by histology of tissue removed during surgery. Patients completed category I AKT. Hearing and facial palsy did not improve. There were three cases of TB laryngitis and one of nasal TB both of which were confirmed by tissue diagnosis and responded well to AKT. Most of the results in the present study conform to findings of other studies. High degree of suspicion is necessary to reach diagnosis. Category I AKT is effective. Some cases may require surgery.     

Tuberculosis in blood and marrow transplant recipients

Although one third of the world's population is infected with tuberculosis (TB), TB in blood and marrow transplant (BMT) recipients is relatively less well studied, as the incidence of TB is relatively low in developed countries with BMT units. Since the report of the first two cases in 1983, 52 cases of TB complicating BMT have been reported in the English literature from BMT centers in ten different countries. Not unexpectedly, the two largest series were reported from areas with a high incidence of TB in the general population, with about 45 cases per 10(5) inhabitants per year in Spain and about 100 cases per 10(5) inhabitants per year in Hong Kong respectively. The overall frequency of occurrence of TB in BMT recipients was 0.4% (52 cases among 13 881 BMT recipients), with a male:female ratio of 11:9 and median age of 33 (range 7-57). The incidence of TB in the general population is a major predictor of a higher frequency of occurrence in BMT recipients. Moreover, allogeneic transplantation, graft-versus-host disease, and total body irradiation were found to be risk factors associated with TB. Among the 48 cases in whom the time of manifestation were reported, only one case manifested during the neutropenic period (day 11). On the other hand, 11 cases (23%) manifest after engraftment but before day 100, and 36 (75%) manifest after day 100. The most important aspect towards making the diagnosis is a high index of suspicion, as TB occurred in relatively low frequencies especially in developed countries, and the clinical patterns usually mimic other more common infectious and non-infectious complications after BMT. As the incidence of drug resistant TB is increasing, we prefer to treat our patients for at least one year (as compared with six months in immunocompetent hosts) with four drugs in the first six months and two or three drugs for another six months. In those patients who could not tolerate oral medication, we used an intravenous regimen of rifampicin, ciprofloxacin, and amikacin until oral therapy could be instituted. The absence of relapse after termination of treatment in our patients suggested that secondary prophylaxis would not be necessary as long as immune function has been restored. With the rising incidence of TB in countries that previously enjoyed a very low prevalence of TB, attributed to the growing population of HIV-infected subjects with TB, and the changing patterns of population migration, it is important to bear a high index of suspicion of Mycobacterium tuberculosis as a pathogen in BMT recipients.     

淋巴瘤合并结核21例临床分析

 【摘要】　目的　探讨淋巴瘤合并结核的临床特点、可能的发病机制以及有效的治疗手段。方法　回顾分析21例已确诊的淋巴瘤合并结核患者的临床特点、病理特征、确诊手段、治疗及转归情况。结果　21例患者中,淋巴瘤诊断先于结核诊断者6例,其中5例结核感染时淋巴瘤正在化疗;淋巴瘤诊断在结核感染之后诊断者13例,其中10例陈旧性肺结核者有6例在淋巴瘤治疗过程中复燃;二者同时诊断者2例。淋巴瘤患者中霍奇金淋巴瘤6例,非霍奇金淋巴瘤15例。结论　在结核病的高发地区,结核病和淋巴瘤可同时存在于同一患者;合并结核的淋巴瘤患者中霍奇金淋巴瘤构成比高于普通人群淋巴瘤患者的霍奇金淋巴瘤构成比;对于患有陈旧性肺结核的淋巴瘤患者,化疗过程中要密切注意陈旧性肺结核复燃的可能。     

Magnetic resonance and computed tomography imaging of a grade IV papillary endolymphatic sac tumour

The endolymphatic sac tumour (ELST) is an adenomatous neoplasm of the papillary pattern originating from the endolymphatic sac's epithelium. We describe the computed tomography and magnetic resonance imaging features of a rare grade IV tumour with extensive skull base, cerebello-pontine and nasopharyngeal spread as well as involvement of the left temporomandibular joint. Papillary ELST may easily be misinterpreted on histopathological and even on immunohistochemical examination with other papillary lesions. Thus the radiological imaging features and localization in conjunction with histopathological features and clinical presentation play a paramount role in making the correct diagnosis.     

Non-Hodgkin lymphoma with high adenosine deaminase levels mimicking peritoneal tuberculosis: an unusual presentation

Abdominal tuberculosis is still a medical problem in developing countries. The clinical presentation of tuberculous (TB) peritonitis may be similar to that of peritoneal carcinomatosis. Therefore, its diagnosis is rather difficult only with laboratory investigations. Ascitic fluid adenosine deaminase (ADA) activity has been proposed as a useful diagnostic test in tuberculous peritonitis, as many studies reported high ADA levels in TB peritonitis. On the other hand, ADA activity is usually lower in peritoneal carcinomatosis and malignant ascites. This study described a patient with non-Hodgkin lymphoma with elevated (67 U L(-1)) ADA levels and clinical signs mimicking peritoneal tuberculosis. On admission, this study focused on the high value of ADA in ascites and strongly suspected TP. Although anti-tuberculous agents were initiated, his general condition did not improve. Finally, laparoscopic peritoneal biopsy was performed and non-Hodgkin lymphoma diagnosed. In the light of these findings, ADA level may not reflect TB peritonitis in the absence of histopathological examination. Therefore, non-Hodgkin lymphoma should be kept in mind in the differential diagnosis in patients with high ascitic fluid ADA levels and in non-responders to anti-tuberculosis treatment.     

Metastasis of breast cancer to a uterine leiomyoma

Metastasis of breast cancer to a uterine leiomyoma is rare. We review the clinicopathological features of breast cancer metastasis to a uterine leiomyoma and discuss possible effective treatment. We describe a case of a woman who presented with abdominal discomfort after undergoing mastectomy for breast cancer. At the time of mastectomy, imaging showed osseous metastases involvement to the right kidney. The patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy. Microscopic examination disclosed carcinoma of breast origin localized within the leiomyoma. To date, the patient is alive and asymptomatic after treatment with anastozole and capecitabine for 11 months. Per reports in the literature, abnormal uterine bleeding or a rapidly growing leiomyoma may be symptomatic of breast cancer metastasis to a uterine leiomyoma, especially if a patient has a previous diagnosis of invasive ductal carcinoma of the breast. Palliative hysterectomy can potentially improve prognosis in patients whose cancer is restricted to a uterine leiomyoma with or without involvement of lymph nodes, and may offer relief of genital tract symptoms in patients who have widespread involvement of non-life-threatening metastases.     

T-SPOT.TB for Detection of Tuberculosis Infection among Hematological Malignancy Patients and Hematopoietic Stem Cell Transplant Recipients

The diagnosis of latent Mycobacterium tuberculosis infection (LTBI) is recommended in hematologicalmalignancy patients and before hematopoietic stem cell transplantation (Guidelines for the prevention andmanagement of infectious complications of solid organ transplantation, 2004). Compared to traditional methodssuch as tuberculin skin test (TST), T-SPOT.TB has been shown to be more specific. In the present study weenrolled 536 patients for whom T-SPOT.TB was performed, among which 295 patients also received the TSTtest. The agreement (79%) between T-SPOT.TB and TST was poor (κ=0.274, P<0.001). The patients with positiveT-SPOT.TB results numbered 62 (11.6%), in which only 20 (48.8%) of the 41 receiving the TST test had positiveresults. A majority of the patients with T-SPOT.TB positive results had some other evidence ofTB, such as TBhistory, clinical symptoms and an abnormal chest CT scan. Active TB was found in 9 patients, in which 2 hadnegative TST results. We followed up the patients and no one developed active TB. Our study suggested that theT-SPOT.TB may be more useful for screening LTBI and active TB in hematological malignancy patients andhematopoietic stem cell transplant recipients than the TST test.     

Particular features of detection of patients with urogenital tuberculosis and their management

The rate and trend in extrapulmonary tuberculosis (TB) incidence including urogenital tuberculosis (UTB) were estimated in population of the Sverdlovsk region for the last 25 years. Long-term results of treatment of 591 patients with different forms of UTB (renal parenchyma TB, tuberculosis papillitis, monocavernous and polycavernous renal TB, male genital TB) were studied. Ureter was involved in tuberculosis process in 24.7% of UTB cases, urinary bladder--in 20.1%, renal TB combined with male genital TB. Early (non-destructive) forms incidence increased 2.8-fold while advanced forms incidence decreased 1.7-fold. This shows an increased level of detection. Total number of patients operated in state hospitals with undetected, mostly complicated urogenital male tuberculosis remains high--from 7.3 to 16% from all newly detected patients.     

A Retroperitoneal Dedifferentiated Liposarcoma Producing Granulocyte Colony-Stimulating Factor Accompanied by Spontaneous Rupture: PET/CT Imaging of a G-CSF-Producing Tumor

The patient was a 63-year-old man who was referred to our hospital as an emergency case with the chief complaint of abdominal pain. An abdominal CT revealed a right retroperitoneal tumor of 15 cm and retroperitoneal bleeding. After a transcatheter arterial embolization was performed, the patient was transferred to our department. There was no infective focus. The white blood cell (WBC) count (37,820/μl, normal range <8 pg/ml) and the serum granulocyte colony-stimulating factor (G-CSF) level (2,670 pg/ml, normal range <8 pg/ml) were high. Bone marrow biopsy revealed little fat, significant hyperplasia, and predominantly increased neutrophils, but no findings of bone metastasis or bone marrow involvement. A G-CSF-producing tumor was diagnosed and right nephrectomy and retroperitoneal tumorectomy were performed. However, the tumor had infiltrated into the inferior vena cava, diaphragm and abdominal wall, and only part of the tumor could be removed. In histopathological tests, hematoxylin-eosin staining showed malignant fibrous histiocytoma-like findings mixed with those for well-differentiated liposarcoma, and the case was diagnosed as dedifferentiated liposarcoma. Preoperative (18)F-FDG-PET computed tomography showed diffuse (18)F-FDG uptake throughout the bone marrow and elevated uptake at the tumor site. However, since bone biopsy and bone scintigraphy indicated no bone metastasis or bone marrow involvement, we concluded that PET/CT imaging gave false-positive results in the bone marrow. This is the first report of PET/CT imaging of a G-CSF-producing tumor in a urological disease. The imaging results may be useful for differential diagnosis for this tumor in patients with high WBC counts without infection.     

Assessment of abdominal aortic aneurysm with magnetic resonance imaging

Pre-operative imaging of abdominal aortic aneurysms (AAA) is important in determining suitability for operation and operative approach. Ultrasound imaging is an excellent screening modality but is relatively poor at identifying renal arteries and the extent of iliac involvement. Computed tomography scanning with intravenous contrast and arteriography are invasive modalities that are associated with a small risk. Magnetic resonance imaging (MRI) offers the potential of accurate anatomical definition without use of contrast agents and passage of an intra-arterial catheter. Eight patients who had their AAA evaluated with MRI are reported. All had renal arteries accurately defined, intraaneurysmal thrombosis was well delineated, and iliac extension was correctly identified in four cases. The initial experience has been most encouraging and the authors consider that MRI may become the investigation of choice for pre-operative AAA assessment.     

Sarcoidosis in India: practical issues and difficulties in diagnosis and management

Although sarcoidosis has emerged as an important lung disease in this country, clinicians continue to face difficulties in diagnosis and management of the illness. The relative rarity of sarcoidosis and the remarkable similarity of clinical, radiological and histopathological features with tuberculosis pose problems in the differential diagnosis. Although the pattern and sites of involvement do help, the prevalence of tuberculosis, including those of extrapulmonary sites, is so high that a confident exclusion of the illness is not easy. One important point of difference is the presence of tuberculin-anergy in sarcoidosis vis à vis tuberculosis. Bronchoscopic transbronchial lung biopsy is positive in over 80 percent of patients with sarcoidosis. Exclusion of tuberculosis to diagnose sarcoidosis is important in particular because corticosteroids form the mainstay of treatment for sarcoidosis. Asymptomatic patients with stage I pulmonary and other milder forms of cutaneous sarcoidosis do not need systemic steroid therapy. We have found favorable results with steroid sparing drugs such as methotrexate and azathioprine. Patients with refractory disease, relapse of illness and those with steroid induced complications or concomitant illnesses likely to be worsened by corticosteroids, are mostly treated with weekly, low-dose methotrexate.     

Investigation of healthcare-associated transmission of Mycobacterium tuberculosis among patients with malignancies at three hospitals and at a residential facility

BACKGROUND: Immunocompromised patients have an increased risk of experiencing progression of latent Mycobacterium tuberculosis infection (LTBI) to active tuberculosis (TB) disease. In January 2002, 2 patients with leukemia (Patients 1 and 2) developed pulmonary TB after recent exposure at 3 hospitals (Hospital A, Hospital B, and Hospital C) and at a residential facility for patients with cancer. Neither was known to have LTBI. Within 1 year, 3 other patients with malignancy and TB disease had been identified at these facilities, prompting an investigation of healthcare facility-associated transmission of M. tuberculosis. METHODS: The authors performed genotypic analysis of the five available M. tuberculosis isolates from patients with malignancies at these facilities, reviewed medical records, interviewed individuals who had identical M. tuberculosis genotypic patterns, and performed tuberculin skin testing (TST) and case finding for possible exposed contacts. RESULTS: Only Patients 1 and 2 had identical genotypic patterns. Neither patient had baseline TST results available. Patient 1 had clinical evidence of infectiousness 3 months before the diagnosis of TB was ascertained. Among employee contacts of Patient 1, TST conversions occurred in 1 of 59 (2%), 2 of 34 (6%), 2 of 32 (6%), and 0 of 8 who were tested at Hospitals A, B, and C and at the residential facility, respectively. Among the others who were exposed to Patient 1, 1 of 31 (3%), 1 of 30 (3%), 0 of 40 (0%), and 12 of 136 (9%) who were tested had positive TSTs at Hospitals A, B, and C and at the residential facility, respectively. CONCLUSIONS: Delayed TB diagnosis in 2 patients with leukemia resulted in the transmission of M. tuberculosis to 19 patients and staff at 3 hospitals and a residential facility. Baseline TB screening and earlier clinical recognition of active disease could reduce healthcare facility-associated transmission of M. tuberculosis among patients with malignancy.     

Inflammatory carcinoma of the breast: Characteristic findings of MR imaging

Inflammatory breast carcinoma (IBC) shows a unique clinical appearance and has an extremely poor prognosis. Although immediate intensive therapy has been proposed, diagnosis of this disease tends to be delayed as its clinical features can be confused with acute mastitis. The conventional imaging modalities including mammography and ultrasonography are of limited value in the diagnosis of IBC, as it is difficult to delineate specific findings of the swollen dense breast. Recently, magnetic resonance (MR) imaging has been widely applied to breast diseases. One of the excellent features of this modality is its diagnostic ability in dense breasts. However, few trials to evaluate the capability of this new modality for IBC have been documented. In recent years, we found that a characteristic feature in 5 cases of IBC was a strong signal on T2-weighted images (T2WI) of MR imaging at the retromammary and subcutaneous area. Pathological features of the retromammary area showed marked interstitial edema and focal lymphatic involvement by tumor cells. These characteristic images obtained by MR imaging may be suggestive of inflammatory breast carcinoma. Furthermore, subtracted dynamic MR imaging indicated the site of the tumor. Therefore, the application of MR imaging for swollen breasts would assist in the immediate diagnosis of IBC and would contribute to appropriate and timely therapy.     

Évaluation ganglionnaire chirurgicale dans les cancers du col utérin

Lymph-nodal involvement is a major prognostic factor of cervical cancer. Lymph-node status is classically evaluated by lymph-node dissection. This surgical approach has mainly a prognostic interest. The morbidity related to the lymph-node dissection is not nil, so numerous imaging or surgical techniques have been recently developed in order to reduce this morbidity. Currently, even with the progress of the imaging techniques, surgical lymph-node dissection is the standard approach. For the management of early cervical cancer, surgery is usually the sole treatment. In association with a laparoscopic lymph-node dissection, the sentinel node technique is a new approach that gives interesting data: possibility of performing frozen sections on the sentinel nodes in order to improve the management, discovery in an important proportion of cases of abnormal lymphatic pathways that are a potential aetiology of recurrence, and identification of lymph-node micrometastases that seem to be an important independent prognostic factor. In the future, evaluation of only the sentinel nodes may replace the pelvic lymph-node dissection. For advanced cervical cancers, the treatment is based on chemoradiotherapy. The paraaortic lymph-node status is an important prognostic factor that helps for defining the radiotherapy fields. New imaging techniques as PET Scan, may help for the evaluation of paraaortic lymph-node status. If the PET Scan is positive at the paraaortic level, there is no need for paraaortic lymph-node dissection and radiotherapy should be performed with pelvic and abdominal fields. But the false negative rate of the PET Scan is high and laparoscopic paraaortic lymph-node dissection is required in case of negative PET Scan at the paraaortic level.     

High incidence of tuberculosis after alemtuzumab treatment in Hong Kong Chinese patients

Twenty-seven patients received the anti-CD52 monoclonal antibody alemtuzumab for hematologic malignancies and autoimmune cytopenias in a tuberculosis-endemic area. Seven patients developed mycobacterium tuberculosis (TB) infections (median: 4, 1-24, months from alemtuzumab). The actuarial 1- and 2-year incidence of TB was 31% and 45%. All patients had severe depression of lymphocyte counts subsequent to alemtuzumab treatment, and tuberculosis was extra-pulmonary in three cases. All seven patients had received prior chemotherapy/immunosuppression and tuberculosis had not occurred until alemtuzumab was administered. Patients receiving alemtuzumab in areas endemic for tuberculosis should have careful initial evaluation of TB exposure, so that prophylactic antibiotics might be administered. Tuberculosis reactivation should be considered for unexplained fever and symptoms after alemtuzumab treatment.