Hepatic artery pseudoaneurysms in a patient treated for miliary tuberculosis

A 70-year-old woman with fever was admitted to our hospital. She was diagnosed as miliary tuberculosis and treated with antituberculous drugs. After seven weeks of therapy, she developed a sudden sharp upper abdominal pain and shock. Angiography of the celiac artery showed two hepatic artery pseudoaneurysms with extravasation. The hemorrhage was successfully stopped by microcoil embolization. The clinical course suggested that miliary tuberculosis had caused the pseudoaneurysms. Although aneurysms rarely occur as a complication of miliary tuberculosis, they should be diagnosed as early as possible because of the high rate of rupture and associated high mortality rate.     

A case of miliary tuberculosis presenting as fever and jaundice with hepatic failure looking like the course of fulminant hepatitis]

A 79-year-old male was admitted to the Metropolitan Hiroo Hospital with chief complaints of icterus and fever. A few weeks prior to admission, he developed fever and swelling of right side of the neck and was seen at a local hospital where an anti-inflammatory agent was prescribed. The fever subsided in a few days, but recurred together with development of icterus a few weeks later, precipitating this hospitalization. After admission, hepatic failure progressed rapidly, indicating a fulminant hepatitis. Renal failure also developed and he died. Autopsy revealed diffuse caseous necrosis with demonstration of acid-fast bacilli in the liver, as did in the spleen, kidney and bone marrow. This case epitomizes a subset of miliary tuberculosis in which the hepatic failure predominates the clinical presentation while lacking the ante-mortem chest X-ray features suggestive of pulmonary tuberculosis and post-mortem macroscopic changes indicative of tuberculosis.     

A case of miliary tuberculosis showing acute respiratory failure during pregnancy]

A 36-year-old Philippine woman had had fever and general fatigue from September, 2006 (11th week of pregnancy). She was admitted with high fever, general fatigue and dyspnea on October 16, 2006 (13th week of pregnancy). A chest radiograph on admission showed bilateral miliary shadows and ground glass shadows. She already had severe hypoxia on admission. As acid-fast bacilli were positive in urine (Gaffky 8) and sputum (Gaffky 1), we diagnosed as miliary tuberculosis and pulmonary tuberculosis complicated with acute respiratory distress syndrome (ARDS). We treated her with antituberculosis chemotherapy, corticosteroid, sivelestat sodium hydrate, direct hemoperfusion using a polymyxin B immobilized column, and mechanical ventilation, but she died due to respiratory failure. We emphasize that in this case pregnancy has the risk of to causing disease progression of miliary tuberculosis and we should treat immediately and intensively for miliary tuberculosis complicated with ARDS.     

Imaging diagnosis of 12 patients with hepatic tuberculosis

AIM: To assess CT, MR manifestations and their diagnostic value in hepatic tuberculosis. METHODS: CT findings in 12 cases and MR findings in 4 cases of hepatic tuberculosis proved by surgery or biopsywere retrospectively analyzed. RESULTS: (1) CT findings: One case of serohepatic type of hepatic tuberculosis had multiple-nodular lesions in the subcapsule of liver. Parenchymal type was found in 10 cases, including multiple, miliary, micronodular and low-density lesions with miliary calcifications in 2 cases; singular, low-density mass with multiple flecked calcifications in 3 cases; multiple cystic lesions in i case; multiple micronodular and low-density lesions fusing into multiloculated cystic mass or “cluser“ sign in 3 cases; and singular, macronodular and low-density lesion with multiple miliary calcifications in 1 case. One case of tuberculous cholangitis showed marked dilated intrahepatic ducts with multiple flecked calcifications in the porta hepatis. (2) MR findings in 4 cases were hypointense on both Tl-weighted imagings and T2-weighted imagings in one case, hypointense on Tl-weighted imagings and hyperintense on T2-weighted imagings in 3 cases. Enhanced MR in 3 cases was slightly shown peripheral enhancementor with multilocular enhancement. CONCLUSION: Various types of hepatic tuberculosis have different imaging findings, and typical CT and MR findingscan suggest the diagnosis.     

Miliary tuberculosis as a cause of acute empyema

Adult respiratory distress syndrome (ARDS) and sepsis are known, life-threatening complications of miliary tuberculosis. This report describes a patient with miliary tuberculosis who rapidly developed an acute tuberculous empyema. She had a fulminant course culminating in ARDS, sepsis and subsequent death. This case highlights the rare association of acute empyema with miliary tuberculosis.     

Ofloxacin in miliary tuberculosis

We report one case of severe miliary tuberculosis with liver failure and respiratory insufficiency in a twenty-seven year old patient. We emphasize the presence of hepatic, occular and vestibular toxicities secondary to the treatment and the usefulness of ofloxacin with cycloserine given for nine months.     

Liver Transplantation in Antituberculosis Drugs-Induced Fulminant Hepatic Failure: A Case Report and Review of the Literature

The antituberculosis drugs isoniazid (INH), rifampicin (RMP), pyrazinamide (PZA), and ethambutol (EMB) usually expose patients to the risk of fulminant hepatic failure (FHF). This report presents a case of liver transplantation in antituberculosis drugs-induced FHF and reviews the relevant literature. A 39-year-old woman with pelvic and salpinx tuberculosis experienced complex pelvic exenteration. After the operation, she was administrated INH, RMP, PZA, and EMB to prevent tuberculosis. Two months later, examination revealed severe FHF and the antituberculosis therapy regimen was changed to ciprofloxacin and streptomycin. Subsequently, urgent orthotopic liver transplantation was performed. Posttransplantation, her serum transaminases improved gradually, but her total bilirubin level and direct bilirubin level continued to worsen, which may have been related to the rejection. However, irreversible damage from antituberulosis drugs was note excluded. Two liver biopsies and histological examinations were performed. One year after transplantation, she died as a consequence of ischemic cholangitis and pulmonary infection. A literature review revealed 9 other published cases of antituberculosis drugs-associated FHF with liver transplantation.This report suggests that, in most cases of antituberculosis drugs-induced FHF, discontinuation of toxic drugs and orthotopic liver transplantation are always sufficient treatment.     

Hepatobiliary tuberculosis]

An analysis of 423 cases with hepatic and biliary tuberculosis was reported. The hepatic tuberculosis may be divided into miliary, nodular and abscess type, the biliary tuberculosis may be divided into cholecystic and biliary type.     

A recovery case of acute-onset autoimmune hepatitis presenting as fulminant hepatic failure [corrected], who received living donor-liver transplantation

A 23-year-old woman was admitted to our hospital with jaundice and hepatic coma. She had taken a weight-loss supplement for one month before admission. Her clinical and laboratory findings were consistent with fulminant hepatic failure and fulfilled the criteria of autoimmune hepatitis. Despite corticosteroid pulse therapy and plasma exchange, her symptoms and laboratory findings deteriorated. Her condition improved after she received a living donor-liver transplant from her sister. Autoimmune hepatitis usually follows a chronic course, but it should be considered a type of fulminant hepatic failure and treated promptly.     

Miliary tuberculosis not affecting the lungs but complicated by acute respiratory distress syndrome

A 61-year-old woman was admitted with fever and headache of 10-day duration. She was found to have anemia, jaundice, and signs of meningitis. The erythrocyte sedimentation rate was increased and the tuberculin skin test was positive. A provisional diagnosis of miliary tuberculosis was made and antituberculous therapy was started, although no miliary lesions were seen on chest radiography. However, her condition rapidly deteriorated with diffuse opacification of both lungs and she died on the 7th hospital day. Postmortem examination revealed miliary tuberculosis in several organs but not in the lungs with acute respiratory distress syndrome accounting for the lung pathology. It should be noted that on rare occasions the lungs may not be involved by miliary tuberculosis.     

Clinical characteristics and prognostic indicators of drug-induced fulminant hepatic failure

BACKGROUND/AIMS: In most cases of drug-induced liver injury, it is difficult to diagnose whether these cases would progress to fulminant hepatic failure. We investigated the characteristics of non-viral and suspiciously drug-induced fulminant hepatic failure by comparing clinical data between cases that progressed and those that did not progress to fulminant hepatic failure. METHODOLOGY: Ninety-five cases of suspicious drug-induced liver injury including 22 cases that had been treated at our hospital, and subsequently progressed to fulminant hepatic failure were involved in this study. We investigated the characteristics of drug-induced fulminant hepatic failure by a comparison of non-fulminant and fulminant cases, and simultaneously of survivors and fatal cases in the group of fulminant cases. RESULTS: Many of the clinical variables were significantly deteriorated in fulminant cases. The latent period, which means the duration of drug administration, correlated with the severity of drug-induced liver injury including fulminant hepatic failure. Suspicious cases of drug-induced liver injury where the bilirubin level at the time of definite diagnosis stayed over 13 mg/dL for more than one month were likely to progress to fulminant hepatic failure. CONCLUSIONS: Our results suggest that the latent period and the peak level of total bilirubin would be prognostic factors for the severity of drug-induced fulminant hepatic failure. Early preparation of liver transplantation should be recommended by referring these characteristics.     

Miliary tuberculosis presenting as hepatic and renal failure

A 67-year-old man developed hepatic and renal failure over a six-day period. Despite full supportive measures, he died on his 11th day of hospitalization with fulminant DIC and hepatic, renal, and respiratory failure. Postmortem examination revealed acid-fast bacilli in virtually all organ systems. Miliary tuberculosis should be considered as a potentially treatable cause of hepatic failure.     

Evaluation of accuracy of clinical diagnosis of TB by annual autopsy report

PURPOSE: To investigate the accuracy of clinical diagnosis of TB in Japan in recent years and to compare them with previous studies. METHOD: Data (sex, age, clinical diagnosis, pathological diagnosis as cause of death) on deceased cases clinically or pathologically diagnosed ante mortem as having tuberculosis was collected from annual reports of the pathological autopsy cases in 1984, 1989, 1994, and 1999-2004. Information on TB death from population statistics in those 9 years also was collected and compared with data of autopsied cases. RESULT: Autopsy rate in these years was stably around 10 %. Comparison of gender ratio and mean age between the two surveys showed similar numbers. During 1999-2004, 1725 death cases were diagnosed as TB clinically or pathologically. Number of pathologically proven pulmonary TB cases was 429 and that of miliary TB was 283. 55.7% of pulmonary tuberculosis and only 21.9% of miliary tuberculosis were correctly diagnosed before death. Out of 156 cases clinically diagnosed as non-TB diseases but proven as TB pathologically, 30.8% of clinical diagnosis was pneumonia and/or bronchitis, followed by diagnoses of interstitial pneumonia, respiratory failure, pneumoconiosis and lung cancer. However, the main clinical diagnoses of 175 miss-diagnosed miliary TB cases were diseases other than pulmonary diseases such as renal failure, malignant diseases and sepsis. CONCLUSION: In order to reduce undiagnosed pulmonary TB cases and to prevent nosocomial TB infection, differential diagnosis among pneumonia and/or bronchitis cases should be done. In case of miliary TB, not only pneumonia but also diseases other than pulmonary diseases such as renal failure, malignant diseases and sepsis should be included in the list differential diagnosis.     

猪急性肝衰竭模型的建立及猪纤维介素的表达

目的 建立一个模拟人类疾病进程的猪急性肝衰竭(ALF)模型,用于ALF治疗药物的临床前安全性评价及疗效评价,检测模型中猪纤维介素(pfg12)的表达情况,为针对fg12的基因治疗提供基础和依据. 方法造模组耳静脉快速注射D-氨基半乳糖盐酸盐,剂量1.2 g/kg;对照组耳静脉快速注射5%的葡萄糖,剂量12 ml/kg.观察两组动物临床表现,肝功能指标和肝组织病理学改变,实时定量PCR检测肝组织中pfg12 mRNA表达,免疫组织化学检测肝组织中pfg12蛋白的表达.采用重复测量数据的方差分析和独立样本t检验进行统计学处理.结果 成功建立了与人在临床表现、肝脏生物化学指标、组织病理学改变相似的猪ALF模型;实时定量PCR检测结果显示造模组猪肝组织中pfg12的mRNA表达水平显著增加,与对照组比较,差异具有统计学意义(t=7.695,P＜0.05).免疫组织化学显示造模组猪肝组织中有明显的pfg12蛋白的表达,主要分布在肝细胞坏死区域的肝细胞、炎症浸润细胞、肝血窦内皮细胞及血管内皮细胞,对照组动物肝组织未见pfg12阳性着色.结论 以D-氨基半乳糖盐酸盐诱导的猪ALF模型可用于评价肝衰竭治疗药物的临床前疗效及安全性;pfg12在猪ALF动物模型的肝组织中异常高表达,提示其参与了ALF时肝细胞坏死的发生和发展过程.     

猪急性肝衰竭模型的建立及猪纤维介素的表达

目的 建立一个模拟人类疾病进程的猪急性肝衰竭(ALF)模型,用于ALF治疗药物的临床前安全性评价及疗效评价,检测模型中猪纤维介素(pfg12)的表达情况,为针对fg12的基因治疗提供基础和依据. 方法造模组耳静脉快速注射D-氨基半乳糖盐酸盐,剂量1.2 g/kg;对照组耳静脉快速注射5%的葡萄糖,剂量12 ml/kg.观察两组动物临床表现,肝功能指标和肝组织病理学改变,实时定量PCR检测肝组织中pfg12 mRNA表达,免疫组织化学检测肝组织中pfg12蛋白的表达.采用重复测量数据的方差分析和独立样本t检验进行统计学处理.结果 成功建立了与人在临床表现、肝脏生物化学指标、组织病理学改变相似的猪ALF模型;实时定量PCR检测结果显示造模组猪肝组织中pfg12的mRNA表达水平显著增加,与对照组比较,差异具有统计学意义(t=7.695,P＜0.05).免疫组织化学显示造模组猪肝组织中有明显的pfg12蛋白的表达,主要分布在肝细胞坏死区域的肝细胞、炎症浸润细胞、肝血窦内皮细胞及血管内皮细胞,对照组动物肝组织未见pfg12阳性着色.结论 以D-氨基半乳糖盐酸盐诱导的猪ALF模型可用于评价肝衰竭治疗药物的临床前疗效及安全性;pfg12在猪ALF动物模型的肝组织中异常高表达,提示其参与了ALF时肝细胞坏死的发生和发展过程.     

A case of miliary tuberculosis associated with acute respiratory failure during pregnancy

A case of miliary tuberculosis associated with acute respiratory failure during pregnancy was reported. A 39-year-old, 29-week pregnant woman was admitted to our hospital with complaints of nonproductive cough and fever on June 12. On admission, her temperature was 38.2 degrees C; pulse rate was 90/min., and blood pressure was 120/76 mmHg. Physical examination revealed moist rales at right lung basis. Chest X-ray showed small nodular infiltrates in right lower lung field. Laboratory data revealed positive CRP, accelerated ESR and increased level of alpha 2-globulin. The number of T-cells was markedly decreased (14/mm3). The PPD skin test was negative, and the sputum smears for acid-fast bacilli were negative. Suspected of bacterial or viral pneumonia, the patient was treated with antibiotics (CPM, EM and CAZ), which had no effects for her. On June 16, the Chest X-ray showed infiltrates throughout bilateral lung fields, and the patient became increasingly dyspneic. On June 18, the results of arterial blood gas, analysis under room air were: PaO2 26.7 Torr, PaCO2 29.0 Torr, pH 7.505. Because of severe hypoxemia, she was intubated and placed on a volume-cycled respirator. Hydrocortisone (1000 mg, daily) was added to treatment because ARDS was suspected. Since the smears of tracheobronchial secretions showed acid-fast bacilli on June 24, she was diagnosed to have miliary tuberculosis. Then the intensive therapy with antituberculosis drugs (isoniazid 400 mg, rifampicin 450 mg, and streptomycin 1g, daily) was started. The non specific antibiotics were discontinued; hydrocortisone was tapered and stopped. The next week, she became afebrile and hypoxemia steadily improved.(ABSTRACT TRUNCATED AT 250 WORDS)     

Active tuberculosis undiagnosed until autopsy

In this report 21 patients in whom tuberculosis was the primary cause of death, but which was not diagnosed until necropsy, are reviewed. Of the 21 deaths, 11 were due to pulmonary tuberculosis and 10 to miliary tuberculosis. Proper evaluation of the following factors might have led to the correct diagnosis in many of the patients: A family history of tuberculosis, prior pleurisy, a gastrectomy, diabetes mellitus or end-stage renal failure; all can be associated with an increased incidence of tuberculosis. A negative tuberculin skin reaction does not exclude the presence of active tuberculosis. In the search for Mycobacterium tuberculosis, the examination of just one or two sputum specimens is not an adequate bacteriologic investigation. A positive gastric smear can have diagnostic importance. Ascitic fluid findings can be characteristic of tuberculous peritonitis. A negative bone marrow aspirate for acid-fast bacilli does not exclude miliary tuberculosis. Significant anemia, high fever and leukopenia increases the possibility of tuberculosis. The persistence and/or progression of lung infiltration, irrespective of supposedly specific antibiotic therapy, strongly suggests tuberculosis. Miliary tuberculosis can present as an adult respiratory distress syndrome. All but one patient in this series had fever. The failure to diminish the pyrexia believed due to specific lung infections with presumably effective antibiotics, and the inability of therapy to control other conditions thought to cause the fever indicate the presence of tuberculosis. Tuberculosis, especially miliary disease, should be considered as a possible etiology of fever of unknown origin.If the diagnosis of tuberculosis is highly suggestive, even without bacteriologic confirmation, a therapeutic trial of antituberculosis drugs should be given.     

Hepatic tuberculosis in absence of disseminated abdominal tuberculosis

Liver involvement in tuberculosis in absence of miliary tuberculosis is rare. This study was performed to analyse the spectrum and response to treatment of hepatic tuberculosis in the absence of miliary abdominal tuberculosis. Retrospective analysis of seven cases of hepatic tuberculosis without miliary abdominal tuberculosis who presented at the single tertiary referral center were analyzed. All patients presented with fever and hepatomegaly. Five of them had pain in upper abdomen and vomiting. HIV serology was positive in one patient. All patients had normocytic normochromic anaemia, raised erythrocyte sedimentation rate (Mean 65). Mild elevation of liver enzymes and low albumin (Mean 2.4 gm%) with reversal of albumin globulin ratio (Mean 0.6) were seen in all. Two had jaundice. Prothrombin time was normal in all and lactate dehydrogenase values were elevated in all (Mean 794 IU/L). On ultrasonography, 2 had multiple hypodense lesion, 1 had coarse echotexture of liver, 1 had hyperechoic pattern and 3 had just hepatomegaly. Complete resolution of liver lesions on treatment with 4-drug anti-tuberculosis drug chemotherapy was seen. In conclusion, liver tuberculosis has protean manifestations with nonspecific alteration of liver function tests and is best diagnosed on liver biopsy. Overall response to therapy is satisfactory.     

Atypical Hepatic Tuberculosis Presenting as Obstructive Jaundice

A 78-yr-old female with a short history of malaise, anorexia, mild pyrexia, and obstructive jaundice is presented. A diagnosis of tuberculosis of the liver and gallbladder was established at laparotomy. In spite of anti-tuberculous therapy, the patient died on the 5th postoperative day. Widespread miliary tuberculosis affecting the lung, kidneys, spleen, and mesenteric lymph nodes was observed in postmortem studies, with strikingly severe involvement of the intrahepatic bile ducts. Saccular dilatation of the bile ducts alternating with areas of stenosis and narrowed intrahepatic bile ducts was seen. A correlation of the radiological and hepatic postmortem findings is discussed. The atypical presentation of tuberculosis in present times and the causes of jaundice in atypical cases of hepatic tuberculosis are discussed. The rarity of gallbladder tuberculosis is pointed out.