Isolated splenic tuberculosis]

A case of splenic tuberculosis is reported. The patient was a 79-year-old man who was admitted to the Tokyo Metropolitan Geriatric Hospital because of high fever and loss of body weight. Several finger-tip sized superficial lymph nodes were palpable in bilateral inguinal regions. The intermediate PPD skin test was positive. However, there was no evidences of active tuberculosis on the chest roentgenogram. The computed tomogram of the abdomen showed moderate enlargement of the spleen with multiple low density areas and several swollen lymph nodes in the para-aortic region. Although a lymph node of the inguinal region was resected for the pathologic examination, it showed no specific changes. In order to obtain a final diagnosis, laparotomy was performed. The spleen was markedly enlarged and nodular in appearance. No abnormal findings were observed in the other abdominal organs. Splenectomy was carried out. Numerous yellowish nodules, varying from 0.1 to 5 cm in diameter, were observed on the cut surface of the resected spleen (20 x 20 x 8 cm, 700 g). The bacteriologic examination revealed acid-fast bacilli. The fever subsided after splenectomy and following antituberculous therapy. Recently, isolated tuberculosis of the spleen has become very rare. Since 1965, only six cases in five reports can be found in the English, French and German literature. The present case is considered to be one such very rare cases of tuberculosis. Although splenic tuberculosis is rare at the present time, splenic tuberculosis should be included in the differential diagnosis of fever of unknown origin with splenomegaly.     

Tuberculosis of the spleen: a case report

A 40-year old Thai male presented with epigastric discomfort and weight loss without fever for 2 months. On examination, there was no hepatosplenomegaly or lymphadenopathy. His ultrasonogram showed multiple lesions in the spleen with enlarged abdominal lymph nodes. Pathology revealed caseating granulomas of the spleen and lymph nodes. No AFB were seen but PCR was positive for M. tuberculosis complex. The fever resolved within 3 days of surgery and the patient was treated with antituberculous drugs.     

Protective efficacy of intranasal vaccination with Mycobacterium bovis BCG against airway Mycobacterium tuberculosis challenge in mice

The effect of route of immunization on the protective efficacy of BCG against tuberculosis has been investigated. Immunoprotection was monitored by evaluating the bacterial burden in the lungs and spleen of mice challenged with Mycobacterium tuberculosis H(37)Rv after BCG immunization by intranasal (i.n.) and subcutaneous (s.c.) routes. Our results showed that as compared to s.c. BCG immunization, intranasal BCG vaccination induces significantly higher immune responses at local level (mediastinal lymph nodes, cervical lymph nodes and lung). Further, i.n. BCG vaccination induced significantly higher reduction in bacterial load in the lungs over s.c. BCG vaccination, whereas, the bacilli load in the spleen was comparable in both the groups. Hence, intranasal vaccination with BCG holds promise for pulmonary tuberculosis.     

Myelofibrosis associated with tuberculosis; a report of four cases

Myelofibrosis (fibrotic bone marrow and, usually, an increase in megakaryocytes) is characterized by generalized pains, weakness, loss of weight, enlargementof the liver and spleen and a leuko-erythroblastic anemia.

Four cases of myelofibrosis associated with generalized tuberculosis have beenreviewed in detail. Autopsy examination of the 4 cases revealed acute, caseatingtuberculosis which was considered to be responsible for the bone marrow and generalized fibrosis observed. A similar type of tuberculosis occurred in 7 of 91 casesof myelofibrosis reveiwed in the literature. The pathogenesis of myelofibrosis associated with tuberculosis is discussed.

In the diagnosis of this syndrome, attention is called to the importance of obtaining a bone marrow biopsy and making a complete bacteriologic and pathologicstudy of this tissue for tuberculosis.

The 4 tuberculous cases here reported as compared with 5 cases of idiopathictype, are younger, have hyperpyrexia, less splenic but greater lymph node enlargement and run a shorter course before death.

     

27例血行播散型结核病临床分析

目的 通过对27例血行播散型结核病临床资料的分析,提高对该病的认识。方法 回顾性分析1961～2000年我院收治的尸检证实的27例血行播散型结核病的临床资料。结果 本组患者临床表现多不典型,呼吸道症状隐匿,以发热为主要表现,部分患者可有肝、脾肿大,皮疹,血三系减低。胸部影像学以浸润性改变为主,空洞少见,粟粒性结节影出现较晚。结核菌素试验多阴性。病原学检测阳性率低。尸检证实,急性血行播散型结核病22例(包括无反应性结核3例),慢性血行播散型结核病5例。均合并活动性肺结核,肺外病变主要累及肝、脾、肾、淋巴结等部位。生前误诊12例,误诊率为44．4％。12例中有11例(92％)因伴发或疑为结缔组织病、血液系统疾病或肿瘤而误诊。27例患者中17例(63％)长期应用激素或反复化疗导致结核病播散。结论 临床医师应加强对结核病的警惕性,特别是有结核病史、免疫缺陷(包括长期使用激素或化疗)病史或合并营养不良的患者。出现长期发热和(或)有多系统损害、原发病经正规治疗无缓解时,应警惕耐多药结核的可能。应严格掌握糖皮质激素使用的适应证,未确诊前不能盲目应用糖皮质激素,以免诱发结核复发或血行播散。     

Four cases of the tuberculous adenitis

We report four cases of tuberuculosis with the lymph nodes swelling in the porta hepatis. Case 1 is 52 years-old man, who was admitted to our hospital because of anorexia. The chest X-ray film showed abnormal shadow and he was diagnosed as tuberculosis by sputum examination. At the time of hospitalization, patient's conjunctiva is icteric on physical examination. The serum T-Bil was 3.21 mg/dL and D-Bil was 2.54 mg/dL. The enhanced CT showed compression of the extrahepatic common bile duct which was caused by enlarged lymph nodes secondary to tuberculous adenitis. Case 2 is 25 years-old man, who was admitted to our hospital because of low grade fever and lower abdominal pain. The chest X-ray film showed abnormal shadow and he was diagnosed as tuberculosis by sputum examination. An enhanced CT showed the swelling of the lymph nodes in the porta hepatis. Case 3 is 21 years-old woman, who visited the outpatient clinic bacause of neck lymph node swelling. And she was diagnosed as tuberculous adenitis of the cervical lymph-nodes by the neck lymph node biopsy. The patient complained of upper abdominal pain during the clinical course. The enhanced CT showed the swelling of the lymph nodes in the porta hepatis. A Case 4 is 31 years-old man, who visited to outpatient clinic bacause of fever. The chest X-ray film showed mediastinal lymphadenopathy, and he was diagnosed as tuberculosis by the thoracoscopic biopsy. The enhanced abdominal CT showed lymph nodes swelling in the porta hepatis. All of lymph nodes swelling found in our four cases markedly reduced in size on abdominal enhanced CT or ultrasonography after the initiation of anti-tuberculous standard chemotherapy. Symptom of all cases got better as well. In these clinical circumstances, it was clinically important to rule out malignant lymphoma and lymphadenopathy caused by cancer. The enhanced abdominal CT were useful for diagnosis and follow-up as tuberculous adenitis.     

Abdominal lymph node tuberculosis: diagnostic value of echography and x-ray computed tomography

The aspects of abdominal ultrasonography and computed tomography (CT) were studied in 4 patients (3 African and 1 Haitian) with abdominal tuberculosis. All were markedly debilitated and three patients had protracted fever. Tuberculosis was documented in all cases by demonstrating Mycobacterium tuberculosis in cultures of lymph nodes taken during laparotomy and/or cultures of products of gastric aspiration. Ultrasonography showed enlarged lymph nodes in the pancreatic and peripancreatic areas and also in the mesenteric, perivascular and hepatic pedicle areas. CT showed hypertrophied lymph nodes with low tissue density ranging from 20 to 35 Hounsfield units. Although non pathognomonic, these aspects were suggestive of tuberculosis. Intravenous contrast medium administration failed to increase the density in the center of lymph nodes but disclosed the existence of a thick hyperdense rim surrounding the hypodense center of the caseous lymph nodes. Repeated ultrasound and CT examination allowed to control the efficacy of antituberculous chemotherapy.     

Abatacept treatment does not exacerbate chronic Mycobacterium tuberculosis infection in mice

OBJECTIVE: Treatment of rheumatoid arthritis and other autoimmune disorders with anti-tumor necrosis factor (anti-TNF) agents is associated with an increased risk of reactivation of latent Mycobacterium tuberculosis. While the mechanism of action of abatacept is fundamentally different from that of anti-TNF therapies, its effect on the protective response to latent tuberculosis is not known. We undertook this study to determine the effect of abatacept treatment in a murine model of chronic M tuberculosis infection. METHODS: Chronic M tuberculosis infection was established in C57BL/6 mice. Four months after infection, mice were treated for up to 16 weeks with abatacept, anti-murine TNF antibody, or vehicle. The primary end point was survival; body weight, bacterial load, histologic features, interferon-gamma (IFNgamma) production by T cells, and cellular infiltration were also assessed. RESULTS: Abatacept- and vehicle-treated groups both maintained control of M tuberculosis infection, with 100% survival after 16 weeks of treatment. These 2 groups had no significant differences in body weight, no clinically relevant differences in bacterial load in the lungs, lymph nodes, or spleen, and no differences in the mean percentage of total or activated T cells, macrophages, neutrophils, or B cells, or in IFNgamma production in the lung or lymph nodes. In contrast, 100% mortality was seen in the anti-TNF antibody-treated group by week 9, with significant body weight loss and increased bacterial load in the lungs, lymph nodes, and spleen. Furthermore, the anti-TNF antibody-treated group had increased pathology consistent with the exacerbation of M tuberculosis infection. CONCLUSION: Abatacept did not impair the ability of mice to control a chronic M tuberculosis infection. In contrast, mice treated with anti-TNF therapy showed increased pathology and bacterial load, with 100% mortality by week 9. The clinical significance of these findings has not yet been determined.     

Case of liver tuberculosis requiring differentiation from liver metastasis of cancer

A 79-year-old woman was admitted to our hospital because of general fatigue. Chest radiograph and computed tomograph showed bronchiectasis and centrilobular nodules in the right middle lobe and lingula, which had not changed from previous examination. Intrahepatic nodular lesions and swelling of the left cervical lymph nodes, supraclavicular lymph node, abdominal paraaortic lymph nodes and inguinal lymph nodes was observed. Biopsy specimen of the liver lesion demonstrated epithelioid cell granulomas. Biopsy of the right inguinal lymph node demonstrated epithelioid cell granulomas with caseous necrosis and culture of the specimen showed Mycobacterium tuberculosis. The patient was diagnosed as having liver tuberculosis and multiple tuberculous lymphadenitis. Antituberculous treatment with isoniazid, rifampicin, ethambutol and pyrazinamide were started and continued for 6 months. All lesions improved after treatment. This was a rare case of liver tuberculosis that was difficult to distinguish from liver metastasis of cancer.     

Bronchial tuberculosis. Radiologic endoscopic and clinical aspects

Nowadays, bronchial tuberculosis is an uncommon, although probably underestimated, form of tuberculosis. The records of 23 patients hospitalized between 1978 and 1989 were reviewed retrospectively. Mean age was 57 years (range: 22 to 84 years). Only one female patient of african origin was a recent immigrant. The disease was pseudo-tumoral in 2 cases and included lymph node fistulae in 4 cases. M. tuberculosis was found at microscopic examination in only 10 patients. The course of the disease was slow and sometimes erratic, even under a well-conducted medical treatment. In one of the female patients, a lymph node fistula appeared after 6 months of chemotherapy, and it is clear that medical treatment must be pursued well beyond the conventional time limits. Several mechanisms are responsible for bronchial tuberculosis: either invasion of the neighbouring bronchi by pulmonary tuberculosis; or lymph node fistula now more frequently due to reactivation of old lesions than to a recent primary infection; or again primary bronchial lesions mimicking bronchial carcinoma.     

Computed tomography in the diagnosis of intrathoracic lymph nodes tuberculosis in children

Computed tomography (CT) was used to examine 48 children aged 3 to 14 years; among them 15 patients were studied for small tuberculosis of intrathoracic lymph nodes (ITLN), 33 for infiltrative and tumorous forms, 19 infected with Mycobacterium tuberculosis with progressive positive hyperergic tuberculin reactions or with its variations. Chest CT study of children with ITLN tuberculosis established the precise site of lymph nodal involvement, evaluated the lymph nodes based on their density, homogeneity, the presence of liquid and solid caseous portions, cavities, calcifications, and the affection of the adjacent mediastinal organs. CT data were used to make a differential diagnosis of bulky mediastinal formations regarded as ITLN tuberculosis. It is recommended to consider CT as the method of choice in the complex X-ray examination of children with ITLN tuberculosis.     

Methods of the detection of non-bacterial tuberculosis and its clinical and X-ray characteristics in children and adolescents

Abacillary tuberculosis is presented by all clinical forms among which tuberculosis of intrathoracic lymph nodes, infiltrative and focal pulmonary tuberculosis are common. Abacillary tuberculous processes are restrictive: the involvement of 1-2 segments of the lung is observed in 95% of cases, that of 1-2 groups of intrathoracic lymph nodes is in 87.5%. Detection rates are 36% at tuberculin diagnosis, 30% at fluorography, and 14% on examination of those in contact with a patient with tuberculosis. Abacillary tuberculosis is asymptomatic. Its major clinical (intoxication and pulmonary) syndromes are commonly mild in 97.8%. The clinical manifestations of the disease are somewhat more pronounced in patients with infiltrative pulmonary tuberculosis.     

A case of esophageal tuberculosis which developed during the treatment for tuberculous lymphadenitis

A 23-year-old man was admitted to the other hospital complaining of fever and lymph node swelling in the left neck. Computed tomography showed swollen mediastinal lymph nodes without intrapulmonary lesions. Mycobacterium tuberculosis were identified by sputum culture and cervical lymph node biopsy and the case was diagnosed as tuberculous lymphadenitis. Three weeks after starting treatment with four anti-tuberculous drugs, he complained chest pain while eating and chest X-ray showed a new infiltrative shadow in the right cardiophrenic angle, then he was admitted to our hospital. Esophagoscopy revealed a deep ulceration with fistulas at 30 cm from the incisor and he was diagnosed as esophageal tuberculosis by histological examination of the biopsy specimen showing remarkable leukocytes infiltration and epithelioid cell granulomas with a few multinucleated giant cells. After antituberculous chemotherapy for six months, the mediastinal and cervical lymphadenopathy were reduced in size and the esophageal ulceration almost disappeared. Although esophageal tuberculosis is rare, the disease might develop during or after mediastinal or periesophageal tuberculous lymphadenitis.     

Tuberculose disséminée sur terrain non immunodéprimé: à propos de trois cas

Introduction. — Disseminated tuberculosis, ie, tuberculosis involving lung, liver, spleen, bone marrow and lymph nodes is rare (2,8%), particularly when immunocompromised diathesis is lacking.Exegesis. — We report three cases of disseminated tuberculosis confirmed by bacteriology or histology, which occurred in non-immunocompromised patients. Disease evolution under antituberculous treatment was favorable in two cases and fatal in the third one.Conclusion. — Disseminated tuberculosis must be suspected when miliary pulmonary lesions are associated with hematologic abnormalities, even in non-immunocompromised host. Early treatment is mandatory to avoid fatal outcome.     

EBUS-TBNA标本检测荧光定量TB-PCR对纵隔淋巴结核的诊断价值

目的研究荧光定量TB-PCR法检测超声支气管镜引导下经支气管透壁针吸活检(EBUS-TBNA)标本的临床应用价值。 方法对2017年01月至2018年06月在我院呼吸内镜中心接受EBUS-TBNA检测的65例患者的临床资料进行回顾性分析,比较病理检查和病理检查联合荧光定量TB-PCR检测法对临床诊断纵膈淋巴结结核的敏感性、特异性和准确性。 结果病理检查对纵膈淋巴结核的敏感性、特异性、准确性分别是75%、83.3%、78.9%,而荧光定量TB-PCR法联合病理学检查对纵膈淋巴结核诊断的敏感性、特异性、准确率分别为90.5%、100%、94.4%。 结论针对EBUS-TBNA标本,采用病理学检查联合荧光定量TB-PCR检测法能够明显提高诊断淋巴结结核的敏感性、特异性、准确性,有利于结节病和纵隔结核、非结核分枝杆菌病的鉴别,具有很高的临床应用价值。     

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.     

A case of spontaneous regression of malignant lymphoma, complicated with miliary tuberculosis, liver dysfunction and pancytopenia

An 82-year-old woman was admitted to Iwamizawa Rosai Hospital, Cardiovascular Medicine, for detailed examination of an aneurysm of abdominal aorta. CT scan revealed marked swelling of para-aortic lymph nodes which regressed spontaneously in three months. She was re-admitted to our hospital because of general malaise and gait disturbance. Her chest X-ray on the second admission revealed miliary disseminated shadows, which were confirmed to be tuberculous granuloma by lung biopsy. She was initially well controlled with anti-tuberculosis drugs, followed by severe liver dysfunction and pancytopenia, and died of respiratory and cardiac failure. At autopsy, wide-spread malignant lymphoma and miliary tuberculosis of the lung were found. The cause of liver dysfunction was strongly suspected to be due to infiltration of the lymphoma cells to portal triads of the liver. Hemophagocytosis found in the bone marrow, spleen and liver might be consistent with clinically so-called "hemophagocytic syndrome", causing pancytopenia, associated with infection.     

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.     

结节病与肺结核的临床病理分析

目的探讨病理难以鉴别的结节病与肺结核两组患者之间的临床综合表现的差异性,以提高临床对结节病与肺结核的鉴别能力。方法回顾性分析2009~2013年广州医科大学附属第一医院病理难以鉴别的结节病与肺结核的50例患者的临床特点。归纳分析结节病和肺结核两者不同的临床表现、影像学特点及检验相关值的变化。结果结节病组22例,肺结核组28例,结节病与肺结核两组临床症状对比,咳嗽、气促症状的差异,有统计学意义(P0.05),对比胸部CT检查纵隔淋巴结肿大特别是双肺门淋巴结肿大,PPD皮试和γ-干扰素释放的T细胞斑点试验(T-SPOT.TB)阳性率的差异有统计学意义(P0.05)。结论病理难以鉴别的结节病与肺结核,通过临床症状、胸部CT影像及T-SPOT.TB检查进行分析可以提高两者的鉴别率。     

Asymptomatic gastric tuberculosis in the gastric body mimicking an isolated microscopic erosion: A rare case report

Introduction:Gastric tuberculosis is rarely seen in clinical practice, which occurs mostly secondary to lung tuberculosis, intestinal tuberculosis, and other common tuberculosis. Gastric tuberculosis rarely presents as a single microscopic superficial erosion. We recently diagnosed such a case, hence reporting it herein.Patient concerns:A 40-year-old female patient was admitted with a chief complaint of painful enlarged cervical lymph nodes. She had no other symptoms or any previous history of remarkable diseases.Diagnosis:Physical examination found multiple enlarged cervical lymph nodes. Computer tomography revealed multiple circular well-defined soft tissue masses in the bilateral carotid sheath spaces. A cervical lymph node biopsy showed caseous necrosis with infiltration of neutrophils and lymphocytes, and most importantly, mycobacteria through staining for acid fast bacilli. Routine gastroscopy showed a 0.5 cm × 0.5 cm well-defined erosion on the large curvature of the gastric body. Gastric biopsy revealed chronic granulomatous inflammation with mycobacteria through staining for acid fast bacilli. The patient was diagnosed as having cervical lymph node tuberculosis and gastric tuberculosis.Interventions and outcomes:She received 6 months of standard anti-tuberculosis therapy. The enlarged cervical lymph nodes shrank in size and the pain was relieved.Conclusions:Gastroscopy should be performed to look for gastric tuberculosis if the patient presents primary tuberculosis in other organs/tissues such as cervical lymph nodes. If any small erosion is found, a biopsy is justified for checking the possibility of gastric tuberculosis.