Penetration of Antitubercular Drugs in Clinical Osteoarticular Tubercular Lesions

In 79 consecutive cases of skeletal tuberculosis the concentration of streptomyein and ethambutol was analysed. The material for analysis was obtained from the diseased joints of 14 patients and from cold abscesses from spinal or osseous lesions in 65 patients. The concentration of the drugs in the serum and in the tuberculous material was measured 3 hours after the systemic administration of the drugs in therapeutic doses. The concentration was expressed as μg per ml of thc tuberculous material and the data were subjected to statistical analysis. Streptomycin and ethambutol penetrated freely into the tuberculous joints; their concentration in the cold abscesses, however, was half to one third of the concentration in the serum. There was a wide range of concentrations; however, in the tuberculous joints as well as in the cold abscesses the concentrations were much higher than those considered to have an inhibitory effect on mycobacterium tuberculosis in clinical material.     

Penetration of Antitubercular Drugs in Clinical Osteoarticular Tubercular Lesions

In 79 consecutive cases of skeletal tuberculosis the concentration of streptomyein and ethambutol was analysed. The material for analysis was obtained from the diseased joints of 14 patients and from cold abscesses from spinal or osseous lesions in 65 patients. The concentration of the drugs in the serum and in the tuberculous material was measured 3 hours after the systemic administration of the drugs in therapeutic doses. The concentration was expressed as μg per ml of thc tuberculous material and the data were subjected to statistical analysis. Streptomycin and ethambutol penetrated freely into the tuberculous joints; their concentration in the cold abscesses, however, was half to one third of the concentration in the serum. There was a wide range of concentrations; however, in the tuberculous joints as well as in the cold abscesses the concentrations were much higher than those considered to have an inhibitory effect on mycobacterium tuberculosis in clinical material.     

Tuberculous sacroiliitis. Four cases

Tuberculous sacroiliitis with no local abscesses or tuberculosis at other sites occurred in four patients, three men and one woman with a mean age of 42 years. Slow progression characterized this uncommon variant of joint tuberculosis. Two patients reported contact with family members known to have tuberculosis. Mean time from symptom onset to presentation was 14 months. Surgical biopsy showed epithelioid and giant-cell granulomas with caseous necrosis; culturing on Lowenstein-Jensen medium recovered the tubercle bacillus. Treatment was with antitubercular drugs, and protection from weight bearing for 4 weeks. These four cases illustrate the slowly progressive course of the clinical and radiological manifestations and underline the diagnostic difficulties met in the early stages of tuberculous sacroiliitis without tuberculosis at other sites. Antitubercular treatment can restore joint function provided the diagnosis is made before radiological destruction occurs.     

CT引导下置管引流局部强化化疗治疗结核性腰大肌脓肿和椎旁脓肿

目的：探讨CT引导下置管穿刺引流、局部强化化疗治疗结核性腰大肌脓肿和椎旁脓肿的安全性和有效性。方法纳入脊柱结核伴腰大肌脓肿和椎旁脓肿患者35例,进行CT引导下置管穿刺引流、局部强化化疗,同时行口服药物全身化疗18个月,每个月监测肝功、血沉,术后1、3、6、9、12、18、24个月复查,分析治疗前后临床表现、脓肿吸收、病椎愈合情况。结果平均随访时间25个月（18～36个月）,引流时间3周～3个月,35例均获得临床治愈,治疗前疼痛视觉模拟量表（visual analogue scale, VAS）评分平均3．6分（2～7分）,最后一次随访VAS评分平均1．1分（0～3分）,无神经功能障碍及其他并发症。结论 CT引导下置管引流、局部强化化疗治疗结核性腰大肌脓肿和椎旁脓肿安全有效,费用低、创伤小,适应证得当可代替病灶清除术。     

Incision Infection With Mycobacterium tuberculosis After Total Hip Arthroplasty Without Any Primary Tuberculosis Focus

We describe a case of a tuberculous abscess unassociated with other clinical features of tuberculosis in a 46-year-old woman with a history of 4 hip surgeries plus total hip arthroplasty (THA) due to developmental hip dislocation. Four months after THA, she developed a collection at the incision site for which specimens produced positive culture findings for Mycobacterium tuberculosis. We could not detect any primary focus of tuberculosis anywhere in the patient's body. We performed soft-tissue debridement and drainage completely above the fascia lata to remove pus. The infection recurred twice despite chemotherapy and the earlier treatment. At a 6-year follow-up examination, there was no sign of either tuberculosis or prosthetic loosening. To our knowledge, this is the first report of localized tuberculous abscess within a THA incision.     

A case of cerebellar tuberculoma

We report a case of cerebellar tuberculoma presenting with headache, without any specific data. A 22-year-old male had headache for recent three months. Because of detection of the tubercle bacillus in his sputum, he was suspected the pulmonary tuberculosis and the tuberculous meningitis. On admission the cerebrospinal fluid revealed no abnormal data and the tubercle bacillus was not detected in the culture. We started medication for the tuberculosis. MRI demonstrated a mass lesion at the right cerebellum, suggesting the presence of a tuberculoma. He underwent total removal of the tumor via the supracerebellar route. Histological examination revealed tuberculoma when there are no abnormal data. The intracranial tuberculoma may be confused with an intracranial neoplasm. It is important to make an overall evaluation to diagnose tuberculosis; for instance, compromised high age, HIV, and the type of steroid administered, will increase intracranial tuberculoma. In this report, we describe a cerebellar tuberculoma without any abnormal data, suggesting that intracranial tuberculoma should be considered in the differential diagnosis of any intracranial mass lesion.     

MRI diagnosis of tuberculous vertebral osteomyelitis

Two patients with suspected tuberculous spondylitis and one patient with previous Pott's disease were evaluated preoperatively with magnetic resonance imaging (MRI). The MRI provided more exact anatomic localization of vertebral and paravertebral tuberculous abscesses in multiple planes not previously available with more conventional diagnostic methods in the patients with suspected tuberculous spondylitis. This was helpful for localization in planning of surgical approaches. In the patient with previous Pott's disease, spinal cord compression was detected using MRI, which showed no evidence of active tuberculosis. Two case reports are offered to show the benefit of using MRI as a diagnostic technique in preoperative evaluation and as a method of monitoring treatment response of tuberculous spondylitis. The third case shows the benefit of using MRI to rule out active infection and to detect other forms of spinal pathology.     

Laparoscopic drainage of bilateral tuberculous psoas abscesses

Psoas abscess secondary to Mycobacterium tuberculosis infection is rare in industrialized countries. Standard treatment options for psoas abscess of any etiology include percutaneous drainage under radiographic guidance and surgery, which is reserved for failure of conservative therapy. A case of bilateral tuberculous psoas abscesses is reported and a surgical method of drainage utilizing a totally extraperitoneal laparoscopic approach is described.     

Tuberculous pseudoaneurysm of the ascending aorta associated with intracranial tuberculoma.

A tuberculous aneurysm is rare and fatal because it may lead to a rupture due to the forming of a pseudoaneurysm. A lesion is especially uncommon in the ascending aorta. We report an unusual case of tuberculous pseudoaneurysm of the ascending aorta which developed 7 months after the onset of multiple intracranial tuberculoma in a 59-year-old man. He was treated for multiple intracranial tuberculomas in another hospital because of headache and left homonymous hemianopia. The temporal intracranial tuberculomas were reduced after antituberculous drug administration. However, they enlarged again shortly thereafter. At that time, a pseudoaneurysm of the ascending aorta was found, so he was introduced to our department. Intensive antituberculous drugs were administered perioperatively and postoperatively. The intracranial tuberculoma was reduced preoperatively. After that, the ascending aorta was successfully replaced with a Dacron graft. A hole was noted in the back of the ascending aorta. Three years after the operation, no symptoms of recurrence have been recognized. A tuberculous pseudoaneurysm of the ascending aorta may easily cause systemic tuberculosis or rupture, therefore it should be treated as early as possible.     

En plaque intradural extramedullary spinal tuberculoma and concurrent intracranial tuberculomas: paradoxical response to antituberculous therapy. Case report

Spinal intradural extramedullary tuberculoma is a rare entity. Rarer still are extensive en plaque intradural extramedullary tuberculomas occurring concurrently with multiple intracranial tuberculomas as a paradoxical response to chemotherapy for tuberculosis (TB). The authors describe the case of a 21-year-old man who was treated for tuberculous meningitis. Three months after the episode of meningitis, while undergoing chemotherapy for TB, he developed features of thoracic myelopathy. Investigations revealed an extensive en plaque intradural extramedullary lesion spanning seven segments in the lower thoracic spine. Magnetic resonance imaging of the brain revealed multiple asymptomatic intracranial tuberculomas. Even after further treatment with antituberculous chemotherapy was initiated, the lesion failed to respond. The authors performed a laminectomy and excised the en plaque intradural extramedullary lesion. The patient's condition responded well to this treatment. Although the appearance of intracranial tuberculoma as a paradoxical response to chemotherapy has been previously reported, no authors have reported on the development of an extensive en plaque intradural extramedullary tuberculoma in conjunction with asymptomatic multiple intracranial tuberculomas as a paradoxical response. In cases in which patients present with compressive myelopathy following therapy for tuberculous meningitis, it is important to consider in the differential diagnosis that intradural extramedullary tuberculoma may be a paradoxical response to chemotherapy. The authors' experience and their review of the literature indicate that surgery has a definitive role to play in the management of spinal intradural extramedullary tuberculoma.     

Chronic hypercalcemia as the presenting feature of tuberculous peritonitis in a hemodialysis patient

Hypercalcemia is a common electrolyte disturbance in chronic dialysis patients. Although most causes are easily identified, some are obscure. Tuberculosis, a granulomatous disease associated with hypercalcemia, can appear at anytime while the infection is active. Dialysis-associated tuberculosis is characterized by a higher risk than that in the general population, with a greater chance of extrapulmonary involvement and a high mortality rate. If the presentation of tuberculosis is atypical and its manifestation nonspecific, diagnosis can be delayed, leading to poor patient outcome. Herein, we report a case of tuberculous peritonitis in a hemodialysis patient. Asymptomatic hypercalcemia was noted 8 months before ascites became detectable. Nevertheless, the patient responded well to antituberculous therapy. We conclude that hypercalcemia can be an early sign of tuberculous peritonitis in the absence of other signs and symptoms. Remaining aware of the possibility of tuberculosis and testing for it, physicians can identify tuberculous infection earlier and initiate appropriate therapy in a timely manner.     

耐多药脊柱结核的原因分析及处理对策

 目的 探讨耐多药脊柱结核的产生原因及临床处理对策。方法 回顾性分析2007年6月至2012年9月收治的16例耐多药脊柱结核患者的相关资料,男12例,女4例;年龄10~49岁,平均26.6岁;累及椎体44个,平均2.75个。胸椎9例,腰椎2例,胸腰段1例,腰骶椎3例,1例累及跳跃节段（T_8,9,T₁₂L₁）。合并肺结核5例,结核性胸膜炎4例,结核性脓胸3例,颈部淋巴结核1例,胸骨结核1例,胸壁结核1例;肾病综合征1例。根据药敏试验制订个体化抗结核治疗方案,分析手术次数与过程,经过长期随访判断治疗效果,并分析耐多药产生原因。结果 16例患者中接受1次外科手术者6例;2次外科手术者7例;3次手术者2例,其中1例第3次手术为一期后路内固定、前路再次病灶清除植骨术;4次外科手术者1例,第4次为窦道切除术。随访时间10~60个月,平均28.4个月。通过术后药敏试验结果及时调整化疗方案,末次抗结核治疗时间为24个月。2例患者分别在术后22个月和46个月复发并再次手术。截止末次随访,所有患者均处于结核稳定状态。16例患者中2例为初始耐药,14例为获得性耐药,原因为反复多器官结核致数次抗结核治疗失败;经历多次失败手术未调整化疗方案;出现严重药物不良反应而被迫中断化疗等。结论 早期进行结核菌培养并获取药敏试验结果,制定个体化的化疗方案并严密监测药物不良反应,选择合适的时机进行外科手术是防止和治愈耐多药脊柱结核的关键。     

Isolated subacute tuberculous spinal epidural abscess of the cervical spine: a brief report of a special case

A tuberculous spinal epidural abscess is seen rarely as a late complication of Pott’s disease or in immunocompromised patients. Such abscesses in isolation are rare indeed and very uncommon in the developed and developing world. We report a patient with an isolated subacute tuberculous spinal epidural abscess without disc or vertebral involvement and no primary focus or risk factors associated with the development of spinal tuberculosis.     

经后腹膜腹腔镜清除结核性腰大肌脓肿的临床应用

目的探讨经后腹膜入路运用腹腔镜清除结核性腰大肌脓肿的微创治疗的有效性及可行性。 方法回顾性分析2010年1月至2014年1月纳入研究的35例行经后腹膜入路运用腹腔镜清除结核性腰大肌脓肿患者的微创治疗情况。纳入研究的所有患者无明显神经功能障碍,不合并严重的脊柱畸形,所有患者术前均进行抗结核治疗至少2周。脊柱结核性腰大肌脓肿诊断依据为临床症状及体征、化验指标、病变部位的CT及MRI检查、试验性抗结核药物治疗有效。对35例胸腰段脊柱结核合并腰大肌脓肿患者,进行经腹膜后入路腹腔镜下脓肿清除、脓苔壁刮除、局部抗结核药灌洗。术中留病理标本进行抗酸杆菌染色、结核杆菌培养,病理结核杆菌培养证实所有患者均为结核性腰大肌脓肿。术后继续进行局部抗结核药物灌洗及全身抗结核治疗,监测血细胞沉降率,定期复查胸腰段X线及MRI。 结果所有患者术后发热及腰背痛等临床症状明显缓解,术后1周、3个月复查时血细胞沉降率分别为(27.0 ± 11.0)mm/h、(18.0 ± 7.0)mm/h,与术前血细胞沉降率 [(65.5 ± 30.8)mm/h] 比较,差异有统计学意义(P<0.05)。随访期至少12个月[(21 ± 9)个月],随访期间1例脓肿复发,1例窦道形成,其他患者未见脓肿复发及其他重大并发症。 结论经后腹膜入路运用腹腔镜清除结核性腰大肌脓肿可以彻底清除腰大肌脓肿及脓肿苔壁,配合局部及全身的抗结核化疗可以迅速遏制脊柱结核病情发展及腰大肌脓肿复发;与开放病灶清除术相比,手术时间、术中出血量、复发率、全身化疗时间均有明显的优势。对于不合并严重脊柱畸形和神经症状的脊柱结核腰大肌脓肿患者,应该首选后腹膜入路运用腹腔镜清除结核性腰大肌脓肿。     

Isolated tuberculosis of the popliteal cyst

We encountered a case of tuberculosis of a popliteal cyst in a 76-year-old man. He visited our department for treatment of the left knee pain which had not responded to treatment over the previous ten months. At first examination, local rubor, swelling and tenderness on a popliteal cyst were noted. Therefore, curettage of the lesion, including resection of the cyst, was performed. Six weeks later, an abscess had formed in the subcutaneous area over the lateral aspect of the knee, which was cleaned out. The abscess recurred in the same area four months later. At the third operation, curettage of the abscess together with a knee joint synovectomy was performed. Upon pathologic examination, a tuberculous lesion of the popliteal cyst and skin were recognised. However, no tuberculous lesion was detected in the synovia of the knee joint. It is generally agreed that it is possible for a popliteal cyst to be infected from synovial tuberculosis of the knee joint. However, in our case, based on the histopathological and clinical observations, the primary tuberculous lesion appeared to have been in the popliteal cyst, which is very rare indeed. Recent developments in preventative medicine and chemotherapy have markedly reduced the incidence of tuberculous arthritis. However tuberculous arthritis is still an important disease in the differential diagnostic of persistent monoarthritis of the knee. Approximately half of the popliteal cyst communicate with the knee joint. However, it is not frequent for tuberculosis to propagate from the knee joint into the popliteal cyst.(ABSTRACT TRUNCATED AT 250 WORDS)     

单纯性附睾结核的诊治分析

目的:提高对单纯性附睾结核的诊治水平。方法:在35例附睾结核患者中通过尿路影像学检查无肾结核及尿抗酸杆菌检测阴性者,定义为单纯性附睾结核20例进行回顾性分析,均行强化抗结核治疗,即异烟肼(INH)、利福平(RFP)、链霉素(SM)或乙胺丁醇(EB)联合用药,2周后行病灶切除术,术中均行附睾结核病灶清除,术后继续常规抗结核治疗6～9个月。结果:随访6个月～5年,16例无异常情况,3例分别于术后3、3.5、5年出现泌尿系结核感染,1例于术后3.5年出现对侧附睾结核。结论:单纯性附睾结核可能为唯一或早期泌尿生殖系结核首发的表现,及时手术治疗,预后较好。     

Multiple intracranial tuberculomas with atypical response to tuberculostatic chemotherapy

Summary Approximately 34 cases of intracranial tuberculomas with paradoxical response to antituberculous chemotherapy have been documented worldwide. In most of the previously reported cases of this entity an associated tuberculous meningitis has been reported. The majority of these patients were children or young adults, who had inoperably located intracranial tuberculomas in high risk regions developing a few weeks or months after the start of appropriate chemotherapy. 53% of them recovered completely, 37% improved with mild neurological deficits and 10% died. It is interesting that these intracranial tuberculomas developed or enlarged at a stage when systemic tuberculosis was being treated successfully. We report our recent experience with these potentially curable tumours of the central nervous system. The literature is reviewed and diagnostic and therapeutic considerations are discussed. The possible immunological mechanisms of this phenomenon are analysed. In conclusion, patients, who are suspected to be suffering from CNS-tuberculosis should receive a prolonged (12–30 months) course of effective antituberculous therapy. Evidence of new intracranial tuberculomas or the expansion of older existing lesions require no change in the antituberculous drug programme. In such cases systemic dexamethasone as adjuvant therapy for 4 to 8 weeks is worthwhile and effective. Surgical intervention may be necessary in situations with acute complications of CNS tuberculosis such as shunting procedures for the treatment of hydrocephalus. When the diagnosis is not firm and there is no response to therapy within 8 weeks, a stereotactic biopsy of a suspected tuberculoma should be performed. If the largest lesion is not located in high risk deep regions of the brain, it should be total removed surgically. With this combined management, a satisfactory outcome can be obtained in the majority of cases.     

Cutaneous Tuberculosis in Heart Transplant

Tuberculosis is a disease with a significant global burden in terms of morbidity and mortality. It usually presents as a pulmonary disease but can occasionally have extrapulmonary presentations. Immunosuppressed people are at an increased risk of tuberculosis and more frequently have atypical manifestations of the disease. Cutaneous involvement is estimated to occur in only 2% of extrapulmonary presentations. We report a case of a heart transplant recipient with disseminated tuberculosis who initially presented with cutaneous manifestations in the form of multiple abscesses that were mistaken for a community-acquired bacterial infection. The diagnosis was made after positive nucleic acid amplification testing and cultures for Mycobacterium tuberculosis from the drainage of the abscesses. After initiating antituberculous treatment, the patient had 2 instances of immune reconstitution inflammatory syndrome. A combination of diminished immunosuppression due to discontinuation of mycophenolate mofetil in the setting of acute infection, rifampin drug interactions with cyclosporine, and the beginning of treatment of tuberculosis all contributed to this paradoxical worsening. The patient responded favorably to increased glucocorticoid therapy and showed no signs of treatment failure after 6 months of antituberculous therapy.     

Use of the 1 tuberculin unit (TU) Mantoux test in the assessment of tuberculous infection in children following neonatal BCG vaccination.

BACKGROUND--BCG vaccination alters the response to tuberculin testing and influences the potential validity of the Heaf test in the diagnosis of tuberculosis. This study used a purified protein derivative 1 tuberculin unit (TU) Mantoux test with a cut off of 5 mm induration as an indicator of tuberculous infection in high risk children to determine whether this would distinguish infection from previous neonatal BCG vaccination. METHODS--Children at high risk of tuberculosis on chest radiography, Heaf test, or contact history who had been screened in the contact tracing clinic and referred for further assessment were included in the study. After clinical examination, chest radiography, and Mantoux testing they were assigned to three groups (tuberculous disease, chemoprophylaxis, or no treatment) and followed up for 6-24 months in the outpatient clinic and subsequently by postal questionnaire. RESULTS--Comparison of the Heaf and Mantoux tests showed a difference in the results with 82% of cases positive by the Heaf test and 59% positive by the Mantoux test. Using the Mantoux test result in combination with clinical and radiographic findings 194 children were allocated to the three groups as follows: primary tuberculosis (5), chemoprophylaxis (101), no treatment (88). During follow up for a mean (range) time of 46 (11-102) months four additional cases received treatment for primary tuberculosis, two in the chemoprophylaxis group and two in the untreated group. CONCLUSIONS--The use of the 1 TU Mantoux test after neonatal BCG vaccination reduced the number of children receiving treatment from 129 to 93-that is, by 36%. Although the numbers are small, there was no increase in the later development of tuberculosis.     

Fine needle aspiration biopsy of tuberculous cervical lymphadenopathy

Fine needle aspiration biopsies of 42 histologically confirmed tuberculous cervical lesions were studied. Thirty-four patients had subsequent excision of cervical lymph nodes and eight had incision and drainage of cervical abscesses. All aspirates except two (which were inadequate) were satisfactory for diagnosis and contained inflammatory cells. Twenty-seven smears revealed cells typical of granulomatous lymphadenopathy, that is, epithelioid and multinucleated giant cells. Of all aspirates, 17 smears had bacteriological staining by Ziehl-Nielsen technique, nine of which (53%) were positive for acid-fast bacilli. An aspiration biopsy diagnosis of granulomatous or tuberculous cervical lymphadenopathy was made in 30 patients (71%). In regions where mycobacterial infection is common, the presence of granulomatous changes in lymph node aspirates is highly suggestive of tuberculosis. When the aspirates contain purulent material or when tuberculosis is suspected, staining and culture for mycobacteria should be performed. FNA biopsy is a sensitive, specific and cost-effective way to diagnose tuberculous cervical lymphadenopathy and is recommended.