Brucellosis and tuberculosis: Clinical overlap and pitfalls

ObjectiveTo identify characteristic features of tuberculosis in patients with culture proven brucellosis.MethodsA retrospective analysis was performed on patients diagnosed with culture proven brucellosis between January and December 2011, based on review of their medical records. Patients with demonstrable co-infection with tuberculosis were excluded. Clinical features, laboratory parameters and tissue histopathology reports where available were noted.ResultsThirty-two patients with brucellosis were included in the study. Twenty-one (65.63%) patients had chronic fever, thirteen (40.63%) had a productive cough, while significant weight loss, evening rise of temperature and night sweats were reported by eight (25.00%), eleven (34.38%) and five (15.63%) patients respectively. Nine (28.13%) patients had at least three of these symptoms. Lymphadenopathy, hepatomegaly and splenomegaly were noted on examination in seven (21.88%), fifteen (46.88%) and twelve (37.50%) patients respectively. Eight (25.00%) patients had hepato-splenomegaly, of these only two had associated significant lymphadenopathy. Respiratory examination was normal in all patients. Elevated ESR greater than 50 mm/hr was seen in eight (25.00%), it was greater than 100 mm/hr in five (15.63%) patients. Hypergammaglobulinemia was seen in eight (25.00%) cases. Bone marrow biopsy showed non-caseating granulomas in three (9.38%) cases, lymph node biopsy showed granulomas in one case. Overall, three (9.38%) patients had known risk factors for tuberculosis, while six (18.75%) had risk factors for brucellosis.ConclusionsThere is a clear overlap between brucellosis and tuberculosis both in terms of clinical presentation and laboratory parameters. It is essential to carefully rule out tuberculosis in all cases of suspected or proven brucellosis before initiating antimicrobial therapy, in order to forestall development of drug-resistant tuberculosis.     

应用纵隔镜检查术诊断纵隔淋巴结结核和结节病

目的寻找和探索一种区分良恶性纵隔淋巴结肿大,确诊纵隔淋巴结结核和结节病的有效方法。方法应用纵隔镜检查术对胸部ＣＴ或ＭＲＩ检查发现的纵隔淋巴结肿大、临床诊断不清疑为淋巴结结核或结节病者实施此检查,获取病理组织,做出明确诊断,以指导治疗。结果本组２５例患者接受纵隔镜检查,其中１６例被病理诊断为纵隔淋巴结结核,占６４％（其中增殖性结核１４例,占８８％;干酪性结核２例,占１２％）;８例诊为结节病,占３２％;１例难于确定为淋巴结结核或结节病,占４％。非典型的纵隔淋巴结结核与结节病在影像诊断上难于区别,而且在显微镜下也极易混淆。这两种疾病常与其他原因引起的纵隔淋巴结肿大（如恶性淋巴瘤、淋巴结转移性癌等）在影像检查中不易区分,极易误诊,造成误治。本组病例术前影像诊断及临床诊断大多考虑为恶性疾病,其中第一诊断为恶性疾病的占８４％（２１／２５）,有２例已在外院接受化疗。结论对于纵隔区域发现的肿大淋巴结,纵隔镜检查术是一种很有价值的确诊手段,治疗前应尽一切可能获取明确的病理诊断     

HIV/AIDS患者浅表淋巴结肿大与其CD＋4T淋巴细胞计数的相关性分析

目的 探讨HIV/AIDS患者肿大浅表淋巴结的病理改变与其CD＋4T淋巴细胞计数的相关性.方法 对81例HIV/AIDS患者肿大的浅表淋巴结组织进行病理学检查,并检测其外周血CD＋4T淋巴细胞计数.结果 CD＋4T淋巴细胞＜100cells/ul有58例,100～200cells/ul有17例,＞200cells/ul有6例.主要病理改变结核病48例,艾滋病相关淋巴结病15例,淋巴结反应性增生14例.合并浅表淋巴结肿大的结核病患者的CD＋4T淋巴细胞计数比较差异有统计学意义（P=0.008）.合并淋巴结反应性增生患者的CD＋4T淋巴细胞计数比较差异有统计学意义（P=0.018）.结论 检测外周血CD＋4T淋巴细胞计数对出现浅表淋巴结肿大的HIV/AIDS患者的临床诊断具有重要的参考价值.     

Hodgkin's disease in homosexual men with generalized lymphadenopathy

The authors present 4 cases of Hodgkin's disease developing in homosexual men with persistent, generalized lymphadenopathy. Laboratory abnormalities associated with the acquired immunodeficiency syndrome (AIDS) and the lymphadenopathy syndrome were present in these patients. In 2 patients, diagnosis of lymphadenopathy syndrome preceded the diagnosis of Hodgkin's disease by 2-3 years; in the other 2, the 2 conditions were noted simultaneously. 2 patients had nodular sclerosing Hodgkin's disease, while the other 2 had mixed cellularity disease. All patients presented with clinical stage III or IV Hodgkin's disease. 2 patients in this group have died: 1 of progressive Hodgkin's disease with evidence of atypical myobacterial infection, and 1 with no evidence of Hodgkin's disease but with AIDS-related infections. The lymphadenopathy syndrome has a presentation similar to that of Hodgkin's disease: lymphadenopathy often accompanied by malaise, fever, night sweats, weight loss, and splenomegaly. When a homosexual man presents with painless adenopathy, with or without constitutional symptoms, the potential diagnosis of Hodgkin's disease or other malignancy should be considered in addition to lymphadenopathy syndrome. Evaluation by lymph node biopsy is advisable. The natural history of Hodgkin's disease in patients at risk for AIDS may be altered to a more aggressive form. Unusual features of Hodgkin's disease observed in this group of patients included presentation with stage IV disease, cutaneous Hodgkin's disease, and bone marrow but no splenic involvement. The effects of the treatment modes used for Hodgkin's disease in homosexual patients should be evaluated for their effect on the risk of AIDS.     

Findings and benefit of liver biopsies in 46 patients infected with human immunodeficiency virus

AIMS: The aim of this work is to evaluate the role of liver biopsy and to determine the histological findings in patients infected with the human immunodeficiency virus (HIV) who have abnormal liver function tests (LFT). METHODS: We performed a percutaneous liver biopsy in 46 HIV-seropositive patients with abnormal LFT. Parts of biopsied tissue were used for bacterial and fungal culture and the rest was processed for histological examination including special staining. RESULTS: Of these 46 patients, 41 patients were males and five were females. The median age was 31+/-6 years. Mycobacterium tuberculosis was the most common histological finding (15 cases). Of 15 tuberculosis patients, 11 (73.3%) had lymphadenopathy and positive acid-fast bacilli (AFB) in node aspiration or biopsy. The other findings included AFB-negative granuloma (eight cases), histoplasmosis (six cases), cryptococcosis (six cases), penicillosis (four cases), viral hepatitis: hepatitis C virus (HCV; one case), hepatitis B virus and HCV infection (one case), fatty liver (two cases), drug-induced hepatitis (one case) and non-specific changes (five cases). There were double infections in three patients. We were able to demonstrate opportunistic infections in 41 cases (89.3%). CONCLUSIONS: Mycobacterium tuberculosis was the most common histological finding in HIV patients with abnormal LFT in Thailand. Liver biopsy was a useful procedure in evaluating abnormal LFT in HIV patients.     

AIDS and tuberculosis in Spain. A report of 140 cases.

From January 1984 to October 1990, 140 of 392 (35.7%) patients with the acquired immunodeficiency syndrome (AIDS) were found to have had tuberculosis. One hundred and sixteen were intravenous drug abusers and 16 were homosexual men. Fever, cough, weight loss and generalised lymphadenopathy were common features of their illness. Tuberculin skin tests were negative in 74% and 55% had intraabdominal lymphadenopathy. The chest radiographs showed hilar lymphadenopathy and lower lobe interstitial or alveolar infiltrates, but rarely cavitation. Forty-one of our patients had pulmonary tuberculosis, 38 had extra pulmonary and in 61 it was disseminated. In 80 cases tuberculosis was the presenting feature of AIDS. Tuberculosis usually responded well to chemotherapy.     

All necrotizing nodes are not tuberculosis – A report of two cases

IntroductionKikuchi-Fujimoto disease is a benign and self-limiting systemic disorder of unknown aetiology characterised by fever, superficial lymphadenopathy and leukopenia. In highly endemic & low-resource country like India, it is frequently misdiagnosed as tuberculosis.Case reportBoth the cases were diagnosed as necrotizing lymphadenitis by fine-needle aspiration cytology. Tuberculin skin prick test (TST) was positive for one case and negative for the other case. Cartridge based nucleic acid amplification test (CBNAAT) from lymph node aspirate was negative for mycobacterium tuberculosis in both the cases, later on histopathology of lymph node showed diagnosis of Kikuchi-Fujimoto disease.ConclusionKikuchi Fujimoto is a self-limiting disease systemic disease of unknown aetiology. A definite diagnosis can be established by incisional/excisional biopsy of the lymph node. When dealing with cases of tubercular lymphadenitis, Kikuchi-Fujimoto disease should be kept as differential diagnosis.     

Pseudoazygos lobe caused by lymph node pneumatocele

In patients with AIDS, the relatively high incidence of pulmonary tuberculosis places them at risk for more severe esophageal tuberculosis (including fistula formation), and tuberculous esophagitis in the setting of AIDS may be more common than had been thought. Tuberculous esophageal fistulae have long been described and are well known. Air tracking from the esophagus into a mediastinal lymph node is very rare and reported previously to collect in small pockets in either of two patterns: irregular (or "amorphous") or peripheral and curvilinear. Complete filling of a large lymph node by air has not previously been reported. Reported here is a case of tuberculous mediastinal lymphadenopathy in an AIDS patient in whom CT scans demonstrated fistula development between a large lymph node and adjacent esophagus; this was accompanied by total replacement of the apparently necrotic content of the node with air, surrounded by the relatively thin, smooth, residual wall of the node. A lymph nodal pneumatocele was thereby created, which has not been previously described, and is the first feature of this case. On frontal chest radiography, the lateral wall of the lymph nodal pneumatocele produced an appearance falsely akin to an azygos fissure, creating the second feature: a previously unreported cause of false appearance of an azygos lobe. It is important to consider tuberculosis when a fistula to the esophagus is demonstrated in an AIDS patient, to be aware that even a large lymph node may "shell out" entirely in that setting, and not to confuse the final resulting appearance with the normal variant it may resemble.     

Clinical-histologic-microbiologic analysis of 419 lymph node biopsy specimens

The results of culture and histopathologic examination of 419 lymph node biopsy specimens obtained from 414 patients in 1978-1983 were correlated with clinical histories. The clinical diagnosis was lymphadenopathy of unknown etiology in 113 cases, sarcoidosis in 93, malignant lymphoma in 86, metastatic carcinoma in 17, histoplasmosis in 18, tuberculosis in 13, and other miscellaneous conditions in 79. All but two clinically significant microbial isolates from lymph nodes were either mycobacteria or fungi: the only exceptions were staphylococcal isolates from two children with lymphadenitis. Of 66 lymph nodes associated with bacterial, mycobacterial, or fungal disease, 48 included granulomatous and/or acute inflammatory lesions. Of 33 lymph nodes that were culture-positive, two had histologic evidence of lymphoid hyperplasia, and the remainder included granulomatous and/or acute inflammatory lesions. With one exception, lymph node cultures in immunocompetent patients were positive only when there was a granuloma and/or an acute inflammatory lesion in the tissue. On the basis of these findings, it was concluded that lymph nodes from immunocompetent patients should be cultured only when a granuloma and/or an acute inflammatory lesion are detected and that the cultures can be limited to mycobacteria and fungi.     

HIV感染/AIDS患者感染性浅表淋巴结病的临床病理特征分析

目的 探讨HIV感染/AIDS患者感染性浅表淋巴结病组织病理学特征、致病病原体形态学特点和分布部位。方法 回顾性分析2018年1月至2019年6月广西壮族自治区龙潭医院收治的,经组织病理学明确诊断为浅表性淋巴结感染性疾病的88例HIV感染/AIDS患者的淋巴结活检组织病理学特点,并对其标本进一步行抗酸染色、过碘酸雪夫(periodic acid schiff, PAS)染色及六胺银染色查找病原体,应用荧光定量PCR技术检测MTB DNA和荧光定量PCR熔解曲线法进行分枝杆菌菌种鉴定。结果 88例患者淋巴结活检组织病理学诊断结果为MTB感染50例(56.8%)、马尔尼菲蓝状菌(Talaromyces marneffei,TM)感染32例(36.4%)、非结核分枝杆菌(nontuberculous mycobacterium,NTM)感染3例(3.4%)、MTB并发TM感染2例(2.3%)、隐球菌感染1例(1.1%)。其中苏木精-伊红(hematoxylin-eosin,HE)染色条件下,不同病原体感染的88例患者可有相同组织病理学表现,如23例(26.1%)MTB、TM、MTB并发TM、隐球菌感染患者可共同表现为典型肉芽肿伴坏死,19例(21.6%)MTB、MTB并发TM、TM感染患者可共同表现为不典型肉芽肿伴坏死;38例(69.1%,38/55)分枝杆菌感染患者可经抗酸染色找到分枝杆菌,34例TM和1例隐球菌感染患者可经PAS染色和六胺银染色找到真菌;分子病理检测MTB DNA阳性52例,菌种鉴定NTM感染3例。结论 HIV感染/AIDS患者感染性浅表淋巴结病的组织病理学形态表现多样,不具有特异性,特殊染色和分子检测技术可提高确诊率。     

Chromosome abnormalities in AIDS-associated lymphadenopathy

Cytogenetic studies were performed on direct and 24-hour culture preparations of eight lymph node biopsies from seven patients with acquired immunodeficiency syndrome (AIDS) or AIDS-related complex (ARC)- associated lymphadenopathy in whom histological evidence of lymphoma was not detected. Three of these seven had chromosomal abnormalities, including chromosome instability in one and clonal chromosomal abnormalities in two; one of the latter was a t(8;14)(q24;q32). The remaining five showed normal karyotypes. Epstein-Barr virus (EBV) titers were elevated in all three patients that exhibited chromosome abnormalities, two of whom later developed malignant lymphoma. A control group of five patients with reactive lymphadenopathy not associated with AIDS failed to reveal chromosomal aberrations, but elevated EBV titers were present in two. These data are consistent with current views on the role of EBV and chromosome change in the development of lymphoma in immunodeficient states and suggest that karyotypically abnormal AIDS-related lymphadenopathy represents a prelymphomatous proliferation.     

Mycobacterium tuberculosis disease in Somali immigrants in Minnesota

STUDY OBJECTIVE: To characterize pulmonary and extrapulmonary Mycobacterium tuberculosis cases in the Somali community in Minnesota. DESIGN: Retrospective chart review of active tuberculosis cases in Somalis reported to the Minnesota Department of Health between January 1993 and June 1998. PATIENTS: Ethnic Somalis in the state of Minnesota with M tuberculosis diagnosed by positive culture or radiographic findings consistent with tuberculosis and clinical improvement when treated with antituberculous drugs. RESULTS: Eighty-two Somali patients were diagnosed with tuberculosis during the study period. Extrapulmonary disease (typically lymphadenopathy) was present in 46% (n = 38). The 1997 incidence of tuberculosis in Minnesota's Somali population was estimated at 170 cases per 100,000 population compared with a national incidence of 20.5 per 100,000 among African Americans and 2.5 per 100,000 among whites. Ninety percent of Somali patients were < 40 years of age; 63% were diagnosed within 1 year of immigration, and > 90% had positive results with the purified protein derivative skin test. M tuberculosis was confirmed in 24 of 25 isolates from extrapulmonary cases. Multidrug resistance was present in 3.4%, and only two patients had AIDS. CONCLUSIONS: Somalis have a high incidence of active disease, with frequent extrapulmonary involvement in the absence of AIDS, clinical presentation shortly after immigration, and infrequent infection with resistant organisms. Health-care providers should maintain an increased awareness for tuberculosis when evaluating Somali immigrants.     

Hepatic sarcoidosis.

We describe six cases of hepatic sarcoidosis. Clinical presentation was with weight loss, hepatomegaly and abnormal liver function tests. In addition there was fever, itching, splenomegaly and abdominal lymphadenopathy in some. CT scan revealed mediastinal lymphadenopathy in all. Liver biopsy showed noncaseating epithelioid granulomas. Serum angiotensin converting enzyme was elevated in four cases. All patients had received anti-tuberculosis treatment with clinical diagnosis of hepatic tuberculosis. None of them improved, while some showed clinical deterioration. All patients responded to corticosteroids with disappearance of symptoms and normalization of liver function tests.     

Tuberculose ganglionnaire abdominale et hypertension portale

Abdominal tuberculosis involving the portal vasculature is a rare phenomenon. We retrospectively reviewed the imaging findings of 183 cases of abdominal tuberculosis at our institution from 2002 to 2010 and found thrombosis of the splenoportal axis associated with abdominal lymphadenopathy in seven patients. However, there was no relationship between the lymph nodal size and development of thrombosis. Reversibility was noted in one patient, who had near complete recanalisation of portal vein. Mechanisms, other than direct mass effect on the splenoportal axis, may be involved, like contiguous spread of inflammation or granulomas in the vessel wall.     

艾滋病合并肠系膜淋巴结结核11例临床分析

目的 探讨艾滋病合并肠系膜淋巴结结核的临床特点.方法 回顾性分析深圳市第三人民医院1999年9月至2008年12月收治的158例艾滋病合并结核病患者,其中诊断为艾滋病合并肠系膜淋巴结结核11例(男7例,女4例);除1例8岁儿童外,其余10例年龄22～55岁.结果 艾滋病合并肠系膜淋巴结结核患者约占艾滋病合并结核病患者的7%,其中8例CD_4~+＜50×10~6/L,3例CD_4~+为(50～100)×10~6/L;临床表现以发热(11/11)、腹痛(11/11)、腹胀(11/11)、盗汗(7/11)、消瘦(10/11)、腹泻(7/11)、贫血(5/11)、腹部包块(3/11)和腹腔积液(1/11)为特点;腹部B型超声扫描示多个肠系膜淋巴结肿大,腹部CT增强扫描示典型环状强化;2例行肠系膜淋巴结组织活检,病理结果均可见结核结节、干酪样坏死物和朗汉斯巨细胞,抗酸染色均为抗酸杆菌阳性.11例均给予抗结核治疗6个月及抗病毒治疗5个月,病灶吸收和消失.结论 艾滋病合并肠系膜淋巴结结核的临床表现无特异性,CD_4~+＜50×10~6/L、腹部CT增强扫描出现典型环状强化为其特征性表现.     

Lymphadenopathy in an inner-city population consisting principally of intravenous drug abusers with suspected acquired immunodeficiency syndrome

Generalized lymphadenopathy in intravenous drug abusers (IVDAs) at risk for AIDS has not been well studied. We have retrospectively analyzed the results of lymph node biopsies obtained from 27 patients referred to the Infectious Diseases Service for evaluation of generalized lymphadenopathy and suspected AIDS during a recent 18-month period. Fourteen of the patients were heterosexual IVDAs, 7 were male homosexual IVDAs, and 6 were male homosexual non-IVDAs. All of the patients were residents of the Bronx, New York. Mycobacterium tuberculosis (TB) was the most frequent diagnosis established on lymph node biopsies from IVDAs, in 12 out of 21 (57%). Tuberculous adenitis was not diagnosed in the 6 non-IVDAs. All TB patients were febrile, 11 (91%) had lost weight, and 10 (84%) had an abnormal chest roentgenogram. The 5TU PPD skin test, however, was reactive in only 2 (16%) of 12 patients. Tuberculosis is important to consider in patient populations with exposure histories to both AIDS and TB. The alarmingly high prevalence of TB in this drug addict population emphasizes the importance of lymph node biopsies with acid-fast smears and mycobacterial cultures in symptomatic IVDAs. Preventive antituberculosis therapy for HIV-positive persons, especially IVDAs, with a history of positive tuberculin reactions or of recent household contact should be seriously considered.     

Current aspects of spinal tuberculosis: apropos of 16 case reports]

We retrospectively studied the epidemiological, clinical, histological and evolutive aspects of vertebral tuberculosis diagnosed in all consecutive patients recruited in 2 Parisian hospitals between January 1990 and July 1997. The diagnosis relied on a vertebral involvement associated with evidence of tuberculosis (culture of local puncture yielded Mycobacterium tuberculosis) or presumption of tuberculosis (evidence of other tuberculous focus, histological data, good outcome under specific treatment). Sixteen patients (mean age: 41 years; sex ratio: 1.29) have been included; thirteen were migrants. The main symptoms, which appeared within a mean period of 3 months were vertebral pain (13/16) and alteration of patient's general conditions (8/16). RMN imaging showed spondylitis (10/16), spondylodiscitis (4/16) and involvement of posterior arch (8/16). Inflammatory syndrome was present in 14 cases. The diagnosis of vertebral tuberculosis was confirmed in 12 cases according to the results of culture and/or histological grounds of local puncture. The diagnosis of vertebral tuberculosis was presumed in the 4 other cases according to the isolation of M. tuberculosis from an other site (2 cases), the characteristic histological pattern of a lymphadenopathy (1 case), and a favorable outcome upon specific treatment (1 case). All the patients were cured without complications with the exception of one patient who developed a spinal cord compression.     

Tuberculosis and acquired immunodeficiency syndrome--Florida

Florida reported 1858 cases of the acquired immunodeficiency syndrome (AIDS) and 8455 cases of tuberculosis from January 1, 1981, through October 31, 1986. Of the patients with AIDS, 159 (8.6%) also had tuberculosis, and 154 (1.8%) of the patients with tuberculosis also had AIDS. Among patients with both diagnoses, tuberculosis was diagnosed before AIDS by more than 1 month in 50%, was diagnosed within 1 month before or 1 month after the diagnosis of AIDS in 30%, and was diagnosed more than 1 month after the AIDS diagnosis in 20%. Compared with patients with AIDS only, patients with both diagnoses were also more likely to be Haitian, black (other than Haitian), or Hispanic. Compared with patients with tuberculosis only, patients with both diagnoses were more likely to be younger, male, Haitian, black (other than Haitian), and Hispanic, have extrapulmonary tuberculosis and negative tuberculin skin tests, and have noncavitary chest roentgenograms. These data suggest that patients with AIDS may have an increased risk of tuberculosis and that patients with both diagnoses differ in important demographic and clinical characteristics from patients with AIDS only or tuberculosis only.     

Endoscopic ultrasound-guided tissue acquisition of lymph nodes

One of the most common indications for endoscopic ultrasound (EUS)-guided tissue sampling is to diagnose the etiology of suspicious lymphadenopathy. Although most cases of lymphadenopathy are benign and self-limiting, patients with deep-seated lymph nodes living in tuberculosis endemic areas or with suspected malignancy require tissue diagnosis to guide treatment. Fine-needle aspirate and fine-needle biopsy systems have excellent reliability for evaluating both benign and malignant lymph node diseases. The advent of new technologies and addition of ancillary molecular diagnostics have improved the diagnostic potential obtained by fine-needle sampling. In turn, the clinical applications of EUS tissue sampling have evolved and further expanded to include granulomatous diseases and lymphoma. Optimizing tissue acquisition to obtain high-quality specimens is of utmost importance and may be achieved with operative strategies unique to lymph node sampling. This chapter discusses the powerful clinical impact of EUS-guided lymph node sampling and technical considerations of optimizing diagnostic yield.     

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.