Clinicopathological study of miliary tuberculosis in patients with hematologic disease

Seven cases of miliary tuberculosis in patients with hematologic disease were analyzed clinicopathologically. Mean age of the patients was 65 years, and the hematologic diseases were CML, AML, ALL, MDS and malignant lymphoma. Diabetes mellitus was present as a complication in three patients. Miliary tuberculosis was found in 5 cases during the first admission to our hospital owing to hematologic problems. In 4 of 6 cases, fever had started more than two months before admission, consequently, the tuberculosis probably began about that time. After admission, chemotherapy was administered in 5 cases, and steroid in 6 cases for hematologic disease. The mean total quantity of steroid administered was 2,134 mg of prednisolone and average treatment duration was 69 days. The chest roentgenographic shadow was so atypical that miliary tuberculosis was suspected in only one case. The initial chest roentgenogram showed hilar and mediastinal lymph node swelling as well as the shadow of pulmonary tuberculosis in two cases. It was thought that the hilar and mediastinal lymph node swelling could be explained by primary complex, although the patients were of advanced age, or by "secondary complex" reported by Terplan, K in 1940. The diagnosis of tuberculosis was made in two patients before their death by smear of aspirated fluid of cervical lymph node and by bone marrow cell block in one patients, and by pathological examination of mediastinal lymph node biopsy in the other patients. Tubercles were found from bone marrow cell block in 2 out of 5 patients and from bone marrow biopsy in 1 out of 3 patients, but the positive results were reported in 2 patients following death. Smears of sputum, gastric juice, urine, spinal fluid and pleural effusion were negative in all cases. One patient diagnosed as miliary tuberculosis also had pneumocystis carinii pneumonia. This case was treated with antituberculosis drugs for 20 days without improvement. Another patient diagnosed as miliary tuberculosis improved under treatment with antituberculosis drugs, but died of cytomegalovirus pneumonia. Autopsy in 5 cases revealed non-reactive miliary tuberculosis, and pulmonary hemorrhage probably due to DIC was present as a complication in two cases. In these cases, severe immunosuppression, which is a major precipitating factor of miliary tuberculosis, is thought to be induced by hematologic disease itself, chemotherapy, steroid or other underlying disease such as diabetes mellitus. Miliary tuberculosis in such compromised host is cryptic and progresses rapidly. Consequently, early diagnosis is very important. Retrospectively, the unexplained pyrexia was most important to suspect tuberculosis.(ABSTRACT TRUNCATED AT 400 WORDS)     

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.     

The nodular form of local hepatic tuberculosis. A review

Local hepatic tuberculosis without active pulmonary or miliary tuberculosis is an uncommon diagnosis. Even less common is the finding of tuberculoma or tuberculous liver abscess without clinical evidence of tuberculosis elsewhere. Since 1950, 21 cases of isolated tuberculoma or tuberculous abscess of the liver have been reported in the world literature. We report an additional two cases, one tuberculoma and one with multiple tuberculous abscesses. The case reports illustrate the difficulty in reaching the correct diagnosis, unsuspected in nearly all cases and most often confused with carcinoma of the liver. The correct diagnosis was made by histology, identification of acid-fast organisms by smear, and by cultures of Mycobacterium tuberculosis, but required laparotomy in 19 of the 23 cases. A greater awareness of this rare clinical entity may prevent needless surgical intervention since the vast majority of patients respond well to antituberculous chemotherapy.     

Delayed diagnosis of multiple systemic disseminated tuberculosis: A case report

Rationale:The clinical manifestations in patients with disseminated tuberculosis (TB) are nonspecific and may present challenges for early diagnosis.Patient concerns and diagnoses:We describe the case of a 44-year-old man who presented with abdominal pain and discomfort for more than a month. He had undergone surgery for a chest wall abscess 9 months ago. Computed tomography scans showed a miliary pattern in the lung and multiple abscesses in the liver, spleen, left psoas major muscle, skin, and soft tissue, with rim enhancement. Mycobacterium tuberculosis was detected in the drainage fluid of the abscesses and surgical slices, and disseminated TB was diagnosed.Interventions and outcomes:With anti-tuberculosis therapy, the abscesses were gradually absorbed and all cultures were negative.Lessons:The patient exemplifies the difficulty of the early diagnosis of disseminated TB. Disseminated TB should be considered first in patients with multisystem illness, and then evidence should be pursued relentlessly to establish a diagnosis.     

Melioidosis, the great mimicker: a report of 10 cases from Malaysia

Between 1981 and 1986, 10 consecutive cases of melioidosis were seen at the University Hospital, Kuala Lumpur, Malaysia. They illustrate the amazing guises of melioidosis presenting as: abscesses of the supraspinatus muscle, psoas muscle, brain and liver; three different pulmonary forms; an acute suppurative dermal lesion; an acute septicaemia; and chronic lymphadenitis. The majority had underlying diseases: diabetes mellitus, the commonest, was present in six, out of whom three had previous pulmonary tuberculosis; other predisposing conditions were renal failure, corticosteroid therapy and malnutrition. Three patients who died had pre-existing renal impairment and developed renal failure later, suggesting that the former is a bad prognostic sign. Clinical diagnosis was difficult: all cases were diagnosed bacteriologically. A high level of clinical awareness is necessary, especially when presentation simulates pulmonary or extrapulmonary tuberculosis in patients with diabetes or other compromised states.     

Diagnostic problems in pulmonary miliary tuberculosis, an analysis of 125 cases

From Dec. 1984 to Dec. 1985, 4805 cases of various types of pulmonary tuberculosis were admitted to our hospital. Among them, there were 125 cases of pulmonary miliary tuberculosis, accounted for 2.6% of total cases. The rate of delayed diagnosis was 92%. The rate of delayed diagnosis patients of rural areas was higher than that of city (96.9%, versus 82.8%, P less than 0.05). Only 33.6% showed typical miliary changes on chest radiographs. The complication of enlargement of peripheral lymph nodes and extrapulmonary tuberculosis were much higher in miliary tuberculosis patients than that of total cases (36%, 45/125; 4.9%, 236/4805; P less than 0.01. 71.2%, 89/125; 5.8%, 278/4805; P less than 0.01 respectively).     

Tuberculous subcutaneous abscesses developing during miliary tuberculosis therapy

Although rare, paradoxical subcutaneous abscesses may develop during appropriate treatment of miliary tuberculosis. While the pathogenesis of this phenomenon is not clear, some theories have been postulated. A case of a 37-y-old woman diagnosed as having miliary tuberculosis who developed subcutaneous abscesses within the 5 months of antituberculous treatment is described and all 6 similar cases published in English from 1954 to 1999 are discussed.     

AN ATYPICAL LOCALISATION OF TUBERCULOSIS INFECTION IN PATIENTS UNDERGOING HAEMODIALYSIS: A CASE REPORT

Spinal tuberculosis (TB) is a rare skeletal system localisation of TB in haemodialysis patients. In this paper, a case of Pott's disease with a psoas muscle abscess is reported. The patient had been on the dialysis programme for five years and was complaining of back pain, weight loss and weakness, which were investigated. A thoracolumbar magnetic resonance imaging showed multiple paravertebral abscesses invading the psoas muscle. TB diagnosis was made by microbiological analysis of specimen, which was obtained by fine needle aspiration under computerised tomography guidance.     

A clinical study in the collagen disease patients developed pulmonary tuberculosis during corticosteroid administration

The study subjects consisted of 14 pulmonary tuberculosis (PTB) patients with collagen disease. They are under corticosteroid treatment and the mean age is 56.4 years. The length of time from the development of collagen disease to the development of PTB averaged 4.1 years. The breakdown of collagen disease are SLE (6 patients), MCTD (3 patients), PN (2 patients), and PSS, PM, Sjogren syndrome (1 case, each). Thirteen cases were bacilli positive by the sputum examination on admission to our hospital. Chest X-ray findings on admission revealed cavitation in 3 cases and non-cavitation in 11 cases, of which 5 cases had miliary tuberculosis. Corticosteroid preparation had been administered to all of the 14 cases for more than one year. The mean dose of corticosteroid preparation administered when PTB developed was 13.9 mg (prednisolone) and it was more than 20 mg in 8 cases. The median duration from the start of the respiratory symptoms to diagnosis was 39.2 days. The delay in the discovery exceeding 1 month were seen in 9 cases. In the cases of collagen disease, when the disease course extends over a long period of time, and even when the dose of corticosteroid preparations are decreased, there is a need to be note on the risk of developing PTB. There are many non-cavitary cases with sputum smear positive. The fact suggested that an appropriate diagnosis is need so that the discovery of PTB should not be delayed.     

Tuberculous abscesses in patients with AIDS.

Five cases of large tuberculous abscesses in patients with AIDS were observed over a 2-year period at the New York Veterans Affairs Medical Center. These cases represent 11.6% of the 43 cases of tuberculosis diagnosed in patients with AIDS during that period. The abscesses were located in the liver, abdominal wall, psoas muscle, mediastinum, and peripancreatic area. All patients presented with localized pain or swelling, and four of five patients had fever. The diagnosis was made on the basis of detection of abscesses on computed tomography (CT) and the results of culture of abscess material obtained by CT-guided aspiration. CT-guided therapeutic drainage was performed in two cases. Despite administration of therapy, two of five patients died of tuberculous infection. Formation of tuberculous abscesses appears to be a common complication of tuberculosis in patients with AIDS. This diagnosis should be considered for patients with AIDS who have fever and localized pain or swelling.     

The complication with tuberculosis of the central nervous system in patients with miliary tuberculosis

The complication with tuberculosis of the central nervous system (CNS) were studied in 16 patients with miliary tuberculosis who were admitted to our hospital during a period of two years from April, 1997 to March, 1999, and were examined by head MRI. Twelve cases (75%) were diagnosed as having tuberculosis of CNS. Six cases had tuberculosis of CNS which was found during the screening of miliary tuberculosis cases, and all had only cerebral tuberculoma. Meningeal irritative symptoms led to the discovery of tuberculosis of CNS in the remaining six cases, in which cerebral tuberculoma was complicated with tuberculous meningitis. Of these cases of meningitis, three cases showing disturbance of consciousness died, but no cases of death was found in cases by the screening. The length of time from the onset of symptoms to the diagnosis of tuberculosis was long in many of the cases complicated with tuberculosis of CNS compared with the cases without such a complication. In the cases of miliary tuberculosis, the rate of complication with tuberculosis of CNS is high, and the possibility of patients developing serious symptoms suddenly even when they were asymptomatic at the time of diagnosis and the paradoxical expansion that becomes intensified after initiation of treatment have been reported. Therefore, it is necessary to make a close checkup of CNS when the diagnosis of miliary tuberculosis has been made.     

The incidence and clinical characteristics of Mycobacterium tuberculosis infection among systemic lupus erythematosus and rheumatoid arthritis patients in Korea

OBJECTIVES: The aim of this study was to describe the incidence and clinical characteristics of Mycobacterium tuberculosis infection in SLE and RA patients in Korea where the prevalence rate of active pulmonary tuberculosis in a general population is relatively higher than in Western countries. PATIENTS: We reviewed the medical records of 283 SLE and 284 RA patients retrospectively and then assessed the incidence, risk factors, and clinical characteristics of active tuberculous infection. We then compared the results for the two different groups. RESULTS: Tuberculosis was documented in 15 SLE and 7 RA patients with an incidence rate of 7.9/1,000 patient-years and 2.3/1,000 patient-years, respectively (p = 0.003). SLE-associated tuberculosis cases included 3 of miliary tuberculosis, 7 of pulmonary tuberculosis (including 1 case of diffuse pulmonary involvement with meningitis) predominantly involving two or more lobes at the mid-/lower lungfield, and 5 extra-pulmonary forms (joint, bone, kidney, larynx, pleura). All of the RA-associated tuberculosis cases were pulmonary forms with the majority being localized to single lobe, and only one case had a past history of tuberculosis, whereas a past history of tuberculosis and a longer duration of the underlying disease were significantly correlated with the development of tuberculosis in the SLE patients. Major organ involvement, the mean daily dosage of prednisolone, and a history of over 30 mg of daily prednisolone were not related to the development of tuberculosis. However, when we took only those patients taking corticosteroid until the diagnosis of tuberculosis for analysis, SLE patients with tuberculosis showed a higher daily dosage of prednisolone than those without tuberculosis. CONCLUSION: Taken together, the characteristics of tuberculosis in SLE patients were: (1) a higher incidence rate, (2) more frequent extra-pulmonary involvement, (3) more extensive pulmonary involvement, and (4) a higher relapse rate than in rheumatoid arthritis. Thus, the contributory role of M. tuberculosis infection in the morbidity and mortality of patients with SLE must be emphasized, especially in areas in which this bacteria is endemic.     

Analysis of clinical characteristics and curative effect in 17 urinary tuberculosis children

目的 探讨儿童泌尿系结核临床特征与疗效,提高儿科医师对该病的认识。方法 搜集2015年1月至2020年1月南华大学附属长沙中心医院儿童结核科收治的符合诊断标准的17例泌尿系结核患儿的临床资料进行整理及描述性统计分析。结果 17例患儿均来自湖南各地,其中农村15例,男童11例,年龄中位数(四分位数)为11.0(8.5,16.5)岁。16例接种过卡介苗,6例有明确肺结核密切接触史。并发肺结核、结核性脑膜脑炎和结核性脊髓脊膜炎、腹腔结核分别为14、8、7例。12例有泌尿系症状,其中尿频、尿急、尿痛11例,夜间盗汗9例,发热8例。尿常规异常者12例,PPD试验和结核感染T淋巴细胞斑点试验(T-SPOT.TB)阳性者分别为9和12例。泌尿系CT扫描显示结核典型表现、泌尿系受累、膀胱壁增厚者分别为15、15、9例。本组患儿均延误诊断,延误时间为15d至9个月。均以H-R-Z-E抗结核治疗方案(强化期3~6个月,巩固期12~15个月)为基础,仅1例原发性癫痫患儿将异烟肼改为帕司烟肼,并因病情或疗效原因而联用其他一、二线抗结核药品(如丙硫异烟胺、链霉素、左氧氟沙星、利奈唑胺),最终6例治愈,9例病情好转,处于继续治疗中,2例死亡。结论 本省儿童泌尿系结核患儿以农村、男童、大龄多见,接种卡介苗对该年龄段患儿无保护性;有明显结核病密切接触史、泌尿系症状和其他器官结核,PPD试验和T-SPOT.TB阳性、CT扫描有疑似典型病灶改变有助于辅助诊断。积极治疗后效果良好。     

17例儿童泌尿系结核临床特征与疗效分析

目的 探讨儿童泌尿系结核临床特征与疗效,提高儿科医师对该病的认识。方法 搜集2015年1月至2020年1月南华大学附属长沙中心医院儿童结核科收治的符合诊断标准的17例泌尿系结核患儿的临床资料进行整理及描述性统计分析。结果 17例患儿均来自湖南各地,其中农村15例,男童11例,年龄中位数(四分位数)为11.0(8.5,16.5)岁。16例接种过卡介苗,6例有明确肺结核密切接触史。并发肺结核、结核性脑膜脑炎和结核性脊髓脊膜炎、腹腔结核分别为14、8、7例。12例有泌尿系症状,其中尿频、尿急、尿痛11例,夜间盗汗9例,发热8例。尿常规异常者12例,PPD试验和结核感染T淋巴细胞斑点试验(T-SPOT.TB)阳性者分别为9和12例。泌尿系CT扫描显示结核典型表现、泌尿系受累、膀胱壁增厚者分别为15、15、9例。本组患儿均延误诊断,延误时间为15d至9个月。均以H-R-Z-E抗结核治疗方案(强化期3~6个月,巩固期12~15个月)为基础,仅1例原发性癫痫患儿将异烟肼改为帕司烟肼,并因病情或疗效原因而联用其他一、二线抗结核药品(如丙硫异烟胺、链霉素、左氧氟沙星、利奈唑胺),最终6例治愈,9例病情好转,处于继续治疗中,2例死亡。结论 本省儿童泌尿系结核患儿以农村、男童、大龄多见,接种卡介苗对该年龄段患儿无保护性;有明显结核病密切接触史、泌尿系症状和其他器官结核,PPD试验和T-SPOT.TB阳性、CT扫描有疑似典型病灶改变有助于辅助诊断。积极治疗后效果良好。     

Overt and cryptic miliary tuberculosis misdiagnosed until autopsy

Autopsy confirmed deaths due to miliary tuberculosis in Finland were analysed in order to improve the diagnosis of the disease. Tuberculosis deaths from mortality statistics were examined in order to identify miliary tuberculosis deaths, and the medical records of the autopsied cases were studied. The deceased were divided into 2 groups, 'overt' disease and 'cryptic' disease, on the basis of chest X-ray findings. There were 114 overt (mean age 79 y) and 140 cryptic (mean age 78 y) miliary tuberculosis cases. The majority of patients in both groups were females. There was no difference between the groups in history of previous tuberculosis, in predisposing factors or in symptoms. Suspicion of tuberculosis was recorded before death in 86% in overt form and in 53% in cryptic form. In overt disease 50% of the patients received chemotherapy, but in cryptic form only a quarter were treated. In one third of cases autopsy had been carried out without suspicion of tuberculosis. Suspicion of tuberculosis had arisen too seldom, especially in the cryptic group. On the other hand, those suspected to have tuberculosis were not promptly treated with the appropriate chemotherapy. Absence of suspicion and delayed diagnosis mean increased risk in health care and at autopsy.     

先天性耐药结核病一例并文献复习

目的: 结合文献复习先天性结核病的临床特点以及诊治过程,旨在积累临床医师的诊疗经验。 方法: 回顾性分析西安市胸科医院2020年10月31日收治的1例先天性耐药结核病患儿及患儿母亲的临床资料,通过查阅中国知网、万方数据库、中华期刊全文数据库及PubMed数据库,以“先天性结核病”为中文关键词,以“Congenital tuberculosis”为英文关键词进行文献检索,共搜索到国内外相关文献24篇,其中2例为耐药结核病。本研究主要选取母亲行体外受精-胚胎移植(IVF-ET)后新生儿发现先天性结核病的11篇文献共17例患儿,结合本例患儿对其临床特征、诊断及治疗情况进行分析。 结果: 文献报道加上本例共18例患儿,其中2对双胞胎。本研究中患儿母亲有结核病病史或结核病密切接触史的共12例,无结核病病史以及密切接触史的4例;母亲在助孕前行结核感染筛查的5例,未进行筛查的11例。18例中16例患儿前期按“新生儿肺炎、脓毒血症、发热待查等”抗感染治疗无效后才进行结核病的筛查,发病到诊断时间范围为3~44d。先天性结核病的临床主要表现为:发热、咳嗽、呼吸困难、肝脾肿大、黄疸、呼吸暂停、腹泻、耳部流脓。胸部CT扫描结果多提示:弥漫分布的粟粒状结节影,纵隔、肺门淋巴结肿大,少量胸腔积液。本研究中15例患儿按一线抗结核方案治疗后,11例预后良好,4例因发现结核病时病情危重,死亡。3例为先天性耐药结核病,1例胃液标本行药物敏感性试验(简称“药敏试验”),结果显示“利福平”耐药,1例胃液标本药敏试验提示“异烟肼”耐药,本例药敏试验提示“异烟肼、利福平、利福喷丁、帕司烟肼”耐药。3例均给予二线抗结核治疗,未见明显药物不良反应,患儿预后良好。 结论: 先天性耐药结核病临床表现缺乏特异性,但临床症状却较为严重。二线抗结核治疗药物不良反应少,相对安全。     

Miliary tuberculosis. Report of 4 cases proved by autopsy

Four cases of acute miliary tuberculosis, including one case of nonreactive tuberculosis, are reported in this article. Final diagnoses were proved by autopsy. Literature review shows that symptoms of the disease vary greatly in different cases, but fever with unknown causes and overwhelming infection is the constant features. Nonreactive tuberculosis is common in the patients with low immunity and correct diagnosis depends on autopsy in most cases. Anti-tuberculosis drugs for nonreactive tuberculosis is not very effective and the prognosis is unfavourable. This article provides for the doctors with the experience of mis-diagnosis of acute miliary tuberculosis, especially nonreactive tuberculosis.     

Radiologic manifestations of adult tuberculosis

Adult pulmonary tuberculosis commonly presents with radiographic findings of upper lobe cavitary opacities, in which case the correct diagnosis is usually suspected. However, other radiographic presentations of this disease in the adult include intrathoracic adenopathy, pleural effusion, lower lobe consolidation, a miliary pattern, and a solitary nodule. In these latter cases, tuberculosis may not be considered in the differential diagnosis. This article discusses the protean manifestations of adult pulmonary tuberculosis.     

Acute respiratory failure caused by tuberculosis requiring mechanical ventilation

The patients with active tuberculosis in whom respiratory failure requiring mechanical ventilation developed were studied retrospectively. Nine patients (M 8, F 1) were identified at the National Tokyo Hospital during 5 years from January, 1993 to December, 1997. Seven of 9 patients were single men, and the duration of symptoms before admission was over 1 month in all patients, while the time from first visit to diagnosis was less than 7 days. All patients were identified as malnourished, and 7 patients suffered from another underlying diseases. The patients were classified into two groups. Six of 9 patients had pulmonary tuberculosis and the other three had miliary disease. The proportion of cases requiring mechanical ventilation was 0.3% and 8.6%, respectively, in pulmonary tuberculosis and miliary tuberculosis. At the start of mechanical ventilation, PaO2/FIO2 was lower than 200 in all 9 patients, and 6 patients were probably ARDS. Steroids (methylprednisolone 250-1000 mg/day) were used in all 9 patients. Despite the use of mechanical ventilation and antituberculous therapy, 8 out of 9 patients died. Only one patient with miliary tuberculosis survived. The establishment of the therapy for acute respiratory failure is needed so as to improve prognosis of such cases. At the same time, the delay in consulting a doctor led to acute respiratory failure in most cases, so it is also important to encourage tuberculosis patients to visit a doctor as soon as possible, after the appearance of symptoms.