Pulmonary miliary tuberculosis in a patient with anti-TNF-alpha treatment

No difference in the number of serious adverse events was reported in previous clinical trials in rheumatoid arthritis (RA) and inflammatory bowel disease (IBD) patients treated with TNF-alpha blockade, but a patient died because of disseminated tuberculosis. A tuberculosis reactivation in a patient with IBD and anti-TNF-alpha treatment has been recently reported. Very recently 70 cases of tuberculosis were reported from the FDA Adverse Event Reporting System. We report a case of pulmonary miliary tuberculosis in a RA patient treated with TNF-alpha blockade. The important role of TNF-alpha in defence against tuberculosis and possible mechanisms of anti-TNF-alpha agents impairing tuberculosis immune response are discussed.     

肿瘤坏死因子-α拮抗剂引发结核二例分析并文献复习

目的 提高临床医生对肿瘤坏死因子(TNF)-α州拈抗剂治疗引发结核的认识.方法 报道2例类风湿关节炎(RA)患者经TNF-α拮抗剂治疗后发生结核病的临床情况,并复习近年国内外相关文献.结果 病例1在3个月内接受4次英夫利昔3 ms/ks静脉注射治疗后出现右锁骨上淋巴结结核,手术切除及四联抗结核治疗后痊愈.病例2接受依那西普25 mg皮下注射2次/周治疗1.5个月后发生肺结核瘤,手术切除后好转.文献复习显示TNF-α拮抗剂治疗可增加结核的发病率,英夫利昔的致结核作用强于依那西普,发生结核的患者多为老年人,肺外结核及播散性结核的发生率较高.结论 TNF-α拮抗剂治疗可增加结核的发病率,治疗前结核筛查、治疗期间及治疗后监测结核的发生很有必要.     

Tratamiento de la enfermedad tuberculosa pulmonar y extrapulmonar

The purpose of tuberculosis treatment is twofold: to provide an individual benefit centred on healing the patient with TB, and to provide a collective benefit to the community in which the patient resides. The different treatment regimens for tuberculosis sensitive to first-line antituberculosis drugs as well as resistant tuberculosis are examined and the peculiarities in the management of pulmonary and extrapulmonary tuberculosis are discussed.     

Tuberculosis of the Esophagus

A case of tuberculosis of the esophagus is presented in a patient with pulmonary tuberculosis. The patient, complaining of dysphagia, had esophagoscopic examination which showed a submucosal tumor with central ulceration. Tissue biopsy, under direct vision from the tumor mass, confirmed the diagnosis of tuberculosis. The patient has been asymptomatic under treatment. Both esophageal and pulmonary lesions are largely improved.
The rarity of the lesion and necessity of taking biopsy are emphasized.     

Disseminated tuberculosis presenting as a tubercular sinus with myositis of forearm in an immunocompetant patient

Disseminated tuberculosis is a life-threatening form of tuberculosis resulting from haematogenous spread of M. tuberculosis. It is most commonly seen in an immunocompromised patient. Here we report a case of Pulmonary tuberculosis with Tubercular myositis of forearm flexors and carpal tunnel syndrome presenting as a discharging sinus in an immunocompetent patient.     

Hospital outbreak of Mycobacterium tuberculosis resulting from autopsy exposure

An epidemic outbreak of tuberculosis resulting from exposure at an autopsy occurred at the National Defense Medical College Hospital. It consisted of 3 tuberculosis patients and 68 infected staff members over a 6-year observation period from 1997 to 2002 after exposure to an index patient. We report the incident and the background of the tuberculosis infection in our hospital. A 72-year-old man with myelodysplastic syndrome was admitted to our hospital and later died. Miliary tuberculosis was diagnosed at autopsy. The first non-periodic health examination was performed on the hospital staff who had contact with the patient. Tuberculosis infection was defined as an area of erythema not less than 30 mm in diameter in the tuberculin skin test. 13 of the 39 hospital staff members who had had contact with the patient were infected, and 3 developed tuberculosis. Of the latter 3 secondary tuberculosis patients, the only contact point two had had with the index case was in the autopsy room, and the other had had contact both in the autopsy room and on the ward. The incidence of tuberculosis infection among the staff who had had contact in the autopsy room alone was higher than among the staff who had had contact on the ward alone (odds ratio = 5.04; 1.08-23.42: 95% confidence interval). Because one of the secondary tuberculosis patients had bronchial tuberculosis, which is a strong source of infection, the second non-periodic health examination was performed on the staff who had had contact with the secondary tuberculosis patient, and 69 inpatients who had had contact with the staff were carefully observed over a two-year period. 58 of the 171 staff members were infected, and none developed tuberculosis. However, 23 patients were diagnosed with active tuberculosis after admission to our hospital during the 6 years from 1997 to 2002. Many of them were elderly patients with underlying diseases. An autopsy was performed on 6 of those who died, but only one was diagnosed with active tuberculosis before death. Five of the six autopsied patients had old, healed tuberculous lesions. This outbreak underlines the need for standard precautions, including anti-air droplet infection at autopsy, because antemortem diagnosis of tuberculosis is not always possible, and there is a risk of elderly hospitalized patients developing tuberculosis if they have been previously infected with Mycobacterium tuberculosis.     

Two cases of pancreatic tuberculosis in nonimmunocompromised patients: A diagnostic challenge and a rare cause of portal hypertension

Pancreatic tuberculosis is very rare, especially in immunocompetent patients, and represents a diagnostic challenge. We describe 2 cases of pancreatic tuberculosis mimicking carcinoma on CT scan. In the first case, explorative laparotomy revealed granulomatous inflammation suggestive of tuberculosis. Cultured smears from the pancreatic tail tested positive for Mycobacterium tuberculosis, and the patient responded well to antituberculous medication. In the second case, fine needle aspirate revealed tuberculosis. This case is unique with regard to development of portal hypertension in pancreatic tuberculosis. Antituberculous medication achieved little improvement, then the patient was lost to follow-up. In suspicion of carcinoma the patient underwent laparotomy in another hospital. Malignancy was excluded, and a purulent necrotic pancreas was resected. The patient finally improved without any antituberculous medication and remains well. Both patients were tested HIV-negative. We summarize the etiology, clinical presentation, diagnosis and treatment of a diagnostic dilemma, which should be considered in clinical practice.     

Simultaneous infection with multiple strains of Mycobacterium tuberculosis.

Drug-susceptible and drug-resistant isolates of Mycobacterium tuberculosis were recovered from 2 patients, 1 with isoniazid-resistant tuberculosis (patient 1) and another with multidrug-resistant tuberculosis (patient 2). An investigation included patient interviews, record reviews, and genotyping of isolates. Both patients worked in a medical-waste processing plant. Transmission from waste was responsible for at least the multidrug-resistant infection. We found no evidence that specimens were switched or that cross-contamination of cultures occurred. For patient 1, susceptible and isoniazid-resistant isolates, collected 15 days apart, had 21 and 19 restriction fragments containing IS6110, 18 of which were common to both. For patient 2, a single isolate contained both drug-susceptible and multidrug-resistant colonies, demonstrating 10 and 11 different restriction fragments, respectively. These observations indicate that simultaneous infections with multiple strains of M. tuberculosis occur in immunocompetent hosts and may be responsible for conflicting drug-susceptibility results, though the circumstances of infections in these cases may have been unusual.     

Bronchial tuberculosis. Report of 4 cases

Four cases of bronchial tuberculosis are reported. The first case was revealed by signs of bronchitis; in the second patient M. tuberculosis was found at light microscopy but x-ray films of the chest were normal; the third patient presented with signs of bronchitis and upper lobe infiltration on fibrous sequelae; the fourth patient showed a pseudo-tumoral bronchial image. These cases and those of the literature show that clinical signs are usually those of bronchitis sometimes with the systemic symptoms of tuberculosis. Chest radiography may be normal or may display disorders of ventilation of lung opacities suggestive of recent tuberculosis. Endoscopy reveals granular inflammation with whitish secretion and progressive stenosis. Diagnosis rests on bacteriological and pathological examinations. Medical treatment does not differ from the standard one. Sequelae consisting of bronchial stenosis or bronchiestasis are extremely frequent. Bronchial tuberculosis is now seldom encountered and usually affects elderly women. However, it may now become more frequent due to the greater number of cases of tuberculosis with a slightly atypical course, as found in AIDS patients.     

抗结核组合药对HBVM阳性肺结核病人肝功能影响的观察

目的　观察抗结核组合药对HBVM阳性肺结核病人肝功能的影响。方法 比较HBVM阳性和阴性肺结核病人组合药治疗前后肝功能损害情况。结果 HBVM阳性病人肝损率比阴性者明显增高(P<0.01);其中“模式Ⅰ”与“模式Ⅱ”病人肝损率差异不显著(P>0.05),而“模式Ⅰ+Ⅱ”病人肝损率比“模式Ⅲ”高(P<0.05)。结论 组合药致肝功能损害,HBVM阳性病人比阴性多见,尤以“模式Ⅰ、Ⅱ”病人更易发生,可能与用药前肝脏病理损害严重程度有关。应慎用组合药并积极采取综合措施防范。     

Relapse of tuberculosis in a patient with the acquired immunodeficiency syndrome despite 12 months of antituberculous therapy and continuation of isoniazid

A 33-year-old man with AIDS and pleuro-pulmonary tuberculosis was treated with a combination of antituberculous medications for 12 months and with continuation of isoniazid. A total of 2 months after completing combination therapy the patient developed fever, malaise, and anorexia. Mycobacterial blood cultures grew M. tuberculosis and the patient improved with the readministration of rifampicin and pyrazinamide. Phage typing of the patient's isolates of M. tuberculosis confirmed that he had experienced a relapse and not a reinfection. The patient had received 5 months of his treatment while hospitalised. We believe he was compliant with therapy outside the hospital because he attended all of his clinic appointments. Follow-up studies of HIV-infected patients with tuberculosis are therefore needed.     

肺结核病人在结防机构与非结防机构治疗情况的调查分析

目的分析肺结核病人在结防机构与非结防机构的治疗效果及费用?方法随机抽样调查6个县的268例肺结核病人,分析其在不同机构的治疗及费用情况?结果结防机构病人治愈率高于非结防机构,而费用却低于非结防机构?结论应加强结核病归口管理,使结核病人能在结防机构进行治疗?     

Possible antistenotic effect of tranilast in a patient with small bowel tuberculosis to prevent intestinal obstruction due to stenosis progression by antituberculous chemotherapy

Small intestinal tuberculosis is a rare disorder of the small intestine. We report the development of deep small bowel tuberculosis in a rheumatoid arthritis patient who was taking methotrexate. The diagnosis of small bowel tuberculosis was ascertained by typical endoscopic findings and production of interferon gamma in the peripheral blood. The patient was successfully treated with antituberculous chemotherapy combined with an antifibrotic agent, tranilast, to suppress the progression of intestinal stenosis toward symptomatic stricture.     

Localization of extrapulmonary tuberculosis in the synovial membrane,skin, and meninges in a patient with systemic lupus erythematosus and IgG deficiency

We report on a 31-year-old female patient with systemic lupus erythematosus (SLE) for 24 years who had a past history of skin tuberculosis (lupus vulgaris), long-term corticosteroid therapy, and IgG deficiency. She presented with monoarthritis and concomitant meningitis from skin tuberculosis after 5 years. The diagnosis of joint and meningeal tuberculosis was defined with clinical symptoms--signs and typical histopathological findings of involved synovium. Clinical improvement was achieved with antituberculous therapy. Cutaneous, articular, and cerebral manifestations of tuberculosis might have been confused with some of the lupus manifestations or lupus activation. It should be kept in mind that tuberculosis may be encountered in SLE due to the nature of the underlying disease and/or its therapy. It is also worth mentioning that, in this patient, tissues involved with extrapulmonary tuberculosis were the primary areas of involvement with SLE.     

Case of rheumatoid arthritis presenting with pulmonary tuberculosis]

A 72-year-old man who had been suffering from rheumatoid arthritis for 25 years developed pulmonary tuberculosis after treatment with infliximab. He had been receiving this treatment since December 2003. Forty-six days later, a fever developed and the patient was hospitalized on February 3, 2004. Chest radiography and chest CT showed an infiltrative shadow with cavity formation. Mycobacterium tuberculosis was detected in the sputum. Infliximab is a monoclonal antibody toward tumor necrosis factor alpha (TNFalpha). It has been reported that infliximab increases the risk of tuberculosis in patients with rheumatoid arthritis in Europe and North America. This is the first case of pulmonary tuberculosis in a patient treated with infliximab in Japan.     

开展患者关怀行动提升结核病防治综合服务质量

终止结核病目标的实现需要提升结核病防治综合服务质量,开展患者关怀行动是关键。为更全面地理解和认识“以患者为中心”的结核病患者医疗服务模式,提升我国结核病防治综合服务水平和质量,作者系统阐述了结核病患者关怀的涵义、工作进展,以及具体举措和意义。为了实现终止结核病目标,在传承既往结核病防治实践经验的基础上,与时俱进开展全方位的结核病关怀行动势在必行。     

Liver tuberculosis in an HIV patient: diagnosis and management

Hepatic involvement is common in miliary and extra-pulmonary tuberculosis but is usually clinically silent. Therefore, it is rarely diagnosed. We report the case of a patient that presented with prolonged fever and hepatomegaly. Liver biopsy revealed non-necrotizing granulomas that led in turn to the diagnosis of generalized tuberculosis and HIV infection. The patient reported an old untreated tuberculosis and depression of the immune system provoked the reactivation of this old tuberculosis focus. We describe the clinical course of the disease and the challenges associated with the complexity of the treatment. Diagnosis of hepatic tuberculosis requires a high degree of suspicion especially in AIDS patients who show atypical presentations. However, it is a potential curable disease and good results have been obtained with the four drug regimen.     

Tuberculosis recurrence: multivariate analysis of serum levels of tuberculosis drugs, human immunodeficiency virus status, and other risk factors.

We examined risk factors for tuberculosis recurrence in patients admitted to a tuberculosis hospital in Florida in 1996 and 1997. Recurrence of tuberculosis was not significantly associated with tuberculosis drug levels or HIV status, which indicates that routine drug monitoring may not be beneficial in general patient management.     

Localisations inhabituelles de la tuberculose : à propos de trois observations

We report three cases of tuberculosis of unusual location in Malagasy patients. The first patient presented with intracardiac tuberculoma during pulmonary tuberculosis. The second patient who had no significant musculoskeletal past medical history presented with tuberculous polymyositis. The remaining one presented with tuberculous epididymitis without involvement of the urinary tract. Diagnosis was histopathological. The outcome was favorable in the two last patients with antituberculous therapy. This report emphasizes the necessary awareness of tuberculosis even in the presence of unusual manifestations in hyper-endemic area of tuberculosis.     

Reactivation of tuberculosis during immunosuppressive treatment in a patient with a positive QuantiFERON-RD1 test

A patient with polymyositis developed tuberculosis during immunosuppressive treatment. Tuberculin Skin Test and chest X-ray failed to demonstrate latent tuberculosis, whereas a blood sample that was tested with a modified QuantiFERON-TB-assay, using the recombinant ESAT-6 and CFP-10, was positive indicating that this patient was latently infected before immunosuppressive therapy. This case indicates the risk of progressing from latent to active tuberculosis given that the subject is RD1 responsive, and we believe that preventive anti-tuberculous treatment could have prevented this case of tuberculosis. We suggest that RD1 based tests are evaluated further in immunocompromised patients.