Hepatic tuberculosis presenting as cholestatic jaundice. A case report.

We report three cases of hepatic tuberculosis with cholestatic jaundice. All three patients presented with cholestatic jaundice, anorexia, fever and weight loss. All had hepatomegaly. No biliary obstruction was detected. Two patients had evidence of extra hepatic tuberculosis but one had no such evidence. Diagnosis of hepatic tuberculosis was confirmed by liver biopsy. Little is known about tuberculous affecting the liver and the general belief is that it is a histopathological entity only, but these cases are a reminder of the unusual manifestation of a very common condition. All the cases recovered with anti-tuberculous treatment.     

Tuberculosis of the Pancreas: Report of Three Cases

Three cases of pancreatic tuberculosis are described. The first patient presented with abdominal pain, weight loss, anorexia., vomiting, hepatomegaly, and mass in the head of the pancreas, on computerized tomographic (CT) scan. The second patient presented with low grade fever, anorexia, and weight loss, and was investigated for gallbladder disease. The third patient presented with obstructive jaundice and mass lesion in the head of the pancreas. Two patients underwent laparotomy for suspected pancreatic tumors. The findings of pancreatic disease was incidental during laparotomy in the second patient. The histopathology revealed caseating granuloma in all of them. The first patient responded well to treatment, and the second patient stopped treatment after 2 months and is well. The third patient is being followed. If malignancy can be ruled out, tuberculosis should be considered in relevant geographic areas, and a tissue diagnosis should be made.     

Genitourinary tuberculosis : Clinical features in a general hospital population

Seventy-eight patients with genitourinary tuberculosis were evaluated during a 12 year period. Active tuberculosis was confined to the genitourinary tract in all but 10 patients. Aside from five cases of miliary tuberculosis, most genitourinary infections developed from the breakdown of granulomes acquired earlier during transient dissemination from a primary pulmonary infection. Patients with genitourinary tuberculosis exhibited features of local organ dysfunction rather than systemic symptoms of infection; fever, weight loss and anorexia were uncommon. Seventy-one per cent of the patients with active tuberculosis of kidneys, ureters and bladder presented because of urinary tract symptoms. Twenty per cent were asymptomatic and were detected because of abnormal urinary sediments. The diagnosis of genitourinary tuberculosis should be suspected on the basis of an abnormal urinalysis (hematuria and/or pyuria) with negative routine cultures, and a positive tuberculin skin test. Intravenous pyelograms disclosed abnormalities in most patients but were rarely diagnostic. Serial intravenous pyelograms disclosed increasing ureteral obstruction during chemotherapy in three patients. Multiple drug chemotherapy is the mainstay of treatment, but reconstructive surgery remains important.     

Screening for tuberculosis in adults with advanced HIV infection prior to preventive therapy.

It is important to exclude tuberculosis prior to preventive therapy, but this can be difficult in patients with symptomatic human immunodeficiency virus (HIV) disease. Patients with clinically advanced HIV disease were screened for active tuberculosis using a symptom questionnaire, measured weight loss, chest radiography, sputum microscopy and culture prior to receiving tuberculosis preventive therapy. Tuberculosis was diagnosed in 11 of 129 patients screened. A simple screening instrument of two or more of the symptoms measured weight loss, cough, night sweats or fever, had a sensitivity of 100% and specificity of 88.1%, and positive and negative predictive values of 44% and 100%, respectively.     

Tuberculosis mimicking cancer—A reminder

The charts of 26 patients who were referred with a presumptive diagnosis of neoplasms and who were ultimately found to have only tuberculosis were reviewed. Twenty-one patients (81 percent) were born in the United States, and only three patients had a history of exposure to tuberculosis. Most patients had few symptoms, and the average duration of symptoms was 2.8 ± 1.5 months. Classic symptoms of tuberculosis, like fever, hemoptysis, and weight loss, were uncommon. Chest roentgenographic abnormalities were present in 62 percent of the patients. Although some of the patients had undergone nondiagnostic biopsy procedures before referral, none had had skin tests for tuberculosis. Underlying conditions were found in eight patients, and alcoholism was the most common. Laboratory abnormalities were rare with the exception of increased platelet counts, which were found in eight patients. The most common form of tuberculosis was pulmonary (14 patients) followed by lymphadenitis (nine patients). Tuberculosis remains an elusive disease even in countries with advanced medical technology. In some cases, its presentation may suggest the presence of malignancy.     

Solitary pancreatic tuberculosis in immunocompetent patients mimicking pancreatic carcinoma

In this study, two cases of biopsy-proven pancreatic tuberculosis are reported. The patients presented with fever, anorexia, fatigue, abdominal pain and weight loss. A differential diagnosis of fever of unknown origin was conducted. Computed tomography (CT) revealed a cystic mass image in the pancreatic head in one patient, and a hypodense lesion in the pancreatic head in the other. The first patient was diagnosed by a wedge biopsy specimen obtained in the exploratory laparotomy. The other patient was diagnosed by percutaneous fine-needle aspiration biopsy. Both patients were successfully treated with quadruple antituberculous therapy for 12 months. We concluded that especially in young patients who present with a mass in the pancreas, pancreatic tuberculosis should be considered among the differential diagnoses, particularly in developing countries and immunosuppressed individuals.     

Case report: disseminated Mycobacterium gordonae infection in a nonimmunocompromised host.

Mycobacterium gordonae is considered the least pathogenic of the Runyon Group II mycobacteria, although there are now well-documented reports of infection varying from localized soft tissue infection to disseminated life threatening diseases. We report a 40-year-old Pakistani housewife, treated in childhood for tuberculosis, who presented with severe systemic illness, fever, ascites, hepatomegaly, persistent dysuria with sterile pyuria, pulmonary disease, and anorexia with weight loss. Liver biopsy histology showed multiple granulomata and multiple isolation of M. gordonae from sputum and urine, in keeping with disseminated mycobacterial infection. She had dramatic response to antituberculosis therapy with streptomycin, isoniazid, rifampicin, and pyrazinamide. No evidence existed for disturbed humoral or cellular immunity and HIV infection. This represents the fifth reported case of disseminated M. gordonae infection, the first from the Arabian Gulf. It was treated successfully with standard antituberculosis regimen.     

Granulocytopenia in hospitalized patients: II. A prospective comparison of two antibiotic regimens in the empiric therapy of febrile patients

The results of empiric antibiotic therapy in 126 hospitalized patients with fever during 192 episodes of granulocytopenia were studied. Febrile granulocytopenic patients were randomly allocated to receive either carbenicillin, methicillin and gentamicin, or carbenicillin and cephalothin. The response rate for the two antibiotic regimens was similar, 49 (60 per cent) of 81 responded to the former and 42 (54 per cent) of 78 to the latter. The response rate in patients receiving other antibiotics because of specific indications or counterindications was 19 (58 per cent) of 33. Thirty-nine (35 per cent) of 110 patients who responded to initial antibiotic therapy had an increase in circulating granulocytes of one log₁₀ or more compared to only 10 (12 per cent) of 79 nonresponders with such an increase. The mortality rate in adult patients receiving carbenicillin, methicillin and gentamicin was eight (16 per cent) of 51, compared to 18 (37 per cent) of 49 in those receiving cephalothin and carbenicillin (P < 0.05). The significance of this difference in mortality rate is uncertain, as there was no difference in the initial response rate or mortality rate between patients treated with the two antibiotic regimens when only patients with documented bacterial infection were considered. Patients who responded to their initial antibiotic regimen, and patients for whose fever no explanation was found, had the best prognosis.     

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.     

Active tuberculosis undiagnosed until autopsy

In this report 21 patients in whom tuberculosis was the primary cause of death, but which was not diagnosed until necropsy, are reviewed. Of the 21 deaths, 11 were due to pulmonary tuberculosis and 10 to miliary tuberculosis. Proper evaluation of the following factors might have led to the correct diagnosis in many of the patients: A family history of tuberculosis, prior pleurisy, a gastrectomy, diabetes mellitus or end-stage renal failure; all can be associated with an increased incidence of tuberculosis. A negative tuberculin skin reaction does not exclude the presence of active tuberculosis. In the search for Mycobacterium tuberculosis, the examination of just one or two sputum specimens is not an adequate bacteriologic investigation. A positive gastric smear can have diagnostic importance. Ascitic fluid findings can be characteristic of tuberculous peritonitis. A negative bone marrow aspirate for acid-fast bacilli does not exclude miliary tuberculosis. Significant anemia, high fever and leukopenia increases the possibility of tuberculosis. The persistence and/or progression of lung infiltration, irrespective of supposedly specific antibiotic therapy, strongly suggests tuberculosis. Miliary tuberculosis can present as an adult respiratory distress syndrome. All but one patient in this series had fever. The failure to diminish the pyrexia believed due to specific lung infections with presumably effective antibiotics, and the inability of therapy to control other conditions thought to cause the fever indicate the presence of tuberculosis. Tuberculosis, especially miliary disease, should be considered as a possible etiology of fever of unknown origin.If the diagnosis of tuberculosis is highly suggestive, even without bacteriologic confirmation, a therapeutic trial of antituberculosis drugs should be given.     

Abdominal tuberculosis--experience of a University hospital in Oman

OBJECTIVE: To determine the clinical presentation and assess the usefulness of various diagnostic modalities and outcome of treatment of abdominal tuberculosis (TB). Materials and methods: The files of patients admitted to Sultan Qaboos University Hospital (SQUH) with a diagnosis of abdominal TB from January 91 to December 99 were studied retrospectively and data abstracted. RESULTS: Eighteen patients were diagnosed during this period, of which ten were males. The median age was 27 years (range 5-65). The common symptoms were fever, weight loss, anorexia, and abdominal pain. Abdominal signs were less frequent and included hepatomegaly and ascites. Eight patients had co-existent immunocompromised disorders; two of these had active pulmonary TB. Diagnostic investigations included gastrointestinal contrast studies in two, ultrasound (US) guided fine needle aspiration cytology (FNAC) in nine, and laparoscopy and/or laparotomy in seven. All patients underwent antituberculous therapy for 9-12 months, in addition to the treatment of associated disorders. The response to antituberculous therapy was good except in one patient with HIV. Four patients died from associated primary disorders. CONCLUSIONS: The clinical presentation was non-specific and nearly half of the patients had associated immunocompromised disorders; thus a high index of clinical suspicion is required. US guided FNAC and selective laparoscopy were the most useful diagnostic modalities. Antituberculous therapy was effective.     

Clinico-roentgenologic characteristics of patients with pulmonary tuberculosis and damage to segment VI and results of their treatment

The clinicoroentgenological pictures of pulmonary tuberculosis located in segment VI in 90 patients and the results of their treatment were analyzed. Among the clinical forms, only infiltrative tuberculosis (88.9 per cent) and tuberculoma (11.1 per cent) were diagnosed. In 92.7 per cent of the patients the destruction phase was stated. Pneumonia was detected in almost half of the patients with acute and subacute processes of the disease. Tuberculosis in them was confirmed within the periods from 1 to 6 months. This is indicative of late diagnosis in some of them. Diagnostic mistakes were mainly associated with the features of the process localization and defective bacteriological and roentgenological examinations since the clinical signs and histories were typical of tuberculosis. The treatment results were estimated in 79 patients who stayed in hospital for at least 2 months. Closure of destructive cavities was observed in 73.7 per cent of the patients against 81.1 per cent in the control group. Abacillation was recorded in 96.5 per cent of the patients.     

肝结核5例诊治分析

[目的]分析肝结核的临床表现、影像学特点及治疗措施,提出诊治对策,提高诊断能力.[方法]回顾性 分析5例肝结核患者的病历资料,以期提高对肝结核的诊断及认识.[结果]5例中,以脐周痛、发热为主要表现1例,以右上腹痛表现1例,以右下胸痛为主要表现1例,以肝功能损害为主要表现1例,以腹胀、多浆膜腔积液为主要表现1例；其中3例经病理及影像学检查确诊,另2例为临床诊断考虑肝结核,给予抗结核治疗有效.[结论]肝结核可表现为腹痛、腹胀,也可无明显腹部症状,或仅有肝功能损害及表现为多浆膜病变；腹部CT表现为肝脏结节,增强后可强化,或有钙化表现；病理活检是金标准,表现为肉芽肿性炎.对于有肺结核病史,近期出现发热、纳差、腹痛、肝脏肿大伴触痛、血沉增高、肝功能异常尤其是γ-GT增高、贫血、甲胎蛋白正常,结合腹部CT及B超表现需考虑肝结核的可能.     

A case of intestinal tuberculosis presenting massive hematochezia controlled by endoscopic coagulation therapy]

The clinical manifestations of intestinal tuberculosis are non-specific. But, abdominal pain, low grade fever, weight loss, anorexia, and diarrhea are major symptoms of intestinal tuberculosis. Massive bleeding has been reported as a rare manifestation of intestinal tuberculosis. Massive hematochezia from intestinal tuberculosis has rarely been reported in the medical literature. Also, most of them were treated with anti-tuberculosis medication only or with surgery. We treated a case of intestinal tuberculosis presenting massive hematochezia with colonoscopic coagulation therapy and anti-tuberculosis medication. Here, we report a Korean man who presented with massive hematochezia from ileal tuberculosis and treated by endoscopic coagulation therapy.     

Hemophagocytic syndrome as an initial presentation of miliary tuberculosis without pulmonary findings

A 9-y-old girl was admitted with fever, weakness and weight loss. She had pancytopenia in peripheral blood, hypocellularity and hemophagocytosis in bone marrow. Disseminated tuberculosis was diagnosed after a long delay, with involvement of the lungs, bone marrow, liver, spleen and central nervous system. Tuberculosis can be a cause of hemophagocytosis and should be taken into account in the differential diagnosis of fever of unknown origin associated with pancytopenia and hemophagocytosis.     

Splenic abscesses due to Mycobacterium tuberculosis in patients with AIDS

Among 60 patients with AIDS seen at our institution, two had splenic abscesses due to Mycobacterium tuberculosis without pulmonary tuberculosis. In both cases splenic abscess was the first manifestation of AIDS; the patients had prolonged fever and had lost weight and experienced malaise; slight hepatomegaly was noted in both instances and peripheral lymphadenopathy in one. Chest radiography gave normal results in one case and showed hilar lymphadenopathy in the other. Ultrasonographic findings were characteristic: homogeneous hepatomegaly and splenomegaly, with multiple filling defects of variable size. Diagnosis required splenectomy in one case and biopsy of cervical lymph nodes in the other. In both cases Ziehl-Neelsen staining gave positive results; M. tuberculosis grew from a culture of splenic tissue of one patient and from a culture of lymph nodal tissue of the other. There was a rapid response to antituberculous therapy. Splenic tuberculosis seems to be a distinct extrapulmonary entity in patients with AIDS. Ultrasonographic images are useful for diagnosis and follow-up.     

Acute sickle cell syndromes in Nigerian adults

The pattern of acute illness was determined in 102 adolescents and adults with sickle cell anaemia who presented to the emergency unit of a Lagos hospital. The patients had a mean age of 20.5 years (SD 13.1) and a male-female ratio of 1.5. The symptoms included fever (72%), fatigue and weakness (59%), anorexia (59%) and pain (57.5%) while major clinical signs were pallor (100%), jaundice (71%) and hepatomegaly (68%). Sixty-eight per cent of patients had sickle cell crises, including one with hemiplegic stroke, 10% with combined anaemia and pain crises, 33% with anaemia crises only and 23.5% with pain crises only. Sixty-three per cent had infection which was malaria in 24.5%, bacterial in 17% and viral in 6%. Of 16 patients with pyrexia of unknown origin, seven responded to treatment with chloroquine and eight to antibiotics. Infection was detected in 50% of the patients with sickle cell crises. The association between anaemia crises and malaria was significant (P < 0.05). Of the eight deaths, seven (88%) had anaemia crises. In contrast to studies conducted two decades ago in the same hospital, the prevalence of anaemia crises now exceeds that of pain crises and malaria now exceeds that of bacterial infection. Severe symptomatic anaemia (anaemia crisis) was more frequently associated with infection (mostly malaria) than was bone pain crisis. The Girdle pain crisis more frequently resulted in a fatal outcome than the uncomplicated bone pain crisis.     

The control of chronic lymphocytic leukemia with mediastinal irradiation

Forty patients with chronic lymphocytic leukemia have been treated with mediastinal irradiation. A full remission was achieved in 18 (45 per cent) patients, a partial response in eight (20 per cent), "WBC control" in eight (20 per cent) and no response in 6 (15 per cent). Although mediastinal irradiation benefited all stages of disease, earlier stages of disease correlated with more complete and longer response to mediastinal irradiation. Toxicity was mild and transient and included leukopenia in five patients (12 per cent), thrombocytopenia in eight patients (20 per cent), mild esophagitis in 12 patients (30 per cent) and pneumonitis in four patients (10 per cent). There were no toxic deaths and mediastinal irradiation did not adversely effect survival. Treatment was readily given on an ambulatory basis and completed within four weeks. In five of 11 patients, abnormal immunoglobulins became normal. Eleven patients had abnormal lymphocyte transformation with PHA, five had marked improvement and three had partial improvements following mediastinal irradiation. This improvement appeared to correlate with response and survival but further study is necessary to confirm this relationship. Although most patients required additional therapy within two years, eight patients have required no further therapy for periods of twenty-eight months to thirteen years.     

Isolated splenic tuberculosis presenting with pyrexia of unknown origin

We report a case of a 62-y-old man who presented with fever, malaise and weight loss. He was diagnosed with pyrexia of unknown origin due to tuberculosis of the spleen. Combination anti-tuberculous therapy was administered and fever gradually subsided after 6 weeks. A 12-month course of anti-tuberculous treatment would appear to be appropriate for the treatment of most patients with splenic tuberculosis.     

Local characteristics of the normal and asynergic left ventricle in man

The significance of ventricular asynergy in determining medical prognosis and surgical risk in patients with coronary artery disease and its delineation by ventriculography have been of increasing interest. To determine the underlying histopathologic and electrographic features of left ventricular asynergy, 39 patients undergoing open heart surgery were studied. Thirty-six histopathologic specimens were obtained in 31 patients (26 as transmural needle biopsies and 10 as aneurysm resections). In four normally contracting areas and 12 hypokinetic areas, neither fibrosis nor early changes of myocardial damage was evident. In contrast, of eight akinetic areas there was more than 50 per cent muscle loss in four and from 30 to 35 per cent muscle loss in three, in only one area was there less than 10 per cent muscle loss. Of 12 dyskinetic zones there was more than 75 per cent muscle loss in 10 zones, 35 per cent in one and no pathologic abnormalities in one.Epicardial electrograms were obtained from 35 areas in 29 patients. Of 10 normally contracting ventricles, in one, pathologic Q waves were demonstrated only over the inferior area. Progressive increases in the severity of asynergy were associated with a progressive increase in frequency of initial abnormal Q waves. In only one of nine hypokinetic areas were epicardial Q waves exhibited, but they were present in six of 10 akinetic and five of six dyskinetic areas.Both histopathologic and electrographic data were available from 20 asynergic areas in 16 patients. Initial epicardial R waves were associated with normal biopsy specimens in seven of eight hypokinetic areas. Of seven akinetic areas, initial R waves were associated with 30 to 35 per cent muscle loss in three; of four areas with initial Q waves, there was a 35 per cent muscle loss in one and more than 50 per cent muscle loss in three. Similarly, of five dyskinetic segments, a QS pattern was associated with more than 75 per cent fibrosis in four. In one dyskinetic area there was an initial R wave in association with a normal appearing biopsy specimen.In summary, a good correlation exists between the severity of asynergy by ventriculography, the degree of muscle loss and the presence of epicardial Q waves. However, a significant amount of histologically and electrographically normal myocardium may be present even in severely asynergic areas.