A Century-Old Threat: Disseminated Tuberculosis in a Healthy Host - Case Report.

Case report - IntroductionA 9.5-year-old girl presented with high-grade fever and rash affecting face, upper arms, chest and back with no other obvious focus. Investigations revealed pancytopaenia, raised inflammatory markers and negative cultures. CT scan of chest and abdomen revealed extensive lymphadenopathy. A diagnosis of juvenile systemic lupus erythematosus (JSLE) was made from the clinical features, including the classical rash and the laboratory profile, after ruling out oncological problems. The diagnosis was complicated by encephalopathy and macrophage activation syndrome, both of which posed therapeutic challenges, but eventually responded to the initial treatment of lupus.Case report - Case descriptionA previously fit and well 9.5-year-old girl of Asian origin, born of non-consanguineous relationship, presented to local hospital with history of high-grade fever (over 39 degree Celsius) and rashes for three weeks. The rash consisted of raised erythematous papules and patches affecting her cheeks, nose, upper arms, chest and back. Her initial blood tests showed anaemia, lymphopaenia and raised inflammatory markers (CRP 47mg/L). She was commenced on broad spectrum antibiotics, which were changed following growth on urine culture. She developed oral ulceration and continued to be lethargic with poor oral intake. High-grade fever persisted with dropping blood counts and inflammatory markers remaining elevated. Further microbiological and immunological (including autoantibody screen) investigations were negative. A CT scan done at this stage showed extensive axillary, mediastinal and abdominal lymphadenopathy. She was transferred to our centre for bone marrow and lymph node biopsies. Her examination revealed cervical and axillary lymphadenopathy, hepatosplenomegaly and ascites, in addition to rashes and oral ulcers. While awaiting the biopsies, she developed multiple episodes of generalised tonic clonic seizures, requiring intubation and ventilation. MRI and MRA of head did not identify an intracranial cause for the encephalopathy. Her rashes were felt to be consistent with lupus and the autoantibody profile showed strongly positive ANA (with coarse speckling pattern) and double-stranded DNA, in addition to profound hypocomplementeamia. She was also positive for Anti SM, RNP and anti-Ro52 antibodies. Her chest radiograph showed pleural effusion while echocardiogram showed global pericardial effusion. She had no proteinuria. The bone marrow and lymph node biopsies ruled out lymphoproliferative pathology. She also satisfied the EULAR (2016) criteria for macrophage activation syndrome (fever, pancytopaenia, ferritin over 32000 microg/L, elevated liver enzymes, hypertriglyceridaemia and hypofibrinogenaemia). The encephalopathy was thought to be due to macrophage activation syndrome (MAS).Case report - DiscussionAlthough her presentation with fever and pancytopaenia with subsequent discovery of extensive lymphadenopathy raised the possibility of lymphoproliferative pathology, the dermatology opinion was clearly favouring JSLE in view of the classical rash. The mouth ulcers, serositis, haematological and immunological profile all supported the diagnosis. She satisfied the clinical and laboratory criteria for MAS, which was thought to be the cause of her encephalopathy too, as there were no changes to suggest lupus or vasculitis, or any other pathology like vascular events or posterior reversible encephalopathy syndrome (PRES), on neuroimaging. She was started on pulse of intravenous methyl prednisolone, which was continued for a further two days due to MAS, followed by cyclophosphamide at 500mg/m2. The plan is to continue cyclophosphamide to induce remission, in addition to slow weaning course of oral steroids and hydroxychloroquine. She had an excellent clinical and laboratory response at the first review since discharge.Case report - Key learning points1) The initial diagnosis with fever and extensive lymphadenopathy was challenging, although it has been reported in the literature as more common in childhood-onset lupus, when compared to lupus presenting in adulthood. The multi-disciplinary team working involving the rheumatology, dermatology, neurology and oncology teams made the diagnostic process more efficient and timely.2) The diagnostic dilemma over the cause of encephalopathy with neuroimaging suggestive of no changes suggestive of lupus, vasculitis, vascular events or other pathology like PRES (although the seizures occurred prior to use of steroids and she had no evidence of hypertension or renal involvement). Although difficult to prove, we put this down to MAS and she had a significant clinical improvement, in line with improvement of laboratory parameters of MAS.3) Her MAS settled down with steroids, without having to resort to alternate agents like cyclosporine or anti-interleukin1 agents. The choice of agent to treat MAS, had it not settled down with the initial pulse of steroids, was debated – we would have had to choose an agent that may not be as effective in the management of lupus. We were not comfortable with choosing two different agents to treat the condition and a complication of the condition; but the extended course of steroids worked well for both.

Atypical disseminated tuberculosis with multi-organ involvement and secondary infertility in an immunocompetent female: a case report and review of the literature

IMMUNE RECONSTITUTION INFLAMMATORY SYNDROME CAUSED BY TWO SPECIES OF NONTUBERCULOUS MYCOBACTERIA PRESENTING AS MEDIASTINAL LYMPHADENOPATHY

Aggregatibacter aphrophilus, a fastidious Gram-negative member of the Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, and Kingella group, is an exceptionally rare cause of hepatic abscess, particularly in immunocompetent individuals. We describe a case of a healthy, middle-aged man who presented with a 5-day history of cyclical fevers, chills, and night sweats. Computed tomography imaging revealed a solitary hepatic lesion, initially suspicious for malignancy. Magnetic resonance cholangiopancreatography confirmed a hepatic abscess. Culture from a computed tomography-guided aspirate identified A. aphrophilus as the causative organism. Despite empiric broad-spectrum antibiotics and drainage, the patient continued to experience febrile episodes until culture-directed therapy led to clinical resolution. He received 3 weeks of intravenous ceftriaxone 2 g q24 h and PO metronidazole 500 mg q8 h and percutaneous drainage. Upon follow-up with infectious disease, no recurrence was noted upon review of repeat computed tomography imaging. This case highlights the importance of early microbiological identification and targeted treatment, even in healthy hosts.

Cryptococcal infections, commonly associated with immunocompromised hosts, are rare but increasingly recognized in immunocompetent individuals. This case report describes a 39-year-old immunocompetent male presenting with cryptococcal pneumonia, initially misdiagnosed as bacterial pneumonia. The patient's persistent symptoms and diagnostic complexities highlight the importance of including cryptococcal infection in the differential diagnosis of chronic respiratory conditions unresponsive to conventional treatment. Treatment with fluconazole was effective, underscoring its role in managing isolated pulmonary cryptococcosis. This report aims to increase clinician awareness of the atypical presentations of cryptococcal infections in healthy hosts and the necessity of thorough diagnostic protocols for appropriate management.

P22 Between the devil and the deep blue sea – a diagnostic dilemma

Introduction and importance:TB, a major health concern caused by Mycobacterium tuberculosis, primarily affects the lungs but can also manifest as extrapulmonary TB (EPTB). Genitourinary tuberculosis (GUTB) ranks third among extrapulmonary TB cases, following lymphatic and pleural involvement.Case presentation:A 45-year-old female from Amahra, Ethiopia presented with long-standing flank pain, constitutional symptoms, and lower urinary tract symptoms. She had no significant comorbidities. Physical examination was unremarkable except for left costovertebral angle tenderness. Abdominal imaging revealed normal renal parenchyma, left hydronephrosis, and a staghorn calculus. A unilateral nephrectomy was performed, and surprisingly, pathological analysis suggested renal tuberculosis. The patient was subsequently treated with a 6-month course of antituberculosis therapy.Case discussion:Isolated renal tuberculosis (RTB) is a rare and often difficult-to-diagnose form of TB due to its nonspecific symptoms. Presentations range from asymptomatic to severe, including complications like staghorn calculi or masses. Rena; TB, while typically associated with certain risk factors, can occur even in their absence, as in this case where the patient only resided in a high TB burden area. Mycobacterium tuberculosis usually reaches the kidneys via hematogenous spread from the lungs, though direct spread is also possible, but isolated renal involvement is rare. Diagnosis of isolated renal tuberculosis is challenging, often requiring histopathology after nephrectomy or biopsy, as urine cultures may be unrevealing. Imaging findings vary with the disease stage, with CT best for calcifications and CT IVP offering broader sensitivity. Treatment involves anti-tuberculosis medications guided by WHO and national guidelines. While medications are often sufficient, advanced cases may require surgical interventions like nephrectomy, with the choice dependent on factors like disease extent and renal function.Conclusion:Isolated renal tuberculosis (RTB) is rare and can be difficult to diagnose due to its varied symptoms Early detection and treatment with anti-TB drugs are key to preventing irreversible kidney damage and nephrectomy.

Brain abscesses caused by Mycobacterium tuberculosis are rarely reported and are typically found in immunocompromised patients. The challenges in identifying the pathogen and the frequent delays in initiating appropriate therapy often result in a poor prognosis for patients. We herein report a rare case of a brain abscess caused by M. tuberculosis in a 63-year-old patient with a history of hypertension but no history of pulmonary tuberculosis. The patient was hospitalized twice because of worsening right upper limb weakness and speech difficulties. Both a pus culture and cerebrospinal fluid culture were negative. Ultimately, the diagnosis of M. tuberculosis infection was confirmed through next-generation sequencing and the tuberculosis-specific T-cell test (T-SPOT). The patient's symptoms improved following anti-tuberculosis treatment. This case highlights the importance of considering M. tuberculosis as a potential cause of brain abscesses, even in immunocompetent individuals, and underscores the need for early diagnosis for effective treatment.

ADENOCARCINOMA OF THE LUNG MIMICKING MILIARY TB AND POTT DISEASE

Coccidioidomycosis, commonly known as “Valley fever,” is caused by Coccidioides immitis or C. posadasii. Although most infections are asymptomatic or limited to mild respiratory symptoms, approximately 1% of cases disseminate to involve other organs, such as the skin, bones, and central nervous system (CNS). The risk of dissemination is higher in individuals with weakened immune systems; however, it can also occur in immunocompetent individuals. The patient is a 48-year-old male who presented with generalized weakness and shortness of breath. Symptoms have been ongoing for four weeks since being diagnosed and treated for pneumonia with oral antibiotics, without improvement. Patient continued to have nonproductive cough and shortness of breath with exertion. He was subsequently given another course of antibiotics and steroids which mildly improved symptoms. Prior to admission he started experiencing worsening weakness particularly in the lower extremities. He noted an intermittent fever, weight loss, and chills. History revealed recent travel to Canada. He denied smoking, occupational exposures, any exotic pets, and no history of lung disease or serious infections. A Computed Tomography scan of the chest was significant for scattered bilateral ground-glass and consolidative airspace opacities compatible with multifocal airspace disease, particularly with a tree in-bud pattern. Labs significant for eosinophilia. Autoimmune and infectious workup was performed, specifically for fungal organisms. Coccidioides antibody was positive. Targeted history revealed some time working in the southwest at construction sites prior to developing symptoms. Bronchoscopy with bronchoalveolar lavage and transbronchial biopsy was performed. The patient was started on fluconazole and discharged to follow up closely. Post-discharge, fungal lavage cultures grew Coccidioides posadasii. Coccidioidomycosis generally presents as a self-limited respiratory illness; however, dissemination can occur, particularly in patients with risk factors, including immunosuppression or recent exposure in endemic regions. This case highlights the potential severity of disease in previously healthy individuals following exposure to the fungus. The patient's generalized weakness, exacerbated by dehydration and hyponatremia, coupled with eosinophilia, raised concerns for possible autoimmune or hypersensitivity reactions. Fluconazole remains the first-line treatment for disseminated disease, while amphotericin B may be necessary in severe cases. The patient showed improvement with antifungal therapy, and no CNS involvement was detected. This case emphasizes the importance of considering coccidioidomycosis in patients presenting with pneumonia, particularly following travel to endemic areas. Disseminated coccidioidomycosis can occur even in immunocompetent individuals and may involve multiple systems. Early diagnosis and appropriate antifungal therapy are critical for ensuring a favorable outcome.

IntroductionIsolated hepatic tuberculosis is an uncommon manifestation of one of the most common infections worldwide, caused by Mycobacterium tuberculosis. Extremely high serum ferritin, which is regarded as a marker of adult onset Still’s disease, has not been observed in patients with tuberculosis of the liver. We report a case of hepatic tuberculosis who presented with clinical criteria of adult-onset Still’s disease and extreme hyperferritinemia, which posed a diagnostic confusion.Case presentationOur patient was a 48-year-old Sri Lankan man who presented with fever, polyarthralgia and a generalized skin rash of three months duration. He had marked constitutional symptoms, oral ulcers, hair loss, anemia and hepatomegaly. Laboratory investigations disclosed an inflammatory syndrome, evidence of hepatic dysfunction, bone marrow suppression and a raised serum ferritin level of 34,674 ng/ml. A rapidly deteriorating course of illness prompted treatment based on a presumptive diagnosis of adult-onset Still’s disease until liver histology was available. The patient died of sepsis followed by multi-organ dysfunction. Later, the liver histology revealed tuberculosis.ConclusionExtrapulmonary tuberculosis, although well known to present with peculiar manifestations, has not been reported to be associated with extremely high levels of serum ferritin in immunocompetent individuals. Isolated hepatic tuberculosis presenting with clinical criteria of adult-onset Still’s disease is remarkable. Since tuberculosis remains a potentially curable disease, an awareness of its’ protean manifestations is essential.

NOT YOUR USUAL PULMONARY NODULE: CASE OF PULMONARY MALTOMA

The occurrence of cholangiocarcinoma following choledochal cyst excision is a rare clinical entity. In cases with extensive lymphadenopathy, where poor oncologic prognosis is anticipated, immune checkpoint inhibitors have recently shown promise as a therapeutic approach in biliary tract cancer. We describe a case involving successful minimally invasive pylorus-preserving pancreaticoduodenectomy in this unusual patient, following neoadjuvant immune chemotherapy. A 44-year-old female, who had previously undergone bile duct excision for choledochal cyst on November 28, 2022, presented with abdominal pain in July 2024. Imaging revealed an 8-cm mass in the pancreatic head, with multiple metastatic lymph nodes noted in the epigastrium, mesentery, retroperitoneum, and both common iliac chains. Endoscopic ultrasound-guided biopsy identified atypical cells with necrosis suggestive of poorly differentiated carcinoma, but immunohistochemistry did not confirm pancreatic origin. Positron emission tomography-computed tomography revealed absence of additional primary malignancy, though it showed multiple enlarged lymph nodes and findings indicative of possible peritoneal seeding. Considering the patient’s prior history of choledochal cyst resection and extensive perihilar lymphadenopathy, a diagnosis of cholangiocarcinoma was favored. Neoadjuvant chemoimmunotherapy with durvalumab, gemcitabine, and cisplatin was administered across 11 cycles. Subsequent imaging demonstrated significant tumor regression, prompting surgical exploration on April 11, 2025. Intraoperatively, extensive adhesions surrounding the hepaticojejunostomy and pancreas were encountered. Pancreaticoduodenectomy was completed utilizing the pre-existing Roux limb for pancreaticojejunostomy. Frozen section analysis of the peritoneum and mesentery was negative for malignancy. Final histopathology confirmed complete remission. This case highlights the potential feasibility and safety of minimally invasive surgery in this rare clinical scenario.

Granulocyte-colony stimulating factor in COVID-19: Is it stimulating more than just the bone marrow?

A RARE CASE OF DISSEMINATED MYCOBACTERIAL SEPTICEMIA (LANDOUZY SEPTICEMIA) IN AN HIV-NEGATIVE PATIENT