Extrapulmonary Tuberculosis in Saudi Arabia.

Abstract

Original ArticlesExtrapulmonary Tuberculosis in Saudi Arabia.A Review of 162 Cases John R. L. Froude and MB BS, MRCP Michael KingstonMD, FRCP John R. L. Froude Internist, Department of Medicine Search for more papers by this author and Michael Kingston Internist, Department of Medicine Search for more papers by this author Published Online::1 Apr 1982https://doi.org/10.5144/0256-4947.1982.85SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutABSTRACTABSTRACTA review of 162 patients with active tuberculosis seen at the King Faisal Specialist Hospital and Research Centre between January 1979 and April 1981 was carried out. Patients with classical pulmonary disease were excluded from the study. The diagnosis was established by culture, smear, or histology in 130 patients and on clinical grounds in 32 patients. Of the latter group, ten had cerebral tuberculoma, nine had meningitis, five had isolated mediastinal lymphadenopathy, and eight had disease elsewhere.Of all the patients, approximately one-half had no evidence of weight loss, fever, raised sedimentation rate, anemia, or hypoalbuminemia. The tuberculin skin test was positive in 78 of 144 patients.Disease involved the central nervous system in 58 patients, tuberculoma in 21, spinal cord in 20, and meningitis in 17 patients. Gastrointestinal disease occurred in 26 patients, cervical lymphadenopathy in 26, disseminated disease in 22, isolated mediastinal lymphadenopathy in ten, involvement of the genitourinary tract in eight, peripheral joints in six, pericardium in five, and skin in one.Tuberculosis is common in Saudi Arabia and a trial of antituberculous drugs is warranted when it is suspected even in the absence of a definitive diagnosis. This applies, particularly, to patients with meningitis and disseminated infection. Superinfection with pyogenic organisms may complicate tuberculosis.The use of computerized tomographic scanning, fiberoptic endoscopy, laparoscopy, ultrasound, and liver biopsy have reduced patient morbidity and simplified the diagnosis and management of extrapulmonary tuberculosis.INTRODUCTIONTuberculosis is the single most important infectious disease in Saudi Arabia. In the past 27 months, 162 patients with TB were seen at the King Faisal Specialist Hospital and Research Centre, not including those with classical pulmonary tuberculosis. The diagnosis was delayed in many patients, often due to unusual presentations.The disease was frequently seen in patients with normal chest radiographs and normal, routine laboratory examinations.This study reviews the variety of clinical presentations and the diagnostic difficulties encountered.MATERIALS AND METHODSThe charts of 162 patients with tuberculosis referred to this Hospital between January 1979 and April 1981 were reviewed. There were 85 males and 77 females. Of those whose ages could be accurately assessed, the range was 12 to 95 years for men (mean 42) and 16 to 72 years for women (mean 34). Table 1 shows the general clinical features, chest radiographic findings, hemoglobin, erythrocyte sedimentation rate (ESR), albumin level, and TB skin test results. The highest temperature was recorded before antituberculous treatment was started at this Hospital.Table 1.Major chest radiographic abnormalities were infiltrates, cavities, pleural effusions, and miliary mottling. Minor chest radiographic abnormalities were those associated with inactive infection such as apical pleural scarring, streaky fibrosis of the kind seen with a healed Ghon focus, and calcified lymphadenopathy. If these minor features increased on subsequent films or if acid-fast bacilli were found in the sputum, these changes were reclassified as major.Patients with active pulmonary tuberculosis of the classical type, namely apical fibrocaseous disease, lung abscess, or bronchopneumonia with a positive smear or culture, without evidence of disease elsewhere were excluded from this study. Patients diagnosed as suffering from tuberculous pleural effusion or tuberculoma appearing as a coin lesion on the radiograph were also excluded.RESULTSTable 1 shows that approximately 50 percent of all patients had no weight loss or fever by history and less than one-half were underweight. The chest radiographs were normal in 63 percent of cases and showed minor change of inactive disease in a further 16 percent. Radiographic evidence suggesting active tuberculosis was found in only 21 percent of patients. An ESR of more than 30 mm/hr Wintrobe, anemia, and hypoalbuminemia were present in less than one-half of the patients. The tuberculin skin tests were negative in 50 percent of patients on whom the tests were done.In particular, patients with lymph node tuberculosis and central nervous system (CNS). tuberculomas had a low frequency of weight loss, fever, elevated sedimentation rate, anemia, and abnormal chest radiographs. These investigations were more commonly abnormal in patients with meningitis and disseminated tuberculosis.PRESENTATION AND DIAGNOSISIntracranial TuberculomaOf the 21 patients with CNS tuberculomas, seven presented with grand mal epileptic seizures, five with stroke, four with impaired vision, four with confusion, and one with dementia. All complained of headaches.All 21 patients had computerized tomographic (CT) brain scans which showed mass lesions, large amounts of edema, and ring enhancement. Figure 1. All 12 patients studied angiographically showed avascular mass lesions.Figure 1A and B. CT head scan: (a) unenhanced, (b) enhanced, showing tuberculoma of the brain.Download FigureCerebrospinal fluid was abnormal in six patients and Mycobacterium tuberculosis was found on a smear in one patient and cultured in another five.The diagnosis of tuberculoma was established in 11, six at surgery, and another five by cerebrospinal fluid (CSF) culture. In ten patients the diagnosis was made on clinical grounds associated with typical CT brain scan findings and an angiograph showing an avascular mass lesion.Spinal Cord TuberculosisSeventeen of 20 patients had spinal cord damage secondary to vertebral involvement and the diagnosis was made in all patients by histological and bacteriological examination of material obtained at surgery or by needle aspiration.Three of 20 patients had arachnoiditis and presented with spinal cord (two patients) or cauda equina (one patient) compression without evidence of bone or disc involvement. This was diagnosed by finding typical myelographic features, a moderate increase in the white cell count with a lymphocyte predominance, elevation of the protein, and a low or low-normal CSF sugar. Clinical recovery on antituberculous drugs was complete in one case and partial in two.MeningitisAll 17 patients with meningitis also had fever. Nine presented with headache, five with confusion, and three in coma. Neck stiffness was absent in nine patients. Hyponatremia (Na+ 100 to 130 meq/l) was found in ten patients and two of these, who had had adrenal failure, recovered during treatment.The diagnosis was confirmed in nine patients only. Five had positive CSF smears and three had positive cultures. The diagnoses were made on clinical grounds in the other nine patients in association with the lymphocytosis, elevated protein, and low or low-normal sugar in the CSF. All of these patients recovered on antituberculous treatment.Gastrointestinal TuberculosisOf the 26 patients with gastrointestinal TB, eight presented with epigastric pain, six with abdominal masses, five with ascites, four with vague abdominal pain, and three with small bowel obstruction. Constipation was a complaint in six patients and diarrhea in four patients.The bowel lumen was diseased in 15 patients, colon only in six, small bowel only in four, both in three, and the stomach in two. Peritonitis occurred in an additional nine patients and isolated abdominal lymphadenopathy in two others. All were diagnosed histologically from tissue obtained during fiberoptic endoscopy (11 patients), laparoscopy (eight patients), and laparotomy (seven patients).Cervical LymphadenopathyOf the 26 patients with cervical lymphadenopathy, only eight had fever or weight loss. Cold abscesses were found in eight patients. This diagnosis was established in 24 patients; caseating granulomas were seen histologically in 21 patients, culture was positive in three of six patients, acid-fast bacilli were seen in pus from four of the patients with cold abscesses and in two of the 20 lymph nodes examined. The two patients without established diagnoses had enlarged cervical lymph nodes and strongly positive TB skin tests. Both responded to treatment. A second lymph node biopsy was necessary in three patients for confirmation of the diagnosis.Mediastinal LymphadenopathyTen patients presenting with the symptoms of fever and weight loss had mediastinal lymphadenopathy. Four had caseating granulomas in tissue obtained by mediastinoscopy and one by thoracotomy. The other five were diagnosed clinically and responded to antituberculous drugs.Disseminated TuberculosisOf the 22 patients with disseminated TB all had fever. Fourteen had miliary mottling on chest radiograph and eight did not. Sputum smears were positive in four of eight patients and, of the six patients studied, five had positive cultures. In liver biopsies taken from six patients, five showed caseating granulomas with Langhans' giant cells.Genitourinary DiseaseTwo women presented with genital tuberculosis, primary infertility in one case and pelvic mass in the other. Both were diagnosed during laparotomies when tuberculous salpingitis was found. Smears and cultures were positive in both and histology showed granulomas in one.Of the eight patients with renal disease, three presented in chronic renal failure, one presented with frequency, one with dysuria, and one with proteinuria.Six patients had positive smears for acid-fast bacilli in the urine. Only three of these were cultured and were all positive. Two patients had acid-fast bacilli demonstrated by renal biopsy with the presence of granulomas. Neither biopsy was cultured.Peripheral ArthritisOf the six patients with peripheral joint tuberculosis, five presented with a progressive monoarthritis involving the knee in two cases and the ankle, hip, and wrist in one case each. One patient had polyarthritis.Joint aspirate provided a positive smear and culture in five of six patients and synovial granulomas were seen in the biopsy results of two patients.PericarditisAll five patients had symptoms and signs of heart failure. Two patients had constrictive disease and three had pericardial effusions.Granulomas of the pericardium were found in three patients at surgery and in one case, acid-fast bacilli were seen in the smear of pericardial fluid. In this and one other case, acid-fast bacilli were cultured. In two cases the presence of pericardial exudate plus recovery after antituberculosis chemotherapy was taken as clinical evidence of the disease.SkinThere was one case of lupus vulgaris diagnosed, clinically, and confirmed by biopsy results.CASE REPORTSCase 1A 46-year-old Saudi Arabian male was transferred from a psychiatric hospital with a six-week history of fever, confusion, and headache. His chest radiograph was normal and this tuberculin skin test was positive. Computerized tomographic scan showed a tuberculoma and he was completely cured with rifampicin, isoniazid, and ethambutol. Figures 1a and b.Case 2A 37-year-old Saudi Arabian male with a two-year history of nonspecific pain with marked weight loss was found to have a large, tender, epigastric mass. Chest radiograph was normal and tuberculin skin test was negative. Ultrasonographic examination showed massive enlargement of the abdominal lymph nodes. Figure 2. Pus was aspirated from one node during laparoscopy, the smear showing acid-fast bacilli.Figure 2. Ultrasonogram showing abdominal lymph node enlargement.Download FigureCase 3A 46-year-old Saudi Arabian male was admitted to the Hospital with a three-week history of breathlessness and fever. His chest radiograph showed miliary mottling. Figure 3. Liver biopsy showed granulomas with Langhans' giant cells. Figure 4. He was treated with rifampicin, isoniazid, and ethambutol and was discharged five weeks later, afebrile and with a clear radiograph.Figure 3. Chest radiograph with miliary mottling.Download FigureFigure 4. Tissue from a liver biopsy showing caseating granuloma with Langhans' giant cells. Hematoxylin and eosin stain.Download FigureCase 4A 22-year-old Saudi Arabian male driver presented with a six-week history of malaise, low-grade fever, and weight loss. Examination and routine investigations were normal except that his tuberculin skin test was positive and chest radiograph showed mediastinal lymphadenopathy. Figure 5. The lymph node biopsy taken at mediastinoscopy showed granulomas and the patient recovered completely on treatment with rifampicin, isoniazid, and ethambutol.Figure 5. Chest radiograph showing mediastinal lymphadenopathy.Download FigureCase 5A 12-year-old boy presented with a one-year history of joint pain and swelling affecting many joints. Figure 6a and B. Aspirated pus showed acid-fast bacilli.Figure 6A and B. Tuberculous polyarthritis.Download FigureCase 6A 38-year-old Saudi Arabian male driver had been treated intermittently, and erratically, for tuberculosis for over 12 years at different institutions. His chest radiograph showed wide-spread destruction of both lungs with several persistent fluid levels. His tuberculin skin test was positive and there were resistant acid-fast bacilli in his sputum. Over the six months before admission to this Hospital, a sore had appeared and gradually ulcerated his nose. Figure 7. Biopsy results showed inflammatory cells, poorly formed granulomas, and scanty acid-fast bacilli.Figure 7. Lupus vulgaris.Download FigureDISCUSSIONAn average of six new patients with pulmonary tuberculosis were seen every month at the King Faisal Specialist Hospital in the 27 months of this study. Although Hospital statistics may not reflect the incidence of the disease in the general population, it seems likely that tuberculosis is common in the Kingdom of Saudi Arabia. The pattern of disease seen here is similar to that reported in non Western countries and in Asian emigrants to the United Kingdom.2Extrapulmonary tuberculosis may be diagnosed late, as in many of the patients in this series, as fever, weight loss, anemia, a raised ESR, hypoalbuminemia, and abnormal chest radiograph are often absent.3 This is especially true of patients with cerebral tuberculomas and cervical lymphadenopathy. Fifty percent of all patients had negative tuberculin skin tests, the causes of which are well documented.4 Moreover, a positive test is unhelpful in countries where the disease is common. The commonest form of extrapulmonary disease occurred in the central nervous system.MeningitisThe most difficult management problems were found in patients with tuberculous meningitis. Cerebrospinal fluid smears for acid-fast bacilli are initially negative in 80 percent of patients.5 The positive yield may be increased by repeated spinal taps and cultures, yet treatment cannot be delayed to await results as prognosis relates closely to the duration of symptoms and to the level of consciousness at the onset of therapy.5 In these circumstances it is essential that antituberculous drugs be given on clinical suspicion alone.Several patients were referred with delayed diagnoses. There are two main reasons for this. Firstly, the illness is attributed to an already diagnosed condition such as hepatic encephalopathy, head injury, or viral meningitis. Secondly, although fever was almost always present, neck stiffness and other general symptoms of infection were absent. A rapid form of the disease mimicking pyogenic meningitis may occur and in rare instances CSF laboratory data may be normal.5Hyponatremia (less than 130 meq/l) may confuse the clinical picture by further depressing the patient's level of consciousness or by causing convulsions. This occurred in over 50 percent of the patients with tuberculous meningitis. Adrenal failure, although uncommon, is the most important, readily treatable cause of hyponatremia, others being malnutrition, overtransfusion with water, renal disease, and the syndrome of inappropriate ADH secretion.5Early ventricular shunting may save the lives of patients with hydrocephalus due to tuberculous meningitis and if cerebral edema cannot be rapidly reversed by medical treatment the patient should be transferred to a center where neurosurgical facilities are available.6,7TuberculomaTuberculomas, although rare in the United States, represent up to 20 percent of intracranial tumors in countries where tuberculosis is widespread.8–10 Fever and weight loss are often absent, and one-half of the patients will have normal chest radiographs.9–11 Intracranial tuberculoma must be considered in the differential diagnosis of headache, rapid deterioration of vision, epilepsy of recent onset, and stroke. In the past a definite diagnosis could only be made at surgery or autopsy.12The advent of computerized tomographic scanning has made diagnosis simpler as the appearance of a mass lesion and abundant cerebral edema with ring enhancement is highly suggestive of tuberculoma especially if there are multiple lesions; angiography shows an avascular tumor. Together with a careful clinical assessment these findings make treatment with antituberculous drugs a reasonable alternative to craniotomy.Vertebral TuberculosisTuberculosis of the vertebral column and spinal cord is as common as tuberculoma or meningitis. Pott's disease has been discussed recently in this Journal.13 Arachnoiditis or radiculomyelitis, however, may cause paraplegia or cauda equina symptoms and signs even in the absence of bone or disc involvement.14Gastrointestinal TuberculosisOf patients with disease involving the bowel, we found constipation commoner than diarrhea unlike other reports.15,16 Other symptoms are often absent apart from vague abdominal pains which may lead to the diagnosis of the irritable bowel syndrome. Patients may, however, present with the features of intestinal obstruction.The colon was most frequently involved with circumferential lesions resembling carcinoma seen on barium enema test results. Gastroduodenoscopy and colonoscopy are proving to be increasingly useful in avoiding the risks of laparotomy.Intra-abdominal lymphadenopathy can present as a large mass without involvement of the gut and peritoneal tuberculomas may or not be associated with ascites. Laparoscopic examination has proven to be the most valuable and least traumatic method of diagnosis in our experience.Disseminated TuberculosisDisseminated tuberculosis follows reactivation of a healed primary focus with hematogenous spread and usually presents as a fever of unknown origin. It must be considered in patients with cirrhosis of the liver and systemic lupus erythematosus, which are common conditions in Saudi Arabia.3, 17 Miliary mottling on the chest radiograph strongly suggests the diagnosis but is often absent for the first six weeks of the illness. Smears taken from the sputum, urine, CSF, bone marrow, material obtained from skin abscesses, lymph nodes, and pleural and peritoneal fluids to test for acid-fast bacilli may sometimes give positive results.3, 18–21 An important diagnostic clue is finding hepatic granulomas in a biopsy.18 Tuberculosis is the commonest cause of granulomatous hepatitis in this environment. Of the others brucellosis, particularly, should be excluded. If the granulomas show caseation and the presence of Langhans' giant cells, the probability of tuberculosis increases. Acid-fast bacilli are rarely seen on tissue biopsy but when present they prove the diagnosis.Disseminated tuberculosis has a 20 to 30 percent mortality rate even with adequate treatment. Hypoxemic respiratory failure is the commonest cause of death, which may occur unexpectedly.18 Superadded pneumonia, pulmonary emboli, pulmonary edema, and adrenal failure were complications seen in this series.Response to treatment is slow. Fever usually takes two to eight weeks to resolve, and although radiographic changes generally clear within one month, they may persist for three months.19 Hypoxemia and impaired carbon monoxide diffusing capacity may not return to normal for several months after the radiograph has cleared.18 This slow resolution may mask other infections.Tuberculous LymphadenopathyTuberculous lymphadenopathy is a common yet less severe form of the disease than those previously mentioned. Single or multiple disease nodes have been found in almost every site but the most usual is the neck. The important differential diagnosis is lymphoma and, in this Hospital, papillary carcinoma of the thyroid; indeed these conditions may coexist with tuberculosis and for this reason biopsy is important. Sometimes, biopsy must be repeated to confirm the diagnosis. Superinfection with staphlococci occasionally complicates the clinical picture.Isolated tuberculous mediastinal lymphadenopathy in adults is rare in the United States yet is common here.22 Conversely, lymphoma and malignant metastases are uncommon in Saudi Arabia and sarcoid is rare. In some cases a trial of therapy with antituberculous drugs is an acceptable alternative to mediastinoscopy or thoracotomy when there is close out-patient supervision.CONCLUSIONBecause tuberculosis is common in Saudi Arabia and presents in so many ways it should be considered in the differential diagnosis of every patient seen. Late diagnosis of this curable disease is a tragedy and treatment should be started whenever the disease is suspected. Modern techniques of investigation have simplified diagnosis, particularly CT scanning for tuberculoma and fiberoptic endoscopy, laparoscopy, ultrasound, and liver biopsy for gastrointestinal and disseminated disease.ARTICLE REFERENCES:1. 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Dhand S, Fisher M, Fewell JW: "Intrathoracic tuberculosis lymphadenopathy in adults" . JAMA 241 (5): 5051979. Google Scholar Previous article Next article FiguresReferencesRelatedDetailsCited byBazaz M, Hossain J, Ashkar K and Bokhari M (2019) An Unusual Case of Abdominal Pain: Pancreatic Tuberculosis, Annals of Saudi Medicine , 11:2, (226-227), Online publication date: 1-Mar-1991. Volume 2, Issue 2April 1982 Metrics History Published online1 April 1982 KeywordsTuberculosisTuberculomaACKNOWLEDGEMENTSThe authors would like to thank Dr Nicholas J. Y. Woodhouse, Endocrinologist, Department of Medicine, King Faisal Specialist Hospital and Research Centre, for the time and effort he contributed in the preparation of this article.InformationCopyright © 1982, Annals of Saudi MedicinePDF download