Acid-fast Bacilli Staining Research Articles

Utility of smear microscopy and GeneXpert for the detection of Mycobacterium tuberculosis in clinical samples

Rapid identification of Mycobacterium tuberculosis (MTB), its resistance to rifampicin and differentiation of MTB from nontuberculous mycobacteria (NTM) is necessary in the management of mycobacterial diseases. Culture, the "gold standard" for the detection of MTB, is time consuming. In spite of its rapidity and low cost, smear microscopy has poor sensitivity for the detection of acid-fast bacilli (AFB). A real-time PCR based rapid diagnostic method like GeneXpert MTB/RIF assay can simultaneously detect M. tuberculosis and rifampicin (RIF) resistance. Hence, we aim to compare the performance of GeneXpert MTB/RIF assay with smear microscopy and culture. In this descriptive cross-sectional study, we compared the performance of GeneXpert in pulmonary (N=127) and extrapulmonary (N=48) clinical specimens with other diagnostic methods like culture, Auramine O (AO), and Ziehl Neelsen (ZN) staining. Rifampicin resistance was detected only by GeneXpert. Demographic data and clinical history of the subjects were collected from the patient's hospital records. AO and ZN staining when compared with mycobacterial growth indicator (MGIT) culture showed the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of 68.6, 95.7, 80, 92.4, 90.3% and 65.7, 95.7, 79.3, 91.8, 89.7%, respectively. The sensitivity, specificity, PPV, NPV and accuracy of GeneXpert was 88.6, 93.6, 77.5, 97.0 and 92.6%, respectively. GeneXpert is the best available rapid diagnostic method as it can detect MTB and rifampicin resistance gene simultaneously. Accuracy and negative predictive value of GeneXpert was found to be better than AFB staining. Thus, a negative GeneXpert test can rule out TB. Further, a negative GeneXpert and a positive smear microscopy results indicate the presence of NTM. However, GeneXpert is expensive and needs sophisticated instrument when compared to smear microscopy.

Granulomatous Tubercular Hepatitis Presenting as Secondary Hemophagocytic Lymphohistiocytosis: A Case Report and Systematic Review of the Literature

Hemophagocytic lymphohistiocytosis is a life-threatening disorder characterized by persistent pathologic activation of cytotoxic T lymphocytes, natural killer cells, and macrophages. We present details of a young patient who presented with high-grade fever, jaundice, and breathlessness. On investigations, he had hepatitis, anemia, neutropenia, and coagulopathy. He also had hypertriglyceridemia, hypofibrinogenemia, and hyperferritinemia. Bone marrow aspiration revealed histiocytosis, and transjugular liver biopsy revealed necrotizing granulomas positive for Mycobacterium tuberculosis on acid-fast bacilli staining. He was successfully managed with a combination of immunosuppressants and antitubercular therapy. Tuberculosis associated hemophagocytosis syndrome is rare and should be considered in patients with unexplained hemophagocytosis syndrome, especially in tuberculosis-endemic regions. Prompt recognition and treatment with antitubercular treatment and immunosuppressants are associated with good outcomes.

Surgical Site Infections Caused by Rapidly Growing Nontuberculous Mycobacteria: an Under-Recognized and Misdiagnosed Entity

Rapidly growing nontuberculous mycobacteria (NTM) such as M. fortuitum and M. chelonae are ubiquitous; have been isolated from natural water, tap water, and water used in showers in hospitals; and can cause surgical site infections. A retrospective chart review at a tertiary care referral hospital was carried out. Patients with SSI in whom wound cultures grew rapidly growing NTM or histopathological examination (HPE) showed granulomatous inflammation were included. A total of 50 patients were analyzed. Thirty-one patients had had laparoscopic surgery, and nineteen had had open surgery. Average time of presentation after surgery was 40 days (range 7 to 90 days). Clinical features included delayed wound healing, chronic discharge at the surgical site, nodular swelling, and sinus tract formation. Histopathology showed granulomatous inflammation in 40 patients with acid-fast bacilli stain positive in 2 patients. Mycobacterial culture was positive in 16 patients: 12 grew M. fortuitum, 2 grew M. abscessus, and 2 had rapid growers that could not be speciated further. Six of these sixteen culture-positive cases also had histopathology showing granulomatous inflammation. All isolates were sensitive to clarithromycin, amikacin, levofloxacin, imipenem, and tigecycline. Forty-two patients received surgical debridement in addition to medical management. Eight patients were treated with medical management alone since they had small nodular lesions or minimal discharge. Medical therapy was with clarithromycin and either levofloxacin or moxifloxacin for 4–6 months, with amikacin for the first 2 months. Of the 50 patients, forty-two recovered completely, 7 were on follow-up and doing well clinically, and one patient was lost to follow-up. Rapidly growing NTM infection should be suspected in patients with delayed onset SSI or chronic discharging sinuses, especially after laparoscopic surgery. The diagnosis can be confirmed by mycobacterial culture and HPE. Response is usually good with surgical debridement, followed by a combination of clarithromycin, quinolones, and amikacin for 4–6 months.

Clinico-pathological spectrum of cutaneous sarcoidosis: an experience from a government institute in North India.

Background and aimsSarcoidosis is a multisystem granulomatous disease of unknown etiology and cutaneous involvement is the second most frequent manifestation in systemic sarcoidosis.The aim of the present study is to evaluate the clinical and pathological spectrum of cutaneous sarcoidosis and compare the same with literature available.MethodsThe present retrospective study was conducted from January 2010–March 2015 and fifteen cases diagnosed as cutaneous sarcoidosis on biopsy were reviewed. The histological spectrum of cutaneous sarcoidosis was evaluated.ResultsThe mean age at diagnosis was 46 years. Nine (60%) cases out of 15 were females. Most common cutaneous lesions were nodules (46.6%) followed by papules (40%). Classically, lymphocyte-poor, non-caseating epithelioid cell granulomas, was the most common histologic finding. Inclusion bodies were seen in 20% cases with occasional presence of fibrinoid necrosis (13.3%). Peri-adnexal granuloma, seen in one case, raised the possibility of tuberculoid leprosy. Foreign body was seen in one case supporting the opinion that sarcoidosis and granulomatous foreign body reaction are not mutually exclusive. Epidermal changes including atrophy, loss of rete pegs, acanthosis, papillomatosis, hyperkeratosis, parakeratosis and basal cell vacuolation were seen in 46.6% cases. Reticulin was positive in all the cases while special stains for acid fast bacilli and fungi were negative.ConclusionThe clinical presentation of cutaneous sarcoidosis may be variable. Presence of naked, reticulin-rich granulomas is the most characteristic histopathological finding. Correlation of clinical history with histologic examination is essential to exclude other granulomatous diseases including leprosy, syphilis, other infectious granulomatous diseases and foreign body reaction.

SAT-339 Calcium Level in a Patient with Rhabdomyolysis. A Tale of Two Phases

Background: Calcium kinetics can be challenging during the different phases of rhabdomyolysis1. We herein report a case of sever hypercalcemia refractory to hemodialysis following a period of hypocalcaemia that developed in a patient with rhabdomyolysis. Case: A 27-year-old male patient was diagnosed with meningoencephalitis complicated with septic shock, continuous seizures, rhabdomyolysis, acute kidney injury and oliguria. His creatinine was 219 μmol/L (53–115), urea was 8 mmol/L (2.5–6.4). Creatine kinase (CK) was significantly high above assay range. Corrected serum calcium was 1.82 mmol/L (2.12- 2.52), phosphate was 0.48 mmol/L (0.81–1.58). He required intermittent sessions of hemodialysis and antibiotics therapy which both have been initiated since the first day of admission. Initially he had hypocalcaemia but as rhabdomyolysis improved, his calcium levels started to rise to reach normal levels by day 13 post admission. By day 16, he started to gradually develop hypercalcemia. Initially, it was 2.73 mmol/L and in another 10 days it was 3.39 mmol/L and reached maximum of 3.90 mmo/L despite the intermittent dialysis sessions. PTH was supressed at 0.62 Pmol/L. Over that time, his renal functions and urine output were gradually improving.The clinical impression was PTH independent hypercalcemia and the work up for that was initiated. CT chest, abdomen and pelvis did not reveal any suspicious masses, lytic bone lesions, or lymphadenopathies. His acid fast bacilli stain and culture were both negative. His chest imaging did not show any findings to suggest sarcoidosis. TSH was normal and random cortisol was 339.2 nmol/l with albumin 20g/L. HIV serology came back negative.He received Calcitonin 500 IU BID for three days and Denosumab 120 mg SC in order to control the hypercalcemia along with, cautious intravenous hydration. Within one week after Denosumab therapy, serum corrected calcium decreased to 3.07 mmol/L. After another week, corrected calcium reached 2.53 mmol/L. When his urine output improved further and his calcium levels dropped, hemodialysis was discontinued. His calcium level later normalised to 2.49 mmol/L.After ruling out the common differential of PTH independent hypercalcemia, and from the diuretic phase the patient went through with concomitant hypercalcemia following hypocalcaemia, it was concluded that the cause of hypercalcemia was rebound hypercalcemia following rhabdomyolysis recovery. Conclusion: hypercalcemia can complicate the recovery phase of rhabdomyolysis. Careful monitoring of calcium levels and management are warranted.

MON-482 Thyroid Tuberculosis - An Unlikely Diagnosis

Background: Mycobacterium tuberculosis (MTB) is an aerobic bacillus responsible for the most cases of tuberculous infection. Approximately one-third of the world’s population is infected. Tuberculosis (TB) of the thyroid gland is an unusual diagnosis with an estimated prevalence of 0.1 to 0.6%. The thyroid TB can mimic different pathologies (thyroid neoplasms, lymphoma, infectious or granulomatous thyroiditis, Graves’ disease or bacterial abscess) and the diagnosis can be easily disregarded, especially in non-endemic countries and if the patient doesn’t have systemic symptoms. The fine needle aspiration and histopathological examination, with acid-fast bacilli staining and TB culture, are the gold standard exams.Clinical Case: A 71-year-old female was referred to our Endocrinology department after a diagnosis of nodular thyroid disease. She had complaints of slight cervical discomfort, with 6 months of duration. She hadn’t personal or familiar relevant antecedents. At observation, a movable, elastic and non-tender nodule of 15mm at the right superior thyroid lobe was identified. Blood tests including a thyroid profile were normal. The neck ultrasound showed, at the right lobe of the thyroid, multiple solid nodules; the dominant had 18mm, was heterogeneous and had multiple calcifications. Moreover, lymph nodes with suspicious ultrasonographic features along the right internal jugular chain were reported. The patient underwent fine-needle aspiration (FNA) of the suspicious thyroid nodule and one lymph node. Results were respectively: non-diagnostic (Bethesda I) and reactive pattern. FNA was repeated on a different occasion and results were similar. Due to ultrasound suspicious of malignancy, a total thyroidectomy was performed and a lymph node from level IV was sampled for extemporaneous examination. Necrotizing granulomas were documented; the Ziehl-Neelson staining (ZNS) was negative; material was sent to microbiology. Following this finding, ganglion emptying was not performed. The thyroid histology showed tuberculoid type granulomas with lymphoid border and central necrosis. However, the ZNS was negative. The diagnosis was definitely established by a positive culture of the lymph node tissue and molecular detection, by polymerase chain reaction (PCR), of MTB. Pulmonary involvement was excluded and she started antituberculous agents planned for 9 months (rifampicin and isoniazid during 9 months and ethambutol and pyrazinamide for 2 months).Conclusion: Thyroid TB is a rare presentation of extrapulmonary tuberculosis. In presence of systemic or specific complaints or history of exposition the diagnosis may be suspected and confirmatory tests requested in order to ensure an adequate treatment. However, sometimes, histopathology remains a key step and the use of cultures improves the sensitivity and specificity of TB tests.

Evidence of Systemic Responses to Viral Pathogens using Malondialdehyde, Tumor Necrosis Factor Alpha and Superoxide Dismutase

Background and Aim: Infectious agents are triggers of oxidative stress and inflammation. This work was designed to determine evidence of systemic responses to viral pathogens using malondialdehyde, tumor necrosis factor alpha and superoxide dismutase. Methods: The subjects recruited for this study include 23 HCV mono-infected volunteers (aged 24-67 years; Male-10; Female-13), 30 HBV mono-infected volunteers (aged 24-67 years; Male-15; Female-15), 18 HIV mono-infected volunteers (aged 24-67 years; Male-8; Female-10), 23 Viral (HCV, HIV, HBV) Co-infected volunteers (aged 24-67 years; Male-10; Female-13) and 50 age matched control volunteers who were not infected with HCV, HIV or HBV (Female-25; Male-25). Subjects tested negative to Acid Fast Bacilli (AFB) and Plasmodium tests were recruited. Test subjects who have not initiated antiviral therapy were recruited for the study. Five milliliters of venous blood was obtained from each of the subjects into lithium heparinized bottles for the assay of HCV, HIV, HBV, TNFα by ELISA, SOD, MDA by Colorimetry, Giemsa thick blood film staining for plasmodium while sputum samples were obtained from each of the subjects for Ziehl Neelsen staining for Acid Fast Bacilli(AFB). Results: There was a significant increase in plasma MDA and TNF α in patients with viral co-infection compared with control and patients with mono-infections of HCV, HBV and HIV (p<0.05). There was a significant decrease in plasma SOD in patients with viral co-infection compared with control and patients with mono-infection of HBV (p<0.05; Table 1, 2; Figure 1, 2). The result also showed a significantly lower plasma SOD in patients with viral co-infection, mono-infection of HIV, HCV and HBV than the results obtained in the control subjects (p<0.05). There was a significant increase in plasma TNF-α in patients with viral co-infection compared with control and patients with mono-infections of HCV, HIV and HBV (p<0.05). The result also showed a significantly higher plasma TNF-α in patients with viral co-infection, mono-infection of HIV, HCV and HBV than the results obtained in the control subjects (p<0.05). Conclusion: The work revealed a significant evidence of systemic responses to viral pathogens as indicated by increased plasma malondialdehyde, tumor necrosis factor-alpha, and decreased plasma superoxide dismutase in viral mono and coinfections.

MICROBIOLOGICALLY PROVEN CASE OF PRIMARY BREAST TUBERCULOSIS

Tuberculosis (TB) of the breast is an uncommon presentation of extrapulmonary TB, it is uncommon even in countries where the incidence of pulmonary and extrapulmonary TB is high and its diagnosis is challenging due to non-specific clinical and imaging findings and often misdiagnosed as abscess or carcinoma. It is mainly diagnosed on the basis of histopathological examination. We have reported a case of primary TB of breast diagnosed by microbiological investigations. A 19-year-old female presented with a painful lump in the breast for the past 3 months. Primary breast TB was diagnosed by sample collect by fine-needle aspiration cytology, wherein Ziehl–Neelsen stain for acid-fast bacilli and cartridge-based nucleic acid amplification test were positive. The patient received antitubercular drugs and at 4 months follow-up, the swelling had resolved and the patient was asymptomatic.

Molecular detection of Mycobacterium leprae using RLEP-PCR in post elimination era of leprosy.

Leprosy is considered as a contagious disease and is still a health problem in several countries including India. Diagnosis of leprosy is based either on clinical findings or on acid fast bacilli staining. Due to low sensitivity of acid fast bacilli staining most of the leprosy cases were remained undetected. The present study aims to assess the efficacy of RLEP-PCR in the field condition where majority of the patients are acid fast bacilli negative and have early disease. A total of 80 suspected leprosy cases were recruited. Slit skin smear samples were taken for microscopy and molecular experimentation. DNA was extracted and RLEP-PCR was executed for all the 80 samples. To establish the statistical correlation χ2 test and Fisher's exact test were made. To elucidate the sensitivity of the test Receiver Operating Characteristic (ROC) was drawn. These 80 leprosy patients comprised of 38 paucibacillary and 42 multibacillary leprosy cases. Of 80 leprosy patients 18 (22.5%) were AFB positive while 53 (66.25%) leprosy cases were RLEP-PCR positive. The results of test of significance (P=0.0001) and Cohen's kappa coefficient(κ) (0.614) indicated that the RLEP-PCR is a better diagnostic tool over AFB microscopy in case detection of leprosy. From the findings we concluded that RLEP-PCR could be used for the definitive detection of leprosy cases in accordance with the clinical findings in the field condition in the post elimination era of leprosy.

A278 TB OR NOT TB OF THE PANCREAS

Abstract Background Pancreatic TB is a rare clinical presentation which has proved difficult to diagnose. Its symptomatology and imaging characteristics mimic neoplastic findings. Aims We present the case of a previously healthy 58-year-old man, from an endemic area who presented with epigastric pain caused by pancreatic TB. Methods Case report and review of literature Results A previously well 58-year-old male presented to the emergency room with severe epigastric pain, without fevers or significant weight loss. He had immigrated to Canada from the Philippines in 2001. He denied a personal history of TB, however, he did report that his father had received treatment for active TB. An abdominal CT revealed intrahepatic and extrahepatic bile tree dilation with an abrupt transition in the pancreatic head, possible stricture, as well as mucosal thickening of the duodenum at the level of the abrupt narrowing of the dilated common bile duct, concerning for malignancy. Initial laboratory investigations revealed WBC 6.1 x10E9 cells/L, amylase 114 U/L and lipase 59 U/L. Malignancy work up revealed a normal Ca 19-9 at 29.6 kU/L. HIV testing was negative. CT chest revealed bilateral apical fibrotic lesions and smaller lesions throughout the upper and mid-zones bilaterally, suggestive of progressive massive fibrosis. This was in keeping with the patient’s former occupation as a miner. There was no evidence of granulomatous disease. EUS was undertaken and this revealed a mass in the head of the pancreas measuring 29 x 29 mm. The mass was invading into the common bile duct. The pancreatic head mass appeared to be invading into the duodenum, as a necrotic ulcerating lesion was also identified in the second part of the duodenum and this was biopsied. The surgical pathology returned as necrotizing granuloma, however, the tissue could not be tested for TB. The patient underwent a repeat endoscopy which again revealed a fungating and friable mass in the second part of the duodenum with biopsies taken. Pathology revealed mild chronic inflammation. Staining for Acid Fast Bacilli was negative, however, Mycobacterium Tuberculosis Complex was isolated on tissue culture. The patient was diagnosed with pancreatic TB and initiated on pyrazinamide, ethambutol, isoniazid and rifampin. Conclusions Pancreatic involvement by TB is very rare but it has been increasingly reported in both immunocompromised and immunocompetent populations. Symptomatically, pancreatic TB can present with a multitude of non-specific symptoms, including epigastric pain, fever, anorexia, weight loss, or jaundice. In addition, imaging findings of pancreatic TB may mimic malignancy. Our patient, from an endemic area, presented with epigastric pain consistent with the existing literature on pancreatic TB. Isolated pancreatic TB is a rare clinical entity but should be in the list of differential diagnoses in a patient with pancreatic mass especially in the setting of risk factors of TB. Funding Agencies None

Evaluation of the clinical utility of reflex GMS and AFB stains on BAL specimens from lung transplant patients

Bronchoalveolar lavage (BAL) has a useful role in the detection of infectious diseases. Grocott methenamine silver (GMS) and acid-fast bacilli (AFB) are ancillary stains that aid in the cytologic detection of fungal and mycobacterial organisms. However, the utility of these stains in conjunction with microbiological testing is unclear. BAL specimens from lung transplant patients between January 1, 2018, to December 31, 2018, were evaluated. Inclusion criteria included cases with both GMS and AFB stains and concurrent fungal and mycobacterial microbiology testing. The staining findings were correlated with concurrent microbiology findings, including cultures and immunofluorescent smears. A total of 231 BAL specimens were identified. GMS stain was positive in 19.5% and AFB in 1.3%. Fungal microbiology was positive in 23.4% and mycobacterial microbiology in 6.1%. A total of 87.9% of cases had concordant findings between cytology stains and microbiology tests and 12.1% had discrepant findings. Notably of the discrepancies, 3.0% had positive GMS and negative fungal microbiology and 6.9% had positive fungal microbiology and negative GMS. No cases had positive AFB with negative mycobacterial microbiology whereas 4.8% had positive mycobacterial microbiology and negative AFB stain. We show that staining for AFB on BAL material in lung transplant patients had limited benefit when concurrent microbiology was performed. GMS staining shows a small benefit. We recommend reflex testing for fungal organisms but not mycobacterial organisms in lung transplant patients.

HANSEN’S DISEASE DIAGNOSED AFTER ANTI-CANCER CHEMOTHERAPY

Background. Leprosy or Hansen’s disease is a chronic granulomatous disease involving predominantly skin, peripheral nerves and nasal mucosa but capable of affecting any tissue or organ. Histoid leprosy is a very rare well-defined clinicopathological variant of multibacillary lepromatous leprosy, which is very difficult to diagnose due to different specific clinical and histopathological findings that mimic a fibromatous disorder. Histoid leprosy occurs generally after treatment failure and sometimes de novo.&#x0D; Objective. The aim of the study was to explore histoid leprosy throughout a case report.&#x0D; Methods. A case report of histoid leprosy diagnosed after cancer chemotherapy is presented.&#x0D; Results. A 25-year-old healthy male presented with multiple skin coloured, discrete, well defined, painless papules and nodules scattered over nape of neck, right side of the trunk and both arms along with numbness as well as tingling sensation over both the arms and trunk. It was a case of non-seminomatous germ cell tumour (NSGCT), left testis, diagnosed and treated with a high inguinal orchidectomy with adjuvant chemotherapy in 2016. Ziehl Neelsen (ZN) stain for Acid Fast Bacilli (Mycobacterium leprae) – a modified Fite stain method showed numerous acid-fast bacilli. Histopathological diagnosis of Hansen’s disease (Histoid) was conducted. The patient was admitted and started on triple drug multi-bacillary multi-drug therapy (MB-MDT). A remarkable improvement was noticed in the lesion status within one month of institution of the therapy.&#x0D; Conclusions. Histoid leprosy is a discrete infrequent form of multibacillary leprosy with distinctive clinical, bacteriological and histomorphological features. Histopathologic examination with modified Fite stain is still the mainstay of diagnosis.

Tuberculoma of the Peripheral Nerve: Illustrative Case and Systematic Review of the Literature

Tuberculomas affecting the peripheral nerve are exceedingly rare. As such, little has been reported about their clinical features, treatment, and outcomes. We report the case of a 10-year-old male patient with histopathologically proven tuberculoma presenting preoperatively as a peripheral nerve tumor. We also performed a systematic review of the SCOPUS and PubMed databases for case reports and case series documenting patients with histopathologically confirmed peripheral nerve tuberculoma and discussed clinical features and treatment outcomes. A total of 7 cases of peripheral nerve tuberculomas were reported in the literature, including the current case. The mean age was 21.4 years with no sex predilection. The ulnar nerve was involved in all cases. The most common clinical manifestations were hand weakness, atrophy, ulnar clawing, and hypoesthesia. The classic histopathologic features of caseous necrosis, epithelioid granulomas, and Langhans giant cells were seen in all cases, while staining for acid fast bacilli was positive in only one case. All patients underwent nerve exploration and lesion resection, and were given antitubercular treatment lasting between 3 and 18 months. Treatment resulted in complete recovery in 43% of cases and partial improvement of neurologic deficits in 57%. Tuberculoma of the peripheral nerve is a rare manifestation of tuberculous disease, with a predilection for the ulnar nerve. Current management includes nerve exploration, lesion resection, and antitubercular treatment, which often results in good neurologic recovery.

Risk factors of delayed isolation of patients with pulmonary tuberculosis

ObjectivesThe aim was to examine the rate of delayed or no isolation of hospitalized patients with pulmonary tuberculosis (TB) and the causes for isolation failure. MethodsThis retrospective study included patients with pulmonary TB at a university-affiliated hospital in South Korea between January 2015 and June 2018 after excluding those with a stay ≤2 days and those who only visited the emergency department. Patients who were not isolated for ≥3 days were classified as the delayed or no isolation group. We compared the clinical findings and diagnostic test results, between patients managed with delayed or no isolation (D-isolation) and timely isolation (T-isolation). ResultsOf 486 patients with pulmonary TB, 222 patients were included. In 106 cases (47.7%), isolation was delayed or not applied, while in 116 cases, isolation was applied in a timely manner. Typical findings of TB were seen on the chest X-rays of 87 (75.0%) patients in the T-isolation group versus 25 (23.6%) patients in the D-isolation group (p < 0.001). Other factors significantly associated with delayed or no isolation on univariate analyses were older age, admission route (emergency room vs. other), admitting department, negative acid-fast bacilli (AFB) stain, and negative MTB PCR. On multivariate analysis, admission through an outpatient clinic, admission to a department other than infectious diseases or pulmonology, an atypical chest X-ray finding and negative sputum AFB stains were risk factors for isolation failure. DiscussionDelayed or no isolation of patients with pulmonary TB was attributed mainly to atypical radiological findings and negative findings of direct TB diagnostic tests.

Acute phase response in anemic patients who received raw liquid extract of the leaves of Solanecio biafrae (wòròwó) to increase their hematocrit

Study Background: Solanecio biafrae (worowo) leaves contain health benefit phytochemicals and phytonutrients which are being used traditionally to treat ailments. Aim and Objective: This work was therefore designed to determine acute phase response in anemic patients who received raw liquid extract of the leaves of to increase their hematocrit. Materials and Methods: Forty-three (43) individuals with low packed cell volume (PCV) (PCV 27 ± 2.0; Female–22; Male-21; age–18–61 years) and 50 age-matched volunteers with normal PCV (PCV 41 ± 2.0; Female-25; Male-25) who were negative in reaction to Giemsa thick-blood film staining for Plasmodium spp., Stool microscopy for hookworm, Ziehl–Neelsen staining for acid fast bacilli, human immunodeficiency virus, anti-HCV and HBsAg ELISA were recruited from herbal homes in Nigeria. Plasma Haptoglobin, C–reactive protein (CRP) and fibrinogen were assayed biochemically while PCV was determine by microhematocrit capillary tube method. Results: There was a significant increase in plasma fibrinogen in Volunteers with low PCV after treatment and in control volunteers with normal PCV compared to the value of the parameter obtained before treatment (P

Lupus miliaris disseminatus faciei: A rare case report

Lupus miliaris disseminatus faciei (LMDF), initially thought to be a tuberculid, is an uncommon independent clinicopathological entity characterized by asymptomatic erythematous papules over the face, usually encountered in young individuals and rarely in the extremes of age group. It was initially thought to be a tuberculid due to similar histopathological features between the two entities. LMDF has a spontaneously resolving course; however, due to its ability to cosmetically debilitate an individual, patients often seek a dermatologist's opinion. Various treatment options, such as oral tetracyclines, steroids, and retinoids, have been tried with varying results. Around 200 cases have been reported till date, and further studies are needed to understand the etiopathogenesis and management of this distinct dermatosis. We report a case of LMDF in a young lady who was started on oral minocycline and topical tacrolimus but was lost to follow-up. We hereby report this case for its rare occurrence. The present paper highlights the clinical importance of LMDF mimicking granulomatous facial dermatitis and the need for further laboratory investigations to rule out tuberculosis. This report reviews the available literature and presents a patient with LMDF. Biopsy done on one of the lesions over face showed epidermal atrophy, dermal perivascular and periadnexal inflammatory infiltrate, focal granulomatous inflammation with multinucleated giant cells, with the special stain for acid-fast bacilli being negative. These findings suggested LMDF. LMDF is a distinct granulomatous inflammatory dermatosis not associated with cutaneous tuberculosis.

Clinical relevance of pulmonary non-tuberculous mycobacterial isolates in three reference centres in Belgium: a multicentre retrospective analysis

Background/objectivesAssessing the clinical relevance of non-tuberculous mycobacteria (NTM) isolated from respiratory samples can be challenging. The epidemiology and pathogenicity of NTM species vary geographically. We aimed to outline the clinical relevance and associated radiological patterns of NTM species isolated in Belgium.MethodsWe performed a retrospective multicentre analysis of all patients identified from the laboratory database with > 1 respiratory sample growing NTM from January 2010 through December 2017. We collected clinical, radiological and microbiological data through medical record review and assessed clinical relevance according to ATS/IDSA criteria for NTM pulmonary disease (NTM-PD).ResultsOf the 384 unique patients, 60% were male, 56% had a smoking history and 61% had pre-existing lung disease. Mycobacterium avium complex (MAC), M. gordonae and M. xenopi were the most frequently isolated species: 53, 15 and 8% respectively. 43% of patients met ATS/IDSA criteria, of whom 28% presented with fibrocavitary disease. Weight loss, fever, nodular bronchiectatic and fibrocavitary lesions on chest CT, and a positive acid-fast bacilli (AFB) stain were significantly associated with NTM-PD. The species with the highest pathogenic potential were M. abscessus (11/12), M. malmoense (6/7) and M. intracellulare (41/64).ConclusionIn our study, MAC was the most commonly isolated NTM species, but M. abscessus and M. malmoense showed the highest probability of being clinically relevant. Clinical relevance varied not only by species but also by radiological findings on chest CT and AFB staining. Clinicians should consider these elements in their treatment decision making. Prospective data including clinical outcome are needed to provide more robust evidence.

Mycobacterium tuberculosis does not show evidence of molecular DNA in human cadaveric ocular tissues in an endemic setting.

Mycobacterium tuberculosis (MTB) in latent infection has been demonstrated in pulmonary/extra-pulmonary locations (lung, spleen, liver, kidney, adipose tissue) in autopsy studies, but its presence in ocular tissues in the latent state is not known. We conducted molecular and histopathological study of 100 cadaver eyes (50 humans) who died from causes other than tuberculosis (TB) (and were potential candidates for corneal transplantation) to detect MTB in ocular tissues in an endemic setting. After removal of the corneal button, an 8 to 10 mm block of tissue (choroid, retina and part of the vitreous) was excised from the remaining globe for DNA isolation. Gel-based IS6110 and devR3 polymerase chain reaction (PCR) assays were done, followed by real-time PCR using beta actin gene as an internal control. Sixteen randomly selected DNA samples were double checked using a commercial kit for MTB and non-tuberculous mycobacteria (NTM) DNA. The remaining larger part of the globe was subjected to histopathology. The mean age was 65.14 ± 18 years. All 100 samples were negative for both IS6110 and devR, and all 16 samples were negative with NTM MTB commercial kit. All samples were negative with Ziehl-Neelsen stain for acid fast bacilli and none showed any inflammation or granulomatous pathology. MTB could not be detected in human ocular tissues in latent state in India, a TB-endemic country. This may suggest the inability of MTB to seed ocular tissues in the latent state, unlike other organs which serve as reservoirs for the bacilli in the absence of manifest disease.

A RARE CAUSE OF CRAZY PAVING: POSTTRANSPLANT LYMPHOPROLIFERATIVE DISEASE

SESSION TITLE: Tuesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Crazy paving on computed tomography (CT) is defined as interlobular septal thickening with areas of ground glass attenuation. It can be caused by a variety of pathologies. Here we describe an unusual cause of crazy paving in an immunosuppressed patient. CASE PRESENTATION: A 58-year old man presented for syncope. His past medical history included acute myelogenous leukemia in complete remission post stem cell transplant, and complicated by cytomegalovirus colitis. Upon arrival to the emergency department, he was found to be obtunded and was intubated. Home medications included tacrolimus, ganciclovir, sulfamethoxazole-trimethoprim, and voriconazole. Vital signs were significant for a blood pressure of 62/38mmHg and heart rate of 138/minute. Laboratory studies revealed a white blood cell count of 13.6K/mm3, with 15% lymphocytes, 5% atypical lymphocytes, 34% plasmacytes, and 44% neutrophils. Lactic acid was 10.8mmol/L, bicarbonate 15mmol/L, and creatinine 3mg/dL. Arterial blood gas was consistent with metabolic acidosis. Tacrolimus level was 6ng/mL (goal 5-10). Computed tomography (CT) of the chest (Images 1-3) revealed interlobular septal thickening with ground glass opacities, and prominent mediastinal, cervical, and axillary lymphadenopathy. The patient required vasopressor support and was started on broad spectrum antibiotics, antivirals, antifungals. Bronchoalveolar lavage showed 38% neutrophils, 52% monocytes, and 10% lymphocytes. Gram stain, cultures, stain for acid fast bacilli, cytology, galactomannan, fungal cultures, and viral respiratory panel were negative. Serum flow cytometry revealed plasmacytoid cells with positive Epstein-Barr virus (EBV) in situ hybridization. Serum EBV PCR showed >39,000,000 copies/mL. These findings were consistent with post-transplant lymphoproliferative disease (PTLD). DISCUSSION: PTLD is a category of lymphoid disorders that arise after solid organ or hematopoietic transplants in the setting of active immunosuppression, most commonly with active EBV infection. Severity is graded as early, polymorphic, or monomorphic. Treatment can involve decreasing immunosuppression, rituximab in CD20+ disease, chemotherapy (with surgery if localized disease), or EBV-targeted cytotoxic T-cell instillation. Prevention of PTLD in transplant patients has included rapid tapering of immunosuppression as appropriate, and close monitoring of EBV viral levels, with elevations prompting reduction in immunosuppression or initiation of rituximab. Given its in vitro inhibition of EBV replication, ganciclovir has been suggested prophylactically, but there is no consensus regarding antiviral prophylaxis. CONCLUSIONS: Our patient rapidly decompensated and went into multiorgan system failure; he was made comfort care and expired. This case demonstrates the need for a high index of suspicion for PTLD in all transplanted patients with crazy paving present on imaging. Reference #1: Al-Mansour Z, Nelson BP, Evens AM. Post-transplant lymphoproliferative disease: risk factors, diagnosis, and current treatment strategies. Curr Hematol Malig Rep. 2013 September; 8(3): 173-183. Reference #2: Rossi SE, Erasmus JJ, Volpacchio M, et al. "Crazy Paving” pattern at thin-section CT of the lungs: radiologic-pathologic overview. Radiographics 2003; 26 (6): 1509-1519. Reference #3: AlDabbagh, MR, Gitman MR, Kumar D et al. The Role of Antiviral Prophylaxis for the prevention of Epstein-Barr virus-associated posttransplant lymphoproliferative disease in solic organ transplant recipients: a systematic review. Am J Transplant. 2017; 17: 770-781. DISCLOSURES: No relevant relationships by Payam Nabizadeh, source=Web Response No relevant relationships by Paul Simpson, source=Web Response

1882 Diagnosing Sarcoidosis From the Gastrointestinal Tract

INTRODUCTION: Sarcoidosis is a multi-system disease with 90% occurrence in the lungs and mediastinal lymph nodes. Involvement of the gastrointestinal tract (GIT) occur in less than 1 % of cases. We illustrate a patient who presented with gastrointestinal symptoms leading to the diagnosis and multidisciplinary management of sarcoidosis. CASE DESCRIPTION/METHODS: 61-year-old African American female with gastroesophageal reflux disease and an umbilical hernia had constipation alternating with diarrhea and vomiting associated with greasy food. Examination showed an umbilical hernia and a soft, non tender abdomen. In her stool, pathogenic parasites and clostridium difficile was negative. Serum tissue transglutaminase and IgA levels were normal. Upper endoscopy and EUS revealed a polypoid mass in the gastric antrum which was limited to the mucosa. Histology showed inflammation, crypt abscesses and non caseating granulomas. Special stains for acid fast bacilli and fungi were negative. Quantiferon gold was negative. Colonoscopy was unremarkable. Suspicion for sarcoidosis led to a CT thorax, which revealed peri-hilar lymphadenopathy. The patient was sent to pulmonology and ophthalmology. Her symptoms were tackled without steroids in a symptomatic fashion. DISCUSSION: When sarcoidosis affects the GIT, the stomach is the most common site and with few reported cases in the esophagus, colon and rectum. Symptoms are non-specific, such as: nausea, vomiting, diarrhea, and abdominal pain. Diagnosis depends on three factors: biopsy confirming non-caseating granuloma in the GIT, involvement in at least one additional organ, and exclusion of other common granulomatous diseases, such as Crohn’s disease, tuberculosis and fungi. Our patient had an antral non-caseating granuloma.Multiorgan involvement was demonstrated by per-hilar lymphadenopathy. Tuberculosis and fungi were ruled out with negative stains and quantiferon gold. Nearly all patients with crohn’s disease develop distal colonic involvement, and upper GIT involvement is rare when there is no disease beyond the ligament of treitz. Our patient had multiple colonoscopies negative for Crohn’s. Management is based upon severity; asymptomatic patients require no treatment and severe cases receive glucocorticoids. Our patient’s did not need any steroids since subsequent endoscopies had no further granulomas. Although rare, sarcoidosis may involve the GIT, and clinicians should begin the work up if granulomas are found and refer the patient to the appropriate departments.