Antitubercular Drug Therapy Research Articles

Clinico-Demographic Characteristics of Intestinal Tuberculosis in Pre-Operative Unsuspected Laparotomy as Incidental Findings in Bangladesh

Background: Clinical presentation of intestinal tuberculosis is varied. It is also essential to know the clinical and demographic characteristics of incidentally detected intestinal tuberculosis patient. Objective: The purpose of the present study was to find out the clinic-demographic characteristics of intestinal tuberculosis in clinically and preoperatively unsuspected laparotomies. Methodology: This cross-sectional study was carried out in the Department of Surgery at Dhaka Medical College Hospital, Dhaka from March 2002 to March 2004 for a period of two (2) years. All the patients underwent laparotomy presented without any suspicion of pulmonary or intestinal tuberculosis were included as study population. Patients who were without the history of cough, haemoptysis, antitubercular drug therapy were included. Per operative suspicion was raised due to enlarged lymph nodes in mesentery, omental masses, ileocaecal masses, suspicious growth in ileum, omental thickening, perforation suspected by tuberculosis. Biopsy was taken from suspicious lesions. Histopathology was confirmed the tubercular lesion. Results: A total number of 300 patients under laparotomy were recruited for this study of which 38 positive cases were found in the study with a percentage of 12.7%. Maximum affected age group was 21 to 30 years which was 16 (42%) cases. Male was predominant to female which was 28 (73.7%) cases and 10 (26.3%) cases respectively. Low socioeconomic people are affected more (76.3%). Most common presentation in positive cases was acute and sub-acute intestinal obstruction 20 (52.6%) followed by intestinal perforation (26.31%). Conclusion: In conclusion young age male patient is the most commonly affected intestinal tuberculosis which is frequently presented with sub-acute intestinal obstruction among the preoperatively unsuspected laparotomy patients.

The Epidemiological Aspects of Tuberculosis Patients in a Tertiary Care Medical College Hospital of Bangladesh

Background and Aims: To assess the clinical and socio-demographic characteristics of tuberculosis patients in a tertiary care medical college hospital of Bangladesh. Methods: An observational study was conducted over a period of one year from September 2015 to August 2016 in the Outpatient Department of Jahurul Islam Medical College Hospital and Department of Pathology, Jahurul Islam Medical College, Kishoregonj, The inclusion criteria of the study were pulmonary and extra pulmonary tuberculosis cases receiving antitubercular drugs therapy. Primary data from each patient was included in tuberculosis patient profile form such as age, gender, educational level, annual income in taka, occupational status and selected social habits like smoking, alcohol. Results: Out of 112 patients studied, 50 (44.6%) were male and 62 (55.4%) were female. The majority of patients 69 (61.7%) were in the age group of 15-34 years. Annual family income of 78 (69.6%) patients ranged between 36,000- 1,50,000 taka. In total 112 patients 43 (38.4%) were illiterate and 36 patients (32.2%) were unemployed. 50% of the patients were smoker. The most common sites involved in extrapulmonary tuberculosis were the lymph nodes (38.2%) followed by the pleura (36.4%). The most common symptoms observed in pulmonary tuberculosis patients were cough with expectoration (96.5%) followed by weight loss (80.7%), fever (73.7%) and loss of appetite (54.4%). Conclusion: Prevalence of infection was noticed between PTB and EPTB with age and it was more common in younger age. However, based on our results TB control programme might usefully target young middle age populations for early diagnosis of TB to decrease TB morbidity and mortality.

Reactivation of Tuberculosis Following Major Abdominal Surgery

AbstractA 46 year old male presented with dysphagia to solids and vomiting. He was evaluated clinically, radiologically and by upper GI endoscopy. He was diagnosed to have carcinoma of the distal 1/3rd of the oesophagus extending onto the Fundus of stomach (Sievert III).A standard transhiatalesophagectomy and total gastrectomy with Roux-en-Y esophagesophageal reconstruction was done. His post op period was relatively uneventful and discharged on POD 22. He was readmitted for radiotherapy as per Protocol. (5040 cGY/25#/5 weeks). He developed persistent cough with expectoration on day 5. A pulmonology consult was given and sputum for AFB was sent. He was tested positive for pulmonary tuberculosis.This man had a significant past history of being treated for TB meningitis 20 years ago. Treatment now was started as per DOTS regimen and was discharged after his course of radiotherapy. His Antitubercular drug therapy has been continued.A search of the English literature survey revealed no similar articles of “Reactivation of Tuberculosis after abdominal surgery”. The possible mechanism may be due to profound immunosuppression following malignancy and its treatment.It is worthwhile to consider Tuberculosis as a differential diagnosis in the appropriate clinical setting as a cause of unexplained fever.

Multifocal pure tubercular osteomyelitis: An unusual presentation in childhood

Tuberculosis is a major health problem in the developing world. One-third of children infected with Mycobacterium tuberculosis have extra pulmonary involvement. Skeletal tuberculosis occurs in 1–6% of them with vertebra being the commonest site. Pure tubercular osteomyelitis without joint involvement occurs in only 2–3% cases of osteoarticular tuberculosis. Common sites are femur, tibia, and fibula. Disseminated skeletal involvement is very rare in children (7%) and calvarial osteomyelitis is even rarer (1%). Here, we report a unique case of disseminated skeletal TB. A 7-year-old tribal girl with no evidence of immunodeficiency presented with multiple lytic lesions involving skull, sternum, and hip bone surprisingly sparing the joints and appendicular skeleton. There was no pulmonary involvement either. FNAC from all three swellings showed presence of acid-fast bacillus. Bone biopsy followed by culture in BACTEC further confirmed the diagnosis. There was complete resolution of the swellings after one year of anti-tubercular drug therapy.

Sinonasal tuberculosis: Report of three atypical cases

Primary sinonasal/nasal tuberculosis is rare amongst the commonly seen cases of extrapulmonary tuberculosis.We report three cases, two of primary sinonasal tuberculosis and one case of nasal tuberculosis in otherwise healthy patients. The diagnosis was based on radiological and histopathological findings. Treatment with antitubercular drug therapy was successful in all three of them.Sinonasal region tuberculosis, despite its rarity, should be added to differential diagnosis of nasal and paranasal sinus disorders particularly with intractable symptoms. Radiological imaging and nasal endoscopy with biopsy should be supplemented for confirmation.

Clinicopathological Study of Tuberculosis Patients in a Tertiary Care Medical College Hospital

Background: The aim of the study was to assess the clinical and socio-demographic characteristics of tuberculosis (TB) patients in a tertiary care medical college hospital of Bangladesh. Methods: An observational study was conducted over a period of 1 year from September 2015 to August 2016 in the Outpatient Department of Jahurul Islam Medical College Hospital and Department of Pathology, Jahurul Islam Medical College, Kishoregonj. The inclusion criteria of the study were pulmonary tuberculosis (PTB) and extrapulmonary tuberculosis (EPTB) cases receiving anti-tubercular drugs therapy. Primary data from each patient were included in TB patient profile form such as age, gender, educational level, annual income in taka, occupational status and selected social habits like smoking and alcohol. Results: Out of 112 patients studied, 50 (44.6%) were male and 62 (55.4%) were female. The majority of patients 69 (61.7%) were in the age group of 15 - 34 years. Annual family income of 78 (69.6%) patients ranged between 36,000 and 150,000 taka. Out of 112 patients, 43 (38.4%) were illiterate and 36 patients (32.2%) were unemployed. Half of the patients were smoker. The most common sites involved in EPTB were the lymph nodes (38.2%) followed by the pleura (36.4%). The most common symptoms observed in PTB patients were cough with expectoration (96.5%) followed by weight loss (80.7%), fever (73.7%) and loss of appetite (54.4%). Conclusion: Prevalence of infection was noticed between PTB and EPTB with age and it was more common in younger age. However, based on our results, TB control programme might usefully target young middle-aged populations for early diagnosis of TB to decrease TB morbidity and mortality. Clin Infect Immun. 2016;1(2):41-44 doi: https://doi.org/10.14740/cii56e

A rare association of tuberculous longitudinally extensive transverse myelitis (LETM) with brain tuberculoma

BackgroundLongitudinally extensive transverse myelitis is characterized by contiguous inflammatory lesion of spinal cord involving three or more spinal segments. It is a well-recognized but rare presentation of Mycobacterium tuberculosis infection.Case descriptionWe report a case of young boy diagnosed with multiple brain tuberculomas. He was on antitubercular drugs therapy for 2 months and became asymptomatic. On 2-month followup visit, the patient complained of acute onset progressive sensorimotor, spastic paraparesis with bladder dysfunction. Magnetic resonance imaging of spine showed longitudinally extensive transverse myelitis extending from thoracic spinal segment T2 to T10 level. He was treated with high dose intravenous methylprednisolone therapy and continued on combination of first line four antitubercular drugs. At 6-month followup, patient was able to walk with support. In our patient, clinical features, previous history of brain tuberculoma and spinal neuroimaging confirmed the diagnosis of tuberculous myelitis. The new onset longitudinally extensive transverse myelitis in our patient was may be related to paradoxical response to antitubercular therapy.ConclusionsOur case highlights that tubercular infection might be an important but overlooked cause of longitudinally extensive transverse myelitis. Therefore, clinicians should have a high index of suspicion to diagnose this potentially treatable cause especially in high-risk conditions like tuberculosis endemic areas, associated brain tuberculosis and HIV infection. Our case is unique because of paradoxical presentation of longitudinally extensive transverse myelitis in cranial tuberculomas, already on antitubercular treatment.

Author Response: Isolated Spontaneous Primary Tubercular Erector Spinae Abscess: A Case Report and Review of Literature.

We appreciate readers for providing their insightful comments and detailed clarification on our article. They have drawn our attention towards the case reported by Indudhara et al. [1]. In our article we have mentioned that there exists one report [2] on isolated spontaneous primary tubercular erector spinae abscess until date. In our report, the usage of the word primarily signifies this case is important because it is 'primary' tubercular erector spinae abscess without any predisposing conditions such as immunocompromised state, any steroid or other drugs intake and presence of tuberculosis at any other body parts. We would like to mention here that the case reported by Indudhara et al. [1] was on renal transplant recipient with tubercular pyomyositis of left erector spinae muscle. This is totally a different case scenario from our case [3], as patient was a renal transplant recipient and had immuno-compromised status. It has already been documented in the literature that risk of dissemination and extraskeletal tuberculosis is more in immunocompromised patients [4]. In our case [3], the patient was immunocompetent young female, who had spontaneous onset of lower back pain. Moreover, our case signifies that magnetic resonance imaging is non-invasive diagnostic modaltiy of choice in such cases as it gives much better details of the diseases affecting soft tissues. We do agree that injection of muscular tissue by the tubercular bacilli without coexistence of active skeletal and extraskeletal tuberculosis is an event of rare occurrence. However, anti-tubercular multi drug therapy with or without surgical intervention (aspiration/incision and drainage) is the treatment of choice and has shown consistent results in the past [1,2,3,5]. We do appreciate the interest, which our readers have shown in our work and stressed appropriately for the awareness in the medical fraternity about the diagnosis and treatment of musculo-skeletal tuberculosis, as it is quite a rare entity in present world medical practice.

A case of skeletal tuberculosis and psoas abscess: disease activity evaluated using 18 F-fluorodeoxyglucose positron emission tomography-computed tomography

BackgroundPsoas abscess complicating tuberculous spondylitis is a rare morbidity in extrapulmonary tuberculosis. There are no established guidelines for evaluating the clinical response of psoas abscess. Although several studies have shown that positron emission tomography-computed tomography with 18 F-fluorodeoxyglucose can play a potential role in diagnosing multifocal tuberculosis and monitoring the clinical response of pulmonary tuberculosis, to our knowledge, this is the first report demonstrating that positron emission tomography-computed tomography is useful for evaluating local inflammation and disease activity of a tuberculous psoas abscess.Case presentationWe report a case of multifocal bone and lymph node tuberculosis with concomitant lumbar psoas abscess in a 77-year-old man, along with a literature review. An initial positron emission tomography-computed tomography scan showed intense 18 F-fluorodeoxyglucose accumulation in the sternum, ribs, vertebrae, and lymph nodes. The patient was successfully treated with antitubercular agents and computed tomography-guided drainage therapy. A follow-up positron emission tomography-computed tomography after abscess drainage and 9 months of antitubercular drug treatment revealed that the majority of lesions improved; however, protracted inflammation surrounding the psoas abscess was still observed. These results indicate that disease activity of psoas abscess can remain, even after successful drainage and antitubercular medication regime of appropriate duration.ConclusionWe have successfully followed up the extent of skeletal tuberculosis complicated with psoas abscess by positron emission tomography-computed tomography. In this patient, positron emission tomography-computed tomography is useful for evaluating the disease activity of tuberculous psoas abscess and for assessing the appropriate duration of antitubercular drug therapy in psoas abscess.

Low plasma levels of cholecalciferol and 13-cis-retinoic acid in tuberculosis: Implications in host-based chemotherapy

ObjectiveThe aim of this study was to estimate the concentration of cholecalciferol and 13-cis-retinoic acid (RA) in the plasma and pleural fluid of patients with tuberculosis (TB) against controls. MethodsPlasma levels of cholecalciferol and 13-cis-RA were measured in 22 patients with TB and healthy controls and their pleural fluids levels were measured in 6 TB patients and diseased controls by established high-performance liquid chromatography–based procedure. ResultsCholecalciferol levels in plasma and pleural fluid of patients with TB and healthy controls were 67.45 (10.71) nmol/L and 21.40 (8.58) nmol/L compared with 117.43 (18.40) nmol/L (P < 0.001) and 94.73 (33.34) nmol/L (P = 0.0049), respectively. 13-cis-RA level in the plasma of patients with TB and healthy controls were 1.51 (0.72) nmol/L and 6.67 (0.81) nmol/L (P < 0.001), respectively. 13-cis-RA was not detectable in pleural fluid. The levels of both the agents were lower in patients with TB than in controls. ConclusionIt was observed that in patients with TB there is a combined deficiency of cholecalciferol and 13-cis-RA compared with healthy volunteers. Because cholecalciferol and 13-cis-RA are in equilibrium with active ingredients of vitamins A and D, we feel that there is a combined deficiency of these vitamins in patients with TB. There is an evidence that concomitant vitamin A and D supplementation can kill intracellular Mycobacterium tuberculosis in vitro. Therefore, the observations made in this study can pave the path for a trial of combined supplementation of available formulations of vitamin A and D (cholecalciferol and 13-cis-RA) for novel anti-tubercular drug therapy. Because such an approach is host-based it has potential to treat even multidrug-resistant and extensively drug-resistant forms of TB.

Comparing the Daily Versus the Intermittent Regimens of the Anti-Tubercular Chemotherapy in the Initial Intensive Phase in Non-HIV, Sputum Positive, Pulmonary Tuberculosis Patients.

Tuberculosis (TB) is a major health problem in the universe and India is no longer exempted from this crisis .The emergence of HIV and MDRTB (Multi Drug Resistant Tuberculosis) have further made the situation critical. Our aim was to compare the efficacy of the daily and the intermittent doses of the Anti Tubercular Drug (ATD) therapy which is under the Revised National Tuberculosis Control Programme, amongst the sputum positive pulmonary tuberculosis in terms of the sputum conversion rate at the end of the initial phase , the default rate and the adverse drug reactions. This was an observational prospective study. Eighty three patients were selected from the out patient and the inpatient departments of a tertiary medical centre in India. Forty three cases received an intermittent regimen, where the major age group belonged to the under 40 years age group, the default rate to the therapy was 9.3%, the sputum conversion rate was 94.87% and adverse drug reactions were found in 25.58% of the patients. In the daily regimen, there was an equal proportion of the age group of the patients, both above and below 40 yrs, the sputum conversion rate was 94.74%, a default rate was found in 5% cases and adverse reactions were found in 35% of the cases. Both the intermittent and the daily regimens showed equal sputum conversion rates and the drug default cases were found more in the intermittent group. However, the adverse reactions were found more in the daily regimen category.

Intra-medullary tuberculoma of the spinal cord presenting with typhoid and paraplegia: a case report

IntroductionIntra-medullary spinal tuberculoma is a rare form of tuberculosis, with an incidence of only two in 100,000 patients with tuberculosis. We present a case of intra-medullary tuberculoma from Pakistan, which was diagnosed by radiological findings and analysis of cerebrospinal fluid using polymerase chain reaction testing.Case presentationWe present the case of a 28-year-old Sindhi male with intra-medullary tuberculoma of the spinal cord at the C3 level. Our patient was treated solely with anti-tubercular drug therapy with no surgical intervention.ConclusionsWe discuss the possible clinical management of such rare cases, considering both chemotherapeutic and surgical options. Additionally, diagnostic procedures and findings are discussed; we suggest cerebrospinal fluid analysis via polymerase chain reaction and gadolinium-diethylenetriamine pentaacetic acid magnetic resonance imaging as important chemical and radiological tests to be performed in such cases.

Tuberculosis of the entheses

Tuberculosis of the osteoarticular system usually manifests as joint arthritis. There is no available English literature on the tubercular involvement of the enthesis (tendon-bone junction). We performed a retrospective analysis on 14 patients with tuberculosis of the tendon-bone junction. Patients presenting with a sinus with or without presence of radiological evidence of bone destruction around the enthesis, and pain unresponsive to a trial of analgesics and physical therapy, were evaluated by closed or open biopsy for tuberculosis. A staging system is proposed for biopsy-proven tuberculosis of the enthesis. Between 2006 and 2010, we treated 14 patients with tuberculosis of the tendon-bone junction. Biopsy-proven cases of tuberculosis of the enthesis were administered anti-tubercular drugs for a period of one year. Sequestrectomy was performed in advanced lesions. The tendon-bone junction was rested until the features of its healing were clinically evident. The patients aged between 18 and 52 years were followed up for an average of 1.7 years after cessation of anti-tubercular drug therapy. They responded favourably, and none had recurrence of the disease. This study describes the tubercular involvement of the entheses, which heretofore has not been described in the literature. The rarity of its occurrence and lack of suspicion of an infectious aetiology in these locations frequently results in late diagnosis and incorrect initial treatment. This study also supports the "microtrauma theory" in the genesis of osteoarticular tuberculosis.

Design, Synthesis, and Antimycobacterial Property of PEG–bis(INH) Conjugates

Poly(ethylene glycol) derivatives of isoniazid with varying molecular weight of poly(ethylene glycol) were designed as antimycobacterial agents. Poly(ethylene glycol)-diacrylate of three different molecular weights (MW 258, 575, and 700) was conjugated with isoniazid by the Michael addition approach. The poly(ethylene glycol)-bis(isoniazid) conjugates thus obtained were completely characterized by FT-IR, (1)H and (13)C NMR, and ESI-MS spectroscopic techniques. Comparative MTT assay of the poly(ethylene glycol)-bis(isoniazid) conjugates showed much lower cytotoxicity than the neat isoniazid. MIC studies on Mycobaterium tuberculosis H37Rv showed potential antimycobacterial activity than the free isoniazid on a molar basis. The poly(ethylene glycol)-bis(isoniazid) conjugates were successfully radiolabeled with 99m-Technetium with more than 97% efficiency and stability to assess their in vivo fate. The (99m)Tc labeled poly(ethylene glycol)-bis(isoniazid) conjugates showed higher blood retention time in New Zealand rabbits which increased with increasing molecular weight of poly(ethylene glycol). Biodistribution studies in infection-induced murine models (BALB/c mice) showed significant retention of these conjugates at the site of infection for 72 h. The results of this study illustrate the potential utility of the PEGylated isoniazid conjugates as long circulating carriers for improved antitubercular drug therapy.

Calvarial tuberculosis: Uncommon manifestation of common disease – a series of 21 cases

Objective. Tuberculosis is an endemic disease in developing countries like India. It can involve almost any part of human body. One such, albeit rare, is the extra pulmonary manifestation – tuberculosis of calvaria. There have been many isolated case reports and short series published on this unusual presentation. The aim of this presentation is to acquaint the reader with the varied presentation; to emphasise the role of prompt surgical debridement; as also to stress the role of complete anti-tubercular drug therapy in the management of this rare disease.Methods. A retrospective analysis of a total of 21 patients over a period of 10 years period (July 1995 to June 2005). All patients were screened for the evidence of primary pulmonary tuberculosis. As part of their radiological workup, they were subjected to either a CT scan–head or MRI–brain. All patients were surgically managed at the institute. ATT was prescribed for 18 months. Follow-up period ranged from 6 months to 8 years.Results. All patients improved following the completion of therapy with no evidence of recurrence.Conclusion. Calvarial tuberculosis is endemic in developing countries. This disease mainly affects the young population. With the rising incidence of AIDS, neurosurgeons all over the world are more likely to be exposed to this disease. CT–head and MRI–brain is the mainstay for radiological diagnosis. Definitive diagnosis rests on a biopsy report. Surgical debridement followed by anti-tubercular therapy for 18 months is the mainstay of the management of this unusual presentation.

Tubercular Osteomyelitis of the Clavicle: A Report of Four Cases

We report the clinicoradiological features of tuberculosis in the clavicle in 4 patients. The patients' ages ranged from 9 months to 29 years. All patients were managed with antitubercular drug therapy for one year and one underwent surgical debridement and curettage as well. Clinicians should be aware of the varied presentation (pain, non-healing ulcer, abscess, multifocal osteoarticular tuberculosis) of this condition. With the worldwide resurgence of tuberculosis, clinicians should maintain a high index of suspicion. The diagnosis of osteoarticular tuberculosis is usually made on clinico-radiological features.

Genital Tuberculosis-A Silent Infection in Infertile Indian Population

Background: Genital tuberculosis is reported to be a major factor causing infertility in Indian women and often exists without any apparent signs and symptoms. Aim: To study the effect of tuberculosis, a common infectious disease in the Indian subcontinent, its subsequent effect on female fertility. To assess the clinical presentation of genital tuberculosis and to study various modes of diagnosis. Method: Study was done between Jan 2005- Dec 2006 on 250 infertile women at an infertility care and assisted reproductive unit in Central India, in whom there was clinical suspicion of genital tuberculosis. All underwent diagnostic laparoscopy and biopsy for confirmation and other causes of infertility were excluded. Utility of various laboratory parameters AFB smear, AFB culture and PCR to diagnose genital tuberculosis were assessed. Laparoscopic findings were correlated with laboratory results. Result: The prevalence of genital TB was higher than one might imagine. Among the 170 infertile women affected with genital tuberculosis there were cases of primary (n = 149) and secondary (n = 21) infertility The diagnosis of endometrial tuberculosis was confirmed by AFB smear 52, AFB culture 6, PCR112. Treatment with anti-tubercular drug therapy resulted in increased conception rate. Laparoscopy examination is a valuable procedure for the etiological diagnosis of tubal infertility and correspond with positive PCR 88%, AFB smear 72% and AFB culture in 98%. Conclusion: It is essential for a gynaecologist working in developing countries to anticipate possibility of genital tuberculosis in infertile patients. This study highlights the fact that tuberculosis, a chronic infectious disease, is one of the major etiologic factors of female infertility, especially on the Indian subcontinent. Female genital tuberculosis is a symptom-less disease inadvertently uncovered during investigation for infertility. Clinicians need to be aware of the existence of this important cause of infertility in women, in view of the current upsurge in tuberculosis worldwide.

Genitourinary Tuberculosis in Pediatric Urological Practice

PURPOSE Genitourinary tuberculosis (GUTB) is much rarer in children. It is a form of secondary tuberculosis with vague symptoms and presentation. Antitubercular therapy forms the cornerstone in the treatment, although surgical intervention is required in a minority of the cases. We retrospectively evaluated our series of children with Genitourinary tuberculosis, with special emphasis on the role of surgery. MATERIAL AND METHODS Case records of 17 children diagnosed and admitted with genitourinary tuberculosis at our center were reviewed. Clinical features, organ involvement, investigations, treatment and outcome of therapy were studied. RESULTS There were 11 male and 6 female children with a mean age of 11.6 years, admitted during the period July 1990 to June 2005. The most common presentation were storage lower urinary tract symptoms. The most commonly involved organ was the ureter in 7 (41%) cases. Mycobacterium tuberculosis was identified in urinary examination in only 5 (29%) cases. A total of 28 procedures, including 15 endoscopic, 4 ablative and 5 reconstructive were performed with some children requiring more than 1 procedure. Renal functional parameters stabilized or improved in 4 of 5 children (80%) in whom they were deranged at presentation. CONCLUSIONS GUTB presents with a wide variety of clinical features and pathological lesions. Diagnosis is often delayed because of late presentation and many children present with cicatrisation sequelae. Antitubercular drug therapy and judicious application of surgery achieves satisfactory results in the majority of cases. With improved Antitubercular drug therapy and experience with the use of bowel segments in the urinary tract, more reconstructive procedures are being performed with satisfactory outcomes. Children undergoing surgical procedures and reconstructive in particular need to be followed up rigorously.

Genitourinary tuberculosis in pediatric urological practice

Objective Genitourinary tuberculosis is a form of secondary tuberculosis with vague symptoms and presentation, and is rare in children. Antitubercular therapy is the cornerstone of treatment, although surgical intervention is required in a minority of the cases. We retrospectively evaluated our series of children with this disease, with special emphasis on the role of surgery. Materials and methods Case records of 17 children diagnosed and admitted with genitourinary tuberculosis at our center were reviewed. Clinical features, organ involvement, investigations, treatment and outcome of therapy were studied. Results There were 11 male and six female children with a mean age of 11.6 years, admitted during the period July 1990 to June 2005. The most common presentation was storage lower urinary tract symptoms. The most commonly involved organ was the ureter in seven (41%) cases. Mycobacterium tuberculosis was identified on urinary examination in only five (29%) cases. A total of 28 procedures, including 15 endoscopic, four ablative and five reconstructive, were performed with some children requiring more than one procedure. Renal functional parameters stabilized or improved in four of five children (80%) in whom they were deranged at presentation. Conclusions Genitourinary tuberculosis presents with a wide variety of clinical features and pathological lesions. Diagnosis is often delayed because of late presentation and many children present with cicatrization sequelae. Antitubercular drug therapy and judicious application of surgery achieve satisfactory results in the majority of cases. With improved drug therapy and experience with the use of bowel segments in the urinary tract, more reconstructive procedures are being performed with satisfactory outcomes. Children undergoing surgical procedures and reconstruction in particular need to be followed up rigorously.

A case of scrotal sarcoidosis that mimicked tuberculosis

A 38-year-old man presented with bilateral testicular swelling, night sweats and weight loss with little response to antibiotics. Examination revealed systemic lymphadenopathy and multiple small masses arising from both testes. Scrotal ultrasound revealed multiple intratesticular, hypoechoic lesions; chest radiograph and abdominal ultrasound were normal. A CT scan revealed multilevel lymphadenopathies. A Heaf (tuberculin) skin test was negative. Testicular biopsy revealed multiple granulomata, some of which showed patchy central necrosis. A diagnosis of tuberculosis was initially made. After 3 months of clinical deterioration despite antitubercular drug therapy, however, the diagnosis was changed to sarcoidosis because blood results revealed hypercalcemia, elevated serum angiotensin-converting enzyme, and an elevated erythrocyte sedimentation rate. The patient improved dramatically on corticosteroid therapy, with complete regression of all testicular lesions on imaging after 2 months. Steroids were tapered, then discontinued after 6 months. The patient remained in complete remission, but became oligospermic by the 3 year follow-up.