Antituberculous Treatment Research Articles

Tubercular osteomyelitis as scalp swelling and alopecia areata

Tuberculosis (TB) is a well-known endemic disease in developing countries. It continues to be one of the major causes of death and disability in such countries. However, extrapulmonary TB is less common than pulmonary TB. Skeletal TB constitutes about 1% of all tubercular cases. Tubercular osteomyelitis of skull is a rare entity. The most common sites affected are the frontal and parietal bones with destruction of both the inner and outer table. We hereby report a young male presenting to us with scalp swelling in the left frontal region with loss of hair in surrounding areas and in left temporal region. NCCT head was suggestive of osteolytic lesion in frontal bone on left side with accompanying periosteal reaction, consistent with osteomyelitis. In Gene Xpert of pus drained from the swelling, Mycobacterium tuberculosis was detected. Patient was started on Antituberculous treatment, and subsequently improved.

PRIMARY ORAL TUBERCULOSIS PRESENTING AS A TONGUE ULCER

Primary tuberculosis of the oral cavity is an extremely rare condition accounting for less than 1% of the extrapulmonary cases. A 36-year-old male patient was referred for consultation complaining of dysphonia and dysphagia associated with a painful nonhealing lesion in the tongue for approximately 60 days. Physical examination revealed a well-defined ulcer affecting the tongue apex. The patient reported the use of topic corticosteroids for over 30 days without any improvement. Hematologic exams were within normal limits and serologic tests for HIV, syphilis, and hepatitis were negative. Incisional biopsy was performed, and histopathologic examination revealed a granulomatous inflammatory process composed of multinucleated giant cells, epithelioid histiocytes, and lymphocytes. A Ziehl-Neelsen stain showed the presence of acid-fast bacilli, compatible with mycobacteria. No chest imaging alterations nor previous respiratory symptoms were present. Sixty days after starting antituberculous treatment, the patient showed complete healing of the lesion.

Magnetic Resonance Imaging Findings of Intraspinal Tuberculoma in Children.

Background and PurposeIntraspinal tuberculoma is a rare disease in children, and its imaging findings have been described in only a few case reports. This study aimed to investigate the magnetic resonance imaging (MRI) features of pediatric intraspinal tuberculoma and to explore the possible pathogenesis of the disease.Materials and MethodsThe clinical and MRI data of 24 child patients with intraspinal tuberculoma (such as 6 cases of intramedullary tuberculoma, 8 cases of intradural extramedullary tuberculoma, and 10 cases of epidural tuberculoma) were retrospectively analyzed. All patients underwent plain and contrast-enhanced MR scans. The diagnosis was confirmed by surgical pathology or by antituberculous treatment and follow-up data.ResultsIntramedullary tuberculoma had a round shape, while intradural extramedullary tuberculoma and epidural tuberculoma presented long-fusiform or en plaque shapes. Regarding MRI signals, intramedullary tuberculoma and extramedullary tuberculoma were mainly isointense on T1-weighted imaging (T1WI) and hypointense or isointense on T2WI. Rim enhancement was observed in intramedullary tuberculoma, and marked homogeneous enhancement was dominant in extramedullary tuberculoma. Ten (10/24) tuberculomas occurred during antituberculous therapy, with intradural extramedullary tuberculoma accounting for 7 cases (7/8), which was significantly more frequent than intramedullary tuberculoma (1/6) or epidural tuberculoma (2/10).ConclusionMRI is important in the diagnosis of intraspinal tuberculoma, which is characterized by isointensity on T1WI, isointensity, or hypointensity on T2WI, and rim or obvious homogeneous enhancement. Some intraspinal tuberculomas, especially intradural extramedullary tuberculomas, might be associated with the “paradoxical response” mechanism during the tuberculosis treatment.

Pulmonary tuberculosis presenting as cystic disease/abscess

There was a 19% increase in year 2021 when compared to 2020 in TB patients’ notification in India, even though TB notifications noted around the period corresponding to India’s two major COVID-19 waves showed a brief decline, the National Tuberculosis Elimination Programme (NTEP) managed to reclaim the lost numbers. Cystic changes of the soft tissue and chest wall associated with pulmonary tuberculosis is rarely diagnosed and reported, and only few patients were diagnosed based only on the radiological and histopathological findings. Herewith, we report the microbiological, histopathological, computed tomographic, ultrasound and clinical findings of cystic change in pulmonary tuberculosis in an immunocompetent 18-year-old male who presented with pain in the Chest and swelling in the left infra mammary region for a short duration of one month. The lesion regressed and patient showed clinical improvement following Anti-tuberculous therapy treatment initiation after linking the patient with NIKSHAY system and is currently under ATT.

Disseminated Mycobacterium Bovis

Intravesical BacillusChalmette- Guerin (BCG) still a popular medication for non-invasive bladdercancer in the low-income country, one of the uncommon side effects is disseminated Mycobacterium Bovis. We present a patient who presented with haematuria, diagnosed as urothelial superficial bladder cancer, treated with incomplete resectionand intravesical BCG, 6 months after treatment, he presented with increasing shortness of breath, headache and abdominal pain, diagnosed as tuberculous, meningitis, massive pleural effusion, granulomatous hepatitis he responded very well to anti tuberculous treatment.

Cerebellar tuberculoma in an immunocompetent patient

Background: Tuberculosis infection of the Central Nervous System is the major cause of death and morbidity in developing countries. The clinical manifestations and radiological findings in tuberculoma are nonspecific. This article reports a rare case of cerebellar tuberculoma with the manifestation related to an intracranial mass and without the typical clinical symptoms of Tuberculosis in an immunocompetent patient. Case Report: A 20-year-old female with seizure, headache, and vertigo. A mass in the posterior fossa was revealed by Magnetic Resonance Imaging. Thorax scan results showed the Tuberculosis process. The patient then underwent surgery. Histopathological examination displayed chronic granulomatous inflammation and the presence of Acid-Fast Bacilli. The patient received anti-tuberculous drug treatment for one year and anti-seizure medication. Discussion: Cerebellar tuberculoma can resemble an intracranial tumor or cranial abscess. Diagnosis is based on clinical, radiological manifestations, and histopathological analysis. Surgical intervention still has a role in the treatment of this disease. The finding of Mycobacterium tuberculosis on histopathological examination is the gold standard in diagnosing Tuberculosis. Conclusions: Although it is rare, the involvement of Tuberculosis in the CNS should be taken into account in both immunocompetent and immunocompromised patients with neurological symptoms who are living in an endemic area.

Efficacy of Posterior and Posterolateral Approach for Decompression and Fusion for Thoracolumbar Tuberculosis

Objective: To study the efficacy of the posterior and posterolateral approach in thoracolumbar tuberculosis.
 Material and Methods: 60 patients with thoracolumbar TB spine were enrolled in the study from 2015 to 2021. These patients had single-level disease with low back pain and neurological compromise in lower limbs. The diagnosis was made on an MRI of the spine and elevated ESR levels. All patients were started with antituberculous treatment. The pain was measured on the VAS score, and neurological status was assessed on the ASIA score. Kyphosis angle was calculated on a lateral x-ray of the spine. All patients were operated on by posterior and posterolateral approaches with decompression and fusion. At follow-up, fusion was assessed on every visit by x-ray along with neurological status and pain score.
 Results: The mean age of patients was 45.8 years (25 to 66 years). 59.5% patients achieved radiological fusion on follow-up x-rays. There was a significant improvement in VAS score preoperatively mean and SD6.38 ± 1.24to postoperatively 4.45 ± 1.09. The mean and SD of kyphosis in patients preoperatively was 22.3 ± 3.06 to post-operative 22.3 ± 3.06 with a p-value < 0.05 which shows significant improvement.
 Conclusion: Posterior and posterolateral decompression and fusion of thoracolumbar tuberculosis is a good surgical approach in respect of neurological outcome, correction of kyphosis, and pain improvement.

A Case Series on GeneXpert Negative Tuberculous Mastitis and the Effect of Anti-tuberculous Treatment

Background: Breast tuberculosis is significant due to its rare occurrence and dilemma in prospective treatment and differentiation from neoplastic lesions. Tuberculosis of the breast usually affects women from Asia, most commonly, the Indian subcontinent and Africa. Tuberculous mastitis has a wide range of clinical presentation, radiological features, and even microbiological presentation. Materials and Method: A prospective study was conducted over 6 months. 40 female patients with varied presentations correlating to tuberculous mastitis with a lump in the breast for a particular period of time were included in the study. Results: The patients’ ages varied from 20 to 45 years. After routine investigations, the patients went in for incision and drainage or incisional biopsy or both and postoperatively their histopathological reports revealed granulomatous breast disease (tuberculous mastitis) with negative GeneXpert (CB-NAAT). Patients were started on an anti-tubercular treatment regimen and showed a progressive decrease in symptomatology. Conclusion: Granulomatous breast abscess/ tuberculous breast abscess has a varied presentation and no fixed treatment regime. Anti-tuberculous drugs in such patients proved to be efficacious in symptomatic relief with prevention of recurrence/ fistula formation.

Application of metagenomic next-generation sequencing in suspected intraocular infections.

To evaluate the efficacy of metagenomic next-generation sequencing (mNGS) and to explore its value in the diagnosis of intraocular infection. A retrospective case-series study of patients with suspected intraocular infection was performed. Intraocular fluid samples were collected from all the patients and sent for mNGS. Detailed clinical data, the results of mNGS and other laboratory examinations, the sequencing data of mNGS, and the final diagnosis were recorded. Fifteen eyes of 15 patients were included in the study. Eight samples were identified as positive for different kinds of pathogens by mNGS, which were all confirmed by other laboratory examinations or effective diagnostic treatment. The mNGS results were negative in seven samples. The final diagnosis was still intraocular infection in four of the seven negative results. Of these, one patient was diagnosed with fungal endophthalmitis according to the clinical characteristics and good treatment response to the anti-fungal therapy, one patient underwent vitrectomy and the bacterial culture of the vitreous sample was positive for Brucella melitensis, and two patients were diagnosed with ocular tuberculosis according to the positive T-SPOT test and effective anti-tuberculous treatments. mNGS could be helpful in determining pathogens in cases of suspected intraocular infection. The mNGS protocols should be optimized for the detection of intracellular bacterial and fungal pathogens.

Lymph Node Tuberculosis in Otolaryngological Practice: A Study of 68 Cases at the Sourô Sanou University Hospital of Bobo Dioulasso, Burkina Faso

Introduction: Lymph node tuberculosis (LNTB) frequently affects peripheral cervical lymph node body sites. We aimed to study epidemiology and diagnostic and therapeutic characteristics of LNTB patients in ENT routine practice. Methods: We conducted a cross-sectional prospective study in the ENT and cervicofacial surgery department at the Sourô Sanou University Hospital of Bobo Dioulasso, Burkina Faso, for a period of 36 months. Results: There were 68 cases with LNTB, of which 54.4% were mostly men. The mean age and the median age were calculated at 37 ± 6.8 and 42 years, respectively. The patient’s age ranged between 3 and 81 years, and the most represented age group was from 30 to 60 years (62%). According to geographical origin, most patients (79%) originated from rural areas. In 6 cases (9%), patients reported diabetes and 12 patients were HIV positives (18%). Most clinical features leading to the ENT consultation were cervical lymph nodes (82%) and cervical scrofuloderma (18%). For the multiple locations, the lymphadenopathies involved mostly the transversal cervical chain (56%) and spinal chain (50%). Histopathology examination was the mostly diagnosed methods used in 68%. A 6-month anti-tuberculous treatment was given with a follow-up of 6 months without any relapse in 62 cases (97%). Conclusion: The frequency of 68 cases of LNTB in 3 years is underappreciated. Among all lymph node sites, transversal cervical chain and cervical spinal chain were mostly affected. Further advanced studies are recommended to determine the prevalence and contributing factors of LNTB in the study area.

Tuberculous peritonitis in peritoneal dialysis: report of three cases

Tuberculous peritonitis is a rare but dreaded complication in peritoneal dialysis.
 We report three cases of tuberculous peritonitis diagnosed in our PD center at over a period of 15 years.
 They are a woman and two men aged 50, 45 and 64 respectively.
 The diagnosis of tuberculous peritonitis was suspected in front of a many of clinical (AEG, abdominal pain, cloudy liquid), biological (inflammatory syndrome, the dialysate liquid with lymphocyte predominance and negative culture) and or radiological (abdominal lymphadenopathy) arguments.
 It was confirmed by the demonstration of Mycobacterium Tuberculosis in the dialysate by GeneXpert or by culture on LOWENSTEIN Jensen medium in 2 cases, and the characteristic appearance on anatomopathological examination in only 1 case.
 The evolution under antituberculous treatment was favorable, with recourse to the ablation of
 The diagnosis of tuberculous peritonitis in peritoneal dialysis is difficult and often late because the clinical signs is non-specific. It should be considered in the presence of any culture-negative peritonitis that is refractory to empirical treatment.
 Bacteriological or histological confirmation should not delay the start of anti-tuberculosis treatment because early diagnosis and rapid initiation of treatment are the keys to recovery and the only guarantee of a good prognosis.

SHINE trial of shorter course tuberculosis treatment

Journal of Paediatrics and Child HealthVolume 58, Issue 5 p. 935-935 Heads UpFree Access SHINE trial of shorter course tuberculosis treatment First published: 02 April 2022 https://doi.org/10.1111/jpc.15957 edited by Craig Mellis (craig.mellis@sydney.edu.au) [Correction added on 12 April 2022, after first online publication: Figure 1 has been removed from the article.] AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat The World Health Organization (WHO) estimates that 1.1 million children worldwide became ill with tuberculosis (TB) in 2020. Treatment adherence is a possible issue in the development of multidrug-resistant TB. The SHINE trial randomised 1204 African and Indian children (median age 3.5 years, range 2 months to 15 years) diagnosed with respiratory sample smear-negative, ‘non-severe’ TB to either 4 or 6 months of anti-tuberculous treatment using child-friendly fixed dose combinations (8 weeks of isoniazid, rifampicin and pyrazinamide ± ethambutol followed by 8 or 16 weeks of isoniazid and rifampicin).1 Of these, 52% were male, 11% had human immunodeficiency virus (HIV) infection, and 14% had bacteriologically confirmed TB. Retention (95% at 72 weeks) and treatment adherence (94%) were very high. The primary endpoint, unfavourable outcome (treatment failure or death), occurred in 16 participants (3%) in the 4-month group compared with 18 (3%) in the 6-month group (adjusted difference, −0.4%; 95% CI, −2.2 to 1.5). Adverse events mainly occurred in the first 8 weeks of treatment and were equally common (8%) in both groups. As a result of the SHINE trial, new WHO guidelines recommend that children with non-severe TB can now receive 4 months of anti-TB treatment. The challenges are accurate classification of ‘non-severe’ disease in resource-limited settings where disease burdens are highest, and whether clinicians in developed countries will feel comfortable treating for 4 months before more clinical experience accumulates. Reference 1Turkova A, Wills GH, Wobudeya E et al. Shorter treatment for nonsevere tuberculosis in African and Indian children. N. Engl J Med 2022; 399: 911– 22. CrossrefWeb of Science®Google Scholar Reviewers: David Isaacs (david.isaacs@health.nsw.gov.au) and Ben Marais (ben.marais@health.nsw.gov.au), Children's Hospital at Westmead and University of Sydney Volume58, Issue5May 2022Pages 935-935 ReferencesRelatedInformation

Disseminated tuberculosis presenting as cardiac tamponade—Uncommon presentation in common disease

Tuberculosis is the most common infection in India, and its incidence accounts for approximately one-fifth of the global burden. Cardiac tamponade resulting from the liver abscess with subdiaphragmatic rupture communicating with pericardial cavity presenting as disseminated tuberculosis is uncommon. Here, we reported a case of a 63-year-old man who presented with the shortness of breath for 3 days with orthopnea. Imaging studies reveal pericardial effusion, left liver lobe loculated lesion, and enlarged right supraclavicular lymph node. Further image-guided pericardiocentesis, left liver lobe aspiration cytology, and right supraclavicular lymph node cytology reveal granulomatous inflammation with positive acid-fast bacillus in the liver aspirate. The patient was managed in the emergency room symptomatically initially and was then successfully treated with antituberculous treatment.

Ruptured tuberculous aneurysms of the abdominal aorta: Two case series.

BackgroundRuptured aneurysms secondary to the tuberculous infection of the aorta are a rare and life-threatening disease. We report a single-center experience of two patients with ruptured infrarenal tuberculous aneurysms.Case presentationWe report 2 patients with ruptures of the tuberculous aneurysm. All patients had acute abdominal pain and were diagnosed by echography then CT scan preoperatively. The first patient (male, 50 years old) had a ruptured saccular aneurysm. The second patient (male, 43 years old) had a retroperitoneal contained rupture. All were treated by open prosthetic repair, by vascular surgeons. The two patients were well after operations. The diagnosis was confirmed by pathology examination. Antituberculous treatment was introduced after the operation.ConclusionsRuptured tuberculous aneurysms are rare but life-threatening. The diagnosis requires a high degree of suspicion. The treatment includes early diagnosis and emergent surgical intervention, extensive excision of infected field, aortic reconstruction, and prolonged antituberculous drug therapy.

Correlation Between CT Features of Active Tuberculosis and Residual Metabolic Activity on End-of-Treatment FDG PET/CT in Patients Treated for Pulmonary Tuberculosis.

Patients who complete a standard course of anti-tuberculous treatment (ATT) for pulmonary tuberculosis and are declared cured according to the current standard of care commonly have residual metabolic activity (RMA) in their lungs on fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (FDG PER/CT) imaging. RMA seen in this setting has been shown to be associated with relapse of tuberculosis. The routine clinical use of FDG PET/CT imaging for treatment response assessment in tuberculosis is hindered by cost and availability. CT is a more readily available imaging modality. We sought to determine the association between CT features suggestive of active tuberculosis and RMA on FDG PET/CT obtained in patients who completed a standard course of ATT for pulmonary tuberculosis. We prospectively recruited patients who completed a standard course of ATT and declared cured based on negative sputum culture. All patients had FDG PET/CT within 2 weeks of completing ATT. We determined the presence of RMA on FDG PET images. Among the various lung changes seen on CT, we considered the presence of lung nodule, consolidation, micronodules in tree-in-bud pattern, FDG-avid chest nodes, and pleural effusion as suggestive of active tuberculosis. We determine the association between the presence of RMA on FDG PET and the CT features of active tuberculosis. We include 75 patients with a mean age of 36.09 ± 10.49 years. Forty-one patients (54.67%) had RMA on their FDG PET/CT while 34 patients (45.33%) achieved complete metabolic response to ATT. There was a significant association between four of the five CT features of active disease, p < 0.05 in all cases. Pleural effusion (seen in two patients) was the only CT feature of active disease without a significant association with the presence of RMA. This suggests that CT may be used in lieu of FDG PET/CT for treatment response assessment of pulmonary tuberculosis.

Brachial plexus tuberculosis: A unique neurological variant of a common clinical disease

Isolated primary tuberculous involvement of the brachial plexus has not been reported in the past. Here, we report the case of a 29-year-old male who developed neck pain and radiculopathy for 3 months. Weakness in the left shoulder-elbow (2/5 MRC grade) and wrist (4/5 MRC grade) was present with numbness to pain and temperature along the C4–C5 dermatome. Magnetic resonance imaging (MRI) revealed a T2 hyperintense heterogeneously contrast-enhancing lesion involving the upper trunk of the brachial plexus. Under suspicion of malignancy, surgical exploration was undertaken. Intraoperatively, pus was noticed with unhealthy granulation tissue extending along the left-sided C4–5 lamina and transverse process. The frozen section suggested granulomatous infection and histopathology confirmed tuberculosis (TB). After 18 months of antituberculous treatment, the patient gradually recovered complete strength in the left upper limb. Follow-up brachial plexus MRI showed near-complete resolution of the lesion. We describe a unique case of a young patient clinically suggestive of the rapid progressive lesion (mimicking malignancy) affecting brachial plexus, turning out as TB on histopathology.

Congenital pulmonary airway malformation-Two case reports and diagnosis challenges in a resource limited setting

Congenital Pulmonary Airway Malformation (CPAM) is a rare abnormality of pulmonary airway malformation and may remain undiagnosed until it is discovered as an incidental finding later in life. Reported here are two cases of CPAM, a seven-month-old infant and a two-year-old toddler. A seven-month-old ex-premature male infant presented with recurrent pneumonia and failure to thrive. He had an unresolving consolidation on chest radiograph and was eventually treated as pulmonary tuberculosis with no response. Computerised tomography scan (CT-scan) chest revealed bilateral CPAM of lungs. A 2-year-old female toddler presented to the University Teaching Hospital, Department of Paediatrics &amp; Child Health, as a referral from a second level hospital with a long-standing history of recurrent symptoms and signs of pneumonia with failure to thrive. She was commenced on antituberculous treatment with no improvement. A CT-scan of the chest revealed bilateral CPAM of lungs. These two cases highlight clinical, diagnostic and treatment challenges in children with CPAM in a resource limited setting like Zambia.

Congenital pulmonary airway malformation-Two case reports and diagnosis challenges in a resource limited setting

Congenital Pulmonary Airway Malformation (CPAM) is a rare abnormality of pulmonary airway malformation and may remain undiagnosed until it is discovered as an incidental finding later in life. Reported here are two cases of CPAM, a seven-month-old infant and a two-year-old toddler. A seven-month-old ex-premature male infant presented with recurrent pneumonia and failure to thrive. He had an unresolving consolidation on chest radiograph and was eventually treated as pulmonary tuberculosis with no response. Computerised tomography scan (CT-scan) chest revealed bilateral CPAM of lungs. A 2-year-old female toddler presented to the University Teaching Hospital, Department of Paediatrics &amp; Child Health, as a referral from a second level hospital with a long-standing history of recurrent symptoms and signs of pneumonia with failure to thrive. She was commenced on antituberculous treatment with no improvement. A CT-scan of the chest revealed bilateral CPAM of lungs. These two cases highlight clinical, diagnostic and treatment challenges in children with CPAM in a resource limited setting like Zambia.

Disseminated paracoccidioidomycosis associated with lymph node tuberculosis in a non immunocompromised child

The association of paracoccidioidomycosis (PCM) and tuberculosis (TB) produces an uncommon hyperinflammatory syndrome, causing multiorgan dysfunction. TB associated PCM is a rare condition, but it is fatal if not treated. Herein, we present a immunocompetent child who is admitted for fever and painful lymphadenopathy, with evidence of acid-alcohol-resistant bacillus (AARB) in cervical lymph node biopsy, antituberculous treatment was started with partial clinical improvement and is given discharge from hospital. At 3 weeks, he was readmitted by fever, weight loss, dyspnea and a greater number of adenopathies, in the new biopsy multiple yeasts were found compatible with PCM, our patient responded well to the combination of antituberculosis therapy(ATT), corticosteroid, and amphotericin B deoxycholate, presenting clinical improvement and subsequently continued with itraconazole.

Pseudoaneurysm of an Internal Mammary Artery Due to Tuberculosis

Tuberculosis is the most common pulmonary infection in developing countries. Vascular complications are known to occur as a part of disease progression. Aneurysm associated with internal mammary artery can be true aneurysm or pseudoaneurysm. Pseudoaneurysm of the internal mammary artery can be due to invasive procedures or as a part of infective etiology. Tuberculosis destroys the wall of blood vessels leading to the formation of pseudoaneurysm. Early identification and intervention of pseudoaneurysm will avoid complications of hemorrhage, hemothorax, and hemorrhagic shock. We present a case of tuberculous empyema that causes pseudoaneurysm of an internal mammary artery managed with coil embolization along with antituberculous treatment.