Initiation Of Anti-tubercular Therapy Research Articles

Ultra-Wide Field Imaging in Paradoxical Worsening of Tubercular Multifocal Serpiginoid Choroiditis after the Initiation of Anti-Tubercular Therapy

ABSTRACTPurpose: To evaluate role of ultra-wide field (UWF) versus conventional imaging in the follow-up and paradoxical worsening (PW) of tubercular (TB) multifocal serpiginoid choroiditis (MSC).Methods: Prospective observational study of patients with TB MSC undergoing UWF imaging, autofluorescence and fluorescein angiography was performed. A circle simulating central 75° field representing conventional imaging was drawn on UWF images. The information yielded by the two modalities, progression of choroiditis lesions and PW was compared.Results: 44 eyes (29 patients, mean age: 30.7 ± 9 years; 23 males) were included. UWF imaging showed additional lesions in 39/44 eyes (88.6%). Overall, 16/44 eyes (36.4%) showed PW; 3/16 eyes (18.7%) showed only peripheral PW, while 10/16 eyes showed both central and peripheral PW. Management was altered in 11 patients (37.93%) based on UWF imaging.Conclusions: UWF is more useful than conventional imaging in identifying additional choroiditis lesions, PW and altering the course of therapy in TB MSC.

Tubercular esophagocutaneous fistula: Rare case report

Tubercular esophagocutaneous fistula is a rare entity with only about five cases reported so far. It can be as a result of primary involvement of esophagus by tuberculosis or due to spread of infection from adjacent structures like lungs or mediastinal lymph nodes. The fistula usually heals with initiation of antitubercular therapy and surgery is rarely required. Here we report a case of 65-year-old diabetic male who developed esophagocutaneous fistula secondary to caseation of mediastinal lymph nodes and was successfully treated with antitubercular treatment.

Optical Coherence Tomography Angiography Features of Paradoxical Worsening in Tubercular Multifocal Serpiginoid Choroiditis

ABSTRACTPurpose: To describe optical coherence tomography angiography (OCTA) features of lesions of tubercular multifocal serpiginoid choroiditis (TB MSC) that developed paradoxical worsening (PW).Methods: In this prospective study, subjects with TB MSC who developed PW upon initiation of anti-tubercular therapy were included. Multimodal imaging was performed using OCTA, enhanced-depth imaging OCT, fluorescein angiography (FA), and indocyanine green angiography (ICGA). Morphologic changes in the retinochoroidal vasculature during progression of TB MSC were assessed on OCTA.Results: Five subjects (4 males, 1 female) were included in the study. PW of the lesions was associated with increased areas of choriocapillaris flow void on en face OCTA in all eyes. The lesions showed partial healing in the center and continuous progression at the active edges. Two eyes showed development of vascular tufts on OCTA as the lesions progressed.Conclusions: OCTA provides high-resolution imaging of progressive choriocapillaris hypoperfusion among TB MSC patients developing PW of the disease.

Paradoxical Worsening of Tubercular Serpiginous-Like Choroiditis after Initiation of Antitubercular Therapy.

In this study, a case with tubercular choroiditis showing severe macular edema and progression of choroidal lesions following initiation of antitubercular treatment is presented and the management of posterior uveitis associated with tuberculosis is evaluated. A 40-year-old female patient was admitted with decreased vision in her right eye and her fundoscopic examination revealed serpiginous choroiditis. It was learned from her medical history that she had taken antitubercular therapy 9 years ago. Mantoux tuberculin skin test showed an area of induration measuring 15 mm and a positive interferon-gamma release assay was documented. Additionally, sequelae lesions due to previous tubercular infection were remarkable on her chest imaging. By excluding other causes of uveitis, the patient was considered presumed ocular tuberculosis and a full standard course of 4-drug antitubercular therapy was initiated. On the seventh day of the treatment existing choroidal lesions showed progression, new foci of choroiditis appeared and severe macular edema occurred. After adding systemic corticosteroid to the treatment, the macular edema resolved and choroidal lesions began to inactivate. In patients with tubercular choroiditis, continued progression may develop after initiation of antitubercular therapy. This paradoxical worsening is thought to be a hyperacute immunologic reaction occurring against antigen load released after antitubercular therapy. This phenomenon may be suppressed by the addition of systemic corticosteroids to the treatment.

English

INTRODUCTION: Right iliac fossa mass may arise from parietal wall or intraperitoneum or retroperitoneum. Mass may arise from right iliac regional structures or extended from adjacent structures. Appendicular pathology is commonest cause for right iliac fossa mass (either appendicular mass or abscess). Other common causes are ileo-caecal tuberculosis and carcinoma caecum. Appendicular mass is formed by inflamed appendix adherent with dilated ileum, greater omentum and caecum. Appendicular abscess due to suppuration in an acute appendicitis or suppuration in an already formed appendicular mass. Abdominal tuberculosis is common in developing countries like India. It is sixth most common type of extra pulmonary tuberculosis. Its incidence is high in HIV infected patients. Ileo-caecal tuberculosis is commonest type of abdominal tuberculosis due to presence of Peyer's patches and stasis of luminal contents favoured by ileo-caecal valve. Commonest type of carcinoma in caecum is adenocarcinoma. Third common site in large bowel carcinoma (12%). Diet with lack of fibres and high fat increases risk. Dietary vitamins A, C, E (antioxidants) and Zinc and high fibre diet reduce the risk. Diagnosis of right iliac fossa mass mainly depends on complete clinical examination, radiological, biochemical, microbiological and pathological investigations. Commonest cause of right iliac fossa mass in our country is appendicular mass or abscess, ileo-caecal tuberculosis and carcinoma caecum. OBJECTIVES: To study the aetiology, pattern of presentation, management and complications in patients with right iliac fossa mass in our institution. MATERIALS AND METHODS: This retrospective study was carried out in our institution over a period of two years from October 2010 to October 2012. All patients who are provisionally diagnosed to have mass in the right iliac fossa by clinical evaluation are included in the study. All data including age, gender, relevant history, investigations (complete blood count, Blood grouping and Rh typing, HIV I & II, Chest radiograph, Ultrasound abdomen and pelvis, CT Scan abdomen and pelvis, IVP and barium follow through and enema, FNAC, BIOPSY) were done to conclude the final diagnosis and appropriate treatment and postoperative complications and final histopathological reports were recorded in the standard forms. Cases are selected by following Inclusion and exclusion criteria; Inclusion criteria: All the cases admitted with Right iliac fossa mass in our institution. Exclusion criteria: Female patients with gynaecological diseases. Paediatric age group (<12 years) patients with right iliac fossa mass. CONCLUSION: Right iliac fossa mass was common in 20 to 50 years of age group. Overall incidence was more common in males as compared to females (1.1:1).Appendicular pathology and Carcinoma caecum was more common in males as compared to females. Ileo-caecal tuberculosis was more common in females. The diseases were more in people from low socio –economic status and the commonest symptom was pain in abdomen. Appendicular pathology (60%) either in the form of appendicular mass (32.5%) or appendicular abscess (27.5%) were the commonest cause of mass in the right iliac fossa. Ileo-caecal tuberculosis (20%), carcinoma caecum (12.5%) was the other common causes of mass in the right iliac fossa. Ultrasound abdomen was the essential investigation and it had a sensitivity of greater than 95%. Normal levels of serum CRP titer essentially ruled out appendicular pathology. Serial titers were helpful in assessing the treatment response of ileo-caecal tuberculosis and in prognosis of carcinoma caecum. In patients with appendicular mass, initial conservative management followed by interval appendicectomy had better results with minimal complications. In patients with appendicular abscess, abscess drainage combined with appendicectomy in the same procedure, had high morbidity compared to patients who underwent interval appendicectomy following abscess drainage. 44% of the patients with ileo-caecal tuberculosis were managed conservatively with anti-tubercular therapy (DOTS-I). Surgery was required in another 56 % of the patients, of which 25 % of the patients presented with acute complications needing immediate surgery. 31 % of the patients presented with sub-acute intestinal obstruction due to adhesions and strictures following the initiation of anti-tubercular therapy, which later required surgical intervention. 80 % of the patients with carcinoma caecum underwent successful surgical resection. 20 % of the patients presented with acute surgical problem requiring immediate surgery. 10 % of the patients presented with advanced disease. Most of the parietal wall and retroperitoneal conditions were treated surgically. Early evaluation and intervention is needed to improve the patients’ outcome and to reduce the morbidity and mortality.

Potential role of F18 FDG PET-CT as an imaging biomarker for the noninvasive evaluation in uncomplicated skeletal tuberculosis: a prospective clinical observational study.

This is a prospective non-randomized observation study done on 33 patients with uncomplicated spinal tuberculosis to observe the imaging characteristics on sequential F-18 FDG PET CT scans. 33 consecutive patients with pathologically proven spinal tuberculosis underwent a baseline contrast-enhanced whole body FDG PET scan before initiation of antitubercular therapy, 6 and 12 months and at 18 months or the end of antitubercular therapy. The baseline peak SUVmax of lesions in our 33 cases had values ranging from 5.9 to 30.3 (mean 14.8). 63.6 % patients had clinically occult non-contiguous multifocal skeletal involvement at the time of the baseline whole body PET CT scanning. The mean change in SUVmax at various time points was highly significant (p value < 0.001). SUVmax can be taken as a reliable marker for serial quantification of metabolic activity in spinal tuberculosis. This may translate into a potential role for FDG as an imaging biomarker for noninvasive response evaluation in skeletal tuberculosis.

Effect of micronutrient deficiency on QuantiFERON-TB Gold In-Tube test and tuberculin skin test in diagnosis of childhood intrathoracic tuberculosis

Data on performance of QuantiFERON-TB Gold In-Tube test (QFT) and tuberculin skin test (TST) in children with active tuberculosis from high burden countries in the context of micronutrient deficiency are scarce. The objective of this study was to evaluate the effect of micronutrient deficiency on the performance of TST and QFT in children with intrathoracic tuberculosis. Children with probable intrathoracic tuberculosis underwent TST, QFT, gastric lavages and induced sputum examination for AFB (Acid-Fast Bacilli) smear and culture. Zinc, copper, ferritin and vitamin D were measured on stored serum samples. The study used cross-sectional data at initiation of anti-tubercular therapy. Three hundred and sixty-two children (median age 115.5 months (interquartile range: 73, 144), 200 (55.3%) girls) were enrolled in the study. Microbiological confirmation of tuberculosis could be obtained in 128 patients. TST and QFT were positive in 337 (93%) and 297 (82%) children, respectively. Performance of both the tests was unaffected by weight-for-age and height-for-age 'z-scores' or by serum copper levels. TST was not affected by serum zinc and ferritin levels. Children with negative QFT results had lower mean serum zinc level (P=0.01) and higher ferritin levels (P=0.007) as compared to those with positive test. Higher proportion of children with positive TST were vitamin D deficient/insufficient (P=0.003). Micronutrient status, especially serum levels of zinc, may influence the performance of QFT in children with intrathoracic tuberculosis. Considering the high prevalence of zinc deficiency in developing countries, QFT should be used cautiously for diagnosing tuberculosis.

Progressive ocular inflammation following anti-tubercular therapy for presumed ocular tuberculosis in a high-endemic setting

To analyze the incidence and clinical course of patients developing progressive ocular inflammation following anti-tubercular therapy (ATT) for presumed ocular tuberculosis (TB). Retrospective analysis of medical records of patients who received ATT for presumed ocular TB and completed at least 12 months follow-up after initiation of ATT. The diagnosis of presumed ocular TB was based on presence of ocular signs suggestive of TB, evidence of past tubercular infection, and exclusion of mimicking clinical entities. All patients received a combination of ATT and corticosteroid therapy. Primary outcome measure was progression (worsening) of ocular inflammation, defined as a two-step increase in level of inflammation (anterior chamber/ vitreous) or the appearance of new lesions following initiation of ATT. A total of 106 patients (64 male, 42 female) received ATT for presumed ocular TB. Twenty-six (24.5%) patients developed progressive intraocular inflammation following ATT. Primary diagnoses in these patients were: anterior uveitis (n=1), intermediate uveitis (n=9), retinal vasculitis (n=3), serpiginous-like choroiditis (n=7), multifocal choroiditis (n=2), and pan-uveitis (n=4). Following progressive inflammation, diagnosis was revised in two patients (7.7%)-both responded to alternative therapy. Of the rest, majority (n=16; 61.5%) resolved with escalation of corticosteroid therapy. Five patients (19.2%)-all having intermediate uveitis-required therapeutic vitrectomy for resolution. Three patients (11.5%) had persistent inflammation at end of follow-up period. Progressive inflammation following ATT for presumed ocular TB is common. It generally resolves on escalation of corticosteroid therapy. Cases not responding to increased immunosuppression need to be re-investigated to rule out a nontubercular cause.

Pitfalls in the management of TB-associated uveitis

The aim of this study is to highlight the pitfalls in the diagnosis and management of tuberculosis (TB)-associated uveitis. This is a retrospective review of case records of four patients with TB-associated uveitis. In cases 1 and 2, failure to treat tubercular uveitis with anti-tubercular therapy (ATT) and unopposed steroid therapy led to a serious systemic consequence--development of intra-cranial tuberculoma. In case 4, similar failure to initiate ATT caused recurrent disease (focal choroiditis) in the eye. All four cases showed appearance of new lesions or worsening of existing lesions in the eye, following initiation of ATT. Such paradoxical reactions resolved by adding/increasing corticosteroid therapy. TB-associated uveitis needs a strong index of suspicion for diagnosis and a combined anti-tubercular plus anti-inflammatory therapy for successful outcome.

Utility of QuantiFERON TB gold test in a south Indian patient population of ocular inflammation

Aim:To study the utility of interferon-γ release assays (QuantiFERON TB gold test) in a south Indian patient population of intraocular inflammation.Design:Evaluation of a diagnostic test- a pilot study from January 2007 to October 2008.Materials and Methods:QuantiFERON TB gold test was performed on the following groups of patients following an informed consent. Group A included healthy volunteers without any exposure to tuberculosis (TB) or past history of TB (n=22). Group B included patients with active systemic TB diagnosed by the demonstration of acid-fast bacilli or by the histopathology finding of caseation with granuloma formation from the sputum, lymph node, skin or intestinal biopsies (n=26). Group C included patients with uveitis of known etiologies other than intraocular TB without any history of exposure to active TB (n=21). Group D included patients with a diagnosis of presumed intraocular TB, who responded to antitubercular therapy by decreased or no recurrences following treatment and with a minimum of nine months follow-up following initiation of antitubercular therapy (n=39).Results:The sensitivity and specificity of the QuantiFERON TB gold test to pick up active systemic TB was 58% and 77% respectively. The sensitivity and specificity of the QuantiFERON TB gold test to pickup intraocular TB was 82% and 76% respectively.Conclusions:QuantiFERON TB gold test alone may not be specific for intraocular TB. The significance of this test in a case scenario needs to be interpreted with clinical presentation and other evidences for intraocular TB.

Anal fistula: an unusual presentation of tuberculosis in a migrant health care professional

We present a case of a young health care professional from the Indian subcontinent, who presented with a low anal fistula and underwent exploration, debridement and fistulotomy twice. The initial working diagnosis was Crohn's disease. However, Mycobacterium tuberculosis, fully sensitive to all first-line drugs was cultured from the specimens sent from the second surgical procedure. On initiation of anti-tubercular therapy the symptoms improved within 5 weeks. The origin of the patient, high index of suspicion for non-infectious reactivation of tuberculosis in migrant health care workers, importance of a proper history taking including previous exposure and diagnostic workup is stressed.