Langhans Giant Cells Research Articles

Interleukin-22 receptor 1 is expressed in multinucleated giant cells: A study on intestinal tuberculosis and Crohn's disease.

BACKGROUNDIt is challenging to distinguish intestinal tuberculosis from Crohn’s disease due to dynamic changes in epidemiology and similar clinical characteristics. Recent studies have shown that polymorphisms in genes involved in the interleukin (IL)-23/IL-17 axis may affect intestinal mucosal immunity by affecting the differentiation of Th17 cells.AIMTo investigate the specific single-nucleotide polymorphisms (SNPs) in genes involved in the IL-23/IL-17 axis and possible pathways that affect susceptibility to intestinal tuberculosis and Crohn's disease.METHODSWe analysed 133 patients with intestinal tuberculosis, 128 with Crohn’s disease, and 500 normal controls. DNA was extracted from paraffin-embedded specimens or whole blood. Four SNPs in the IL23/Th17 axis (IL22 rs2227473, IL1β rs1143627, TGFβ rs4803455, and IL17 rs8193036) were genotyped with TaqMan assays. The transcriptional activity levels of different genotypes of rs2227473 were detected by dual luciferase reporter gene assay. The expression of IL-22R1 in different intestinal diseases was detected by immunohistochemistry.RESULTSThe A allele frequency of rs2227473 (P = 0.030, odds ratio = 0.60, 95% confidence interval: 0.37-0.95) showed an abnormal distribution between intestinal tuberculosis and healthy controls. The presence of the A allele was associated with a higher IL-22 transcriptional activity (P < 0.05). In addition, IL-22R1 was expressed in intestinal lymphoid tissues, especially under conditions of intestinal tuberculosis, and highly expressed in macrophage-derived Langhans giant cells. The results of immunohistochemistry showed that the expression of IL-22R1 in patients with Crohn's disease and intestinal tuberculosis was significantly higher than that in patients with intestinal polyps and colon cancer (P < 0.01).CONCLUSIONHigh IL-22 expression seems to be a protective factor for intestinal tuberculosis. IL-22R1 is expressed in Langhans giant cells, suggesting that the IL-22/IL-22R1 system links adaptive and innate immunity.

A case report of a tongue ulcer presented as the first sign of occult tuberculosis

BackgroundTuberculosis (TB) is a serious infectious disease with considerable fatality, typically affecting the pulmonary system and, rarely, other body organs including the oral cavity. Due to the rarity of oral TB, it is frequently overlooked in differential diagnosis of oral lesions. Despite a declining trend in TB incidence in recent years, it is still a major public health problem with high contagiousness, thereby requiring the early diagnosis and prompt treatment.Case presentationA 57-year-old male patient presented with chief complaint of painful ulcer on tip of his tongue. He reported that the ulcer developed without any remarkable event such as mechanical trauma, vesicle formation or systemic illness. His past medical history revealed the TB over 40 years ago, which had reportedly healed after pharmacological treatments. As the ulceration persisted after topical steroid application and careful education about avoiding possible mechanical stimuli, biopsy was performed and histological finding showed typical findings of oral tuberculosis including intense granulomatous inflammatory features with small red rods of mycobacterial organisms as well as epithelioid cells and Langhans giant cells. After suitable antituberculosis treatments, oral tuberculosis ulcer was almost completely healed. We present a case of oral TB affecting tip of the tongue in a patient with a history of pulmonary TB and emphasize the understanding of intraoral manifestations for early diagnosis and prompt treatment of TB.ConclusionsThe present case represented the importance of understanding oral tuberculosis manifestations for dental clinicians who might be frequently the first health care professionals to encounter various oral lesions.

Leprosy survey among rural communities and wild armadillos from Amazonas state, Northern Brazil.

There is evidence that in southern US, leprosy is a zoonosis infecting wild Dasypus novemcinctus armadillos but the extent of this finding is unknown. This ecological study investigated leprosy in rural communities and in wild armadillos from the Brazilian Amazon. The study area was the Mamiá Lake of Coari municipality, Amazonas State, Northern region, a hyper endemic leprosy area where residents live on subsistence farming, fishing and armadillo hunting and its meat intake are frequent. The leprosy survey was conducted in sixteen communities by a visiting team of specialists. Local partakers provided wild armadillos to investigate M. leprae infection. Volunteers had complete dermato-neurological examination by a dermatologist with expertise in leprosy diagnosis, suspect skin lesions were biopsied for histopathology (Hematoxylin-eosin/HE, Fite-Faraco/FF staining); slit skin smears were collected. Armadillos’ tissue fragments (skins, spleens, livers, lymph nodes, adrenal glands, others) were prepared for histopathology (HE/FF) and for M. leprae repetitive element-RLEP-qPCR. Among 176 volunteers, six new indeterminate leprosy cases were identified (incidence = 3.4%). Suspect skin sections and slit skin smears were negative for bacilli. Twelve wild D. novemcinctus were investigated (48 specimens/96 slides) and histopathological features of M. leprae infection were not found, except for one skin presenting unspecific inflammatory infiltrate suggestive of indeterminate leprosy. Possible traumatic neuroma, granuloma with epithelioid and Langhans cells, foreign-body granuloma were also identified. Granulomatous/non-granulomatous dermatitides were periodic-acid-Schiff/PAS negative for fungus. M. leprae-RLEP-qPCR was negative in all armadillos’ tissues; no bacillus was found in histopathology. Our survey in rural communities confirmed the high endemicity for leprosy while one armadillo was compatible with paucibacillary M. leprae infection. At least in the highly endemic rural area of Coari, in the Brazilian Amazon region where infectious sources from untreated multibacillary leprosy are abundant, M. leprae infected armadillos may not represent a major source of infection nor a significant public health concern.

Recurrent Erythema Nodosum as a Warning of Tuberculous Lymphadenitis

An 84-year-old woman with a history of hypertension and cerebral infarction was referred to the hospital with general malaise and recurrent painful erythema nodosum (EN) on her legs. The EN recurred and resolved within a few weeks several times during the preceding 6 months. Physical examination revealed multiple thumb-sized painful EN lesions on her lower legs, mainly on the posterior surface (Figure A [arrow]). In addition, the right axillary superficial lymph nodes were palpable. Pathological findings of EN were not specific or diagnostic. On the other hand, pathological findings of the right axillary lymph nodes revealed epithelioid granuloma with caseous necrosis and Langhans giant cells (Figure, B [arrows]). Ziehl-Neelsen stain identified organisms that are acid fast (Figure C [arrow]). The interferon-γ release assay (T spot) yielded positive results. Based on these results, the patient was diagnosed as having tuberculous lymphadenitis and associated erythema induratum of Bazin (EIB). She had complete remission of the tuberculous lymphadenitis and EIB after 4-drug antituberculosis therapy. The EIB has not recurred 4 years after the therapy. Erythema induratum of Bazin is a nodular tuberculid, which denotes a skin immunologic reaction to the presence of occult tuberculosis elsewhere in the body. Treatment of EIB does not differ from the conventional therapy for tuberculosis of primary lesion, and the favorable treatment outcome in EN on using antituberculosis therapy reinforces the diagnosis of EIB. Physicians should consider extrapulmonary tuberculosis when patients show characteristic recurrence of EN on the legs.

Para-aortic and Meningitis Tuberculosis: A Case Report

Background : In 2018, Indonesia was in third place as the country with the highest incidence of tuberculosis (TB) in the world. In addition to pulmonary TB, extrapulmonary TB cases are also quite large. Lymphadenitis of the aortic TB can cause a fatal risk if not treated immediately. This study aimed to explore the para-aortic and meningitis tuberculosis case in Klaten Hospital, Central Java. Case presentation: There was a 24-year-old woman with complaints of missing chest pain for 2 months, fear of seeing light (photophobia), and decreased consciousness. The patient was a referral from Klaten Hospital with a diagnosis of a mediastinal tumor. The chest radiograph shows a picture of homogeneous opacity in the anterior mediastinum. Bronchoscopy results show compression stenosis in 1/3 distal and blunt carina. After a sternotomy, it was obtained pus (pus) and tissue granuloma in the area of the aorta. After the rapid molecular test was carried out, the results showed that M tuberculosis detected. The results of histopathology of anatomical pathology show epitheloid tubercle and Datia Langhans cells that suggest an infection with M. tuberculosis. Therapy was done by giving a standard anti-tuberculosis drug, namely Rifampicin 450 mg, INH 300 mg, Ethambutol 1000 mg, and Pyrazinamide 1000 mg. The patient's condition improved marked by weight gain in 2 months. Conclusion: In the case of pulmonary masses (mediastinal tumors), we need to be aware of the possibility of cases of TB lymphadenitis because Indonesia is a country with a high prevalence of TB. This is because a slow diagnosis can lead to life-threatening conditions Keywords : Tuberculosis, para aorta lymphadenitis, meningitis TB, tumor mediastinum, sternotomy Correspondence: Reviono. Department of Pulmonology and Medical Respiration, Universitas Sebelas Maret Jl. Ir. Sutami 36A, Surakarta 57126, Central Java, Indonesia. Email: reviono@staff.uns.ac.id. Mobile: +6281­8474671. Indonesian Journal of Medicine (2019), 4(3): 201-210 https://doi.org/10.26911/theijmed.2019.04.03.02

Morphological diagnosis of Johne’s disease: a case report in cattle

The present case report deals with the morphological (gross and histopathological) and histochemical characterization of Johne?s disease in a cow. The carcass was presented in a hidebound condition with sunken eyes and with a history of persistent and nonresponsive diarrhea. Necropsy revealed generalized gelatinization of the visceral and peripheral fat. Thorough gross examination unveiled major pathological changes in the digestive tract. The gallbladder was distended, with severely thickened walls and blood mixed with bile. The small intestine was severely congested and the mesenteric lymph nodes were enlarged. The opening of the small intestine showed marked thickening of the intestinal walls, with a corrugated appearance. Diffuse granulomatous lesions were observed in the mesenteric lymph nodes. Histopathological examination revealed severe infiltration of intestinal layers and mesenteric lymph nodes by macrophages, lymphocytes, and epithelioid cells with multiple Langhans giant cells. Ziehl=Neelsen staining demonstrated multiple acid-fast bacilli in the cytoplasm of macrophages from impression smears.

Assessment of tubercle bacilli in various organs by staining and polymerase chain reaction technique

Background: Early diagnosis of tuberculosis (TB) by different clinical methods plays a major role in control of TB in early stages. The present study was done with the aim to assess and compare the efficiency of staining techniques and polymerase chain reaction (PCR) for detection of tubercle bacilli in various organs.Methods: The study included data 14,472 patients of both prospective (during March 2008 to 2009) and retrospective cases (past one year of the study period). For prospective cases the cytological material for the study was collected by fine needle aspiration cytology (FNAC). For retrospective cases of past one year were retrieved from the records. TB suspected cases were evaluated by Ziel-Nelson (ZN), Auramine-Rhodamine (A-R) staining techniques and by PCR.Results: Total 284 cases were diagnosed with TB in various organs. In them, epithelioid granuloma was seen 227 cases (79.92%) and Langhans giant cells were seen in 18 cases (6.34%). AFB positivity on ZN staining was observed in 161 cases (56.69%) and 9 cases (3.16%) showed positivity for tubercle bacilli on A-R staining. PCR was done in 20 prospective cases and total percentage of positivity by PCR was seen in 18 cases (90%).Conclusions: The total percentage positivity for detection of tubercule bacilli by PCR assay was found to be more (90%) with high sensitivity and specificity compared to ZN (56.6%) and AR staining techniques (3.16%).

Clinical and laboratory features of PCR-confirmed periocular tuberculosis in China

Experts lack knowledge of periocular tuberculosis (TB) in China. Nested polymerase chain reaction (PCR) shows advantages in diagnosis of extrapulmonary TB. Our study aims to explore the clinical and laboratory features of PCR-confirmed periocular TB. We retrospectively reviewed medical records of presumptive periocular TB and performed nested PCR test to confirm diagnosis. Nine cases were recruited. Clinical symptoms were chronic and insidious. Eight cases achieved favorable visual acuity, while one underwent enucleation due to fungal-TB panophthalmitis. Sensitivity of caseous necrosis, acid-fast bacilli (AFB) staining and interferon γ release assay (T-SPOT) test are 33.3%, 44.4% and 85.7% respectively. Low lymphocyte percentage (P=0.019) and high monocyte-lymphocyte ratio (P=0.042) positively correlate with AFB staining. Male gender (P=0.048) and Langhans giant cell (P=0.048) positively correlate with caseous necrosis. To conclude, traditional TB ancillary tests are not as sensitive as nested PCR technique. Several factors facilitate diagnosis including male gender, decreased lymphocytes, and typical Langhans giant cells.

PRIMARY MASTITIS TUBERCULOSIS CLINICALLY MIMICKING FIBROADENOMA MAMMAE

Introduction: Breast tuberculosis (mastitis TB) is a rare extrapulmonary presentation of tuberculosis that marked pathologily with involvement extensively mamma lobules, which because of infection of Mycobacterium tuberculosis. Many epidemiology studies stated that the incidence of mastitis TB is more common in developing countries than developed countries. Mastitis TB occurs mainly in reproductive woman.&#x0D; &#x0D; Case: A 32-year-old woman came to Surgery Department with chief complaint right upper quadrant palpable breast lump for 4 months. Mammae dextra physical examination confirmed single nodule, size ± 3cm x 3cm x 2.5cm in superior quadrant, mobile, tender, well defined shape, feel like marble, reddish skin, warm, no skin retraction and no nipple discharge. VAS score 2. Mammosonogram was performed and indicated mastitis in the superior quadrant of mammae dextra. Fine needle aspiration revealed negative malignant cells and granulomatous with suppurative inflammation. The histopathological evaluation from mammae excision confirmed datia langhans cells and indicated granulomatous mastitis. Then patient referred to the Pulmonary Department. On TB pulmonary examination confirmed normal chest x-ray and negative acid fast basil (AFB). Patient was diagnosed with primary mastitis TB. Patient was treated with anti-tuberculosis drug (OAT) and gave good response and no side effects.&#x0D; &#x0D; Discussion: Based on the International Standards for Tuberculosis Care (ISTC) diagnosis of mastitis TB can be confirm by anamnesis, physical examination, and also some additional diagnostic test such as sonomammographic imaging, fine needle aspiration or surgical specimens for pathology examination and culture or AFB with Ziehl-Neelsen staining. In Indonesian National Guidelines for TB Control, mastitis TB was treated with fixed drug combination (FDC), intensive phase in 2 months using 4 FDC and advanced phase in 4 months using 2 FDC. In case followed up in 2 months, patient recovered very well and advised to continue the treatment.&#x0D; &#x0D; Conclusions: TB mastitis is rare even in countries with TB endemic. Diagnosis of primary mastitis TB based on clinical, radiological, pathological and microbiological. Treatment of mastitis TB with FDC for 6 months consists of an intensive phase and an advanced phase in this patient gave good outcome.&#x0D; &#x0D; Keywords: Mastitis tuberculosis, diagnosis, treatment.

Tuberculosis Caused by Mycobacterium tuberculosis Complex in a Captive Tapir (Tapirus terrestris)

Background: Tuberculosis is an infectious disease caused by the Mycobacterium tuberculosis complex has already been identified in a great number of wild species. Captive animals may have a potential source for zoonoses, because is related to factors such as cohabitation, direct contact with the public, presence of biological vectors, nutritional deficiencies, absence of sanitary barriers, precautionary hygienic measures and sanitary vigilance. In Brazil, there is little information on tuberculosis in captivity animals, and little attention is given to the risks of disease transmission from humans. The aim of this study was to report the first diagnosed case of tuberculosis Tapirus terrestris in Brazilian Amazon region.Case: One Tapirus terrestris was kept by local zoobotanic foundation in city of Marabá, Southeast of Pará state, Brazilian Amazon, and became ill. Physical examination revealed cough, sneezing, nasal outflow, dyspnea, hyperthermia and lethargy, leading to death. Necropsy demonstrated severe pulmonary alterations: thickening of the inter-alveolar septa, alveolar emphysema, and miliary nodules with dimensions up to 5 mm, which were yellowish-white, caseous, and sometimes calcified. Additionally, large areas of caseous compaction of the parenchyma, characteristic of caseous tuberculosis. Histopathological analysis revealed a process characteristic of mycobacterial infection, with alveoli filled with caseous exudate and thickened septa and fibrocytes, in addition to recently formed tubercles, some with caseous necrosis, calcifications and Langhans cells. In the Ziehl-Neelsen staining, alcohol-acid resistant bacilli were observed in the mesenteric lymph nodes. No mycobacterial growth was observed in Lowenstein-Jensen culture medium. A nested PCR followed by a sequencing assay targeting the hsp65 gene and M. tuberculosis complex member was detected. Water and M. tuberculosis H37Rv were used as negative and positive controls, respectively.Discussion: This article reports the first case of tuberculosis in T. terrestris in Amazonia. The case of infection was caused by a complex of Mycobacterium tuberculosis, as well as reports of other studies described in wild animals. This record presented clinical and pathological similarity with the cases of a tapir and coati at the zoo of Curitiba, and non-human primates in bioteries in Belém. The disease was reported, also, in a T. indicus female in Bangkok, Thailand. In another study with two tapirs there was positivity of tuberculin test result in a Swedish zoo. In necropsy findings of tuberculosis in a Malayan tapir showed multiple white, caseous nodules spread throughout the lungs. Studies have shown that lesions can be in various organs, among them the mediastinal and mesenteric lymph nodes, liver, spleen, kidneys, ovaries, serosa, diaphragm, intestines and uterus. For exemple in a case of disseminated tuberculosis caused by M. tuberculosis in a Malayan tapir were described multiple granulomes, some coalescent, characterized by necrotic caseous centers, with some Langhans giant cells and a discrete fibrotic zone. In the present work, the results of the anatomopathological and molecular assays confirmed the clinical suspicion of respiratory infection and established the conclusive diagnosis of pulmonary tuberculosis caused by M. tuberculosis complex member. It is worth noting that tuberculosis is an important zoonotic disease affecting survival of the species, posing an extinction threat and also a public health concern.

A rare case of thyroid tuberculosis

Thyroid tuberculosis although known to be a rare entity provides a diagnostic challenge to the clinician. Clinically, radiologically and even histologically proving to be difficult to arrive at a diagnosis. Its incidence according to literature is 0.1-0.4%. Tuberculosis may be found at multiple sites but incidence in the thyroid, pancreas, striated and cardiac muscle is extremely rare. Herein, we discuss a case of a 60 year old female complaining of a swelling in the front of the neck (more on the right side) since 45 days. Clinically it appeared to be a thyroid swelling. An ultrasound showed a bulky right lobe with heterogeneous echoes. FNAC showed features suggestive of a follicular adenoma. Intraoperatively a firm thyroid was palpable and total thyroidectomy was done. Histopathological examination was done revealing langhan giant cells and an area of caseous necrosis, confirming tuberculosis. The patient was started on thyroid replacement therapy and anti-tubercular therapy. The patient had no significant complications in the 6 months follow up period. In tuberculosis endemic areas, one must maintain a high index of suspicion for thyroid swellings which may show foci of tuberculosis, especially if they have an elevated ESR and other foci of tuberculosis.

Tuberculoma with phlegmon-like symptoms mimicking soft tissue sarcoma in the wrist: A case report.

Despite the increasing incidence of tuberculosis, even in developed countries like Japan, tuberculoma is a relatively uncommon disease. Furthermore, given the rarity of tuberculoma, a definitive diagnosis is often delayed. We herein present the case of a 79-year-old man who presented with an erythematous and warm mass in the left forearm. Radiography revealed calcification of the wrist's volar side, and magnetic resonance imaging revealed a mosaic pattern at the lesion. Soft tissue sarcoma of the wrist was suspected, and an incisional biopsy was performed, which revealed numerous yellow rice bodies. A rapid pathological evaluation revealed caseous necrosis and Langhans giant cells, and a histological evaluation confirmed the diagnosis of tuberculoma. All the rice bodies were resected and the patient received postoperative antibiotic treatment with pyrazinamide, isoniazid, rifampicin and ethambutol. However, the patient developed hepatic insufficiency during treatment, and the regimen was discontinued. The patient had not experienced recurrence 1 year after the treatment. In conclusion, tuberculoma should be considered in the differential diagnosis of a wrist mass mimicking an inflamed soft tissue tumor.

Monocyte Subsets Have Distinct Patterns of Tetraspanin Expression and Different Capacities to Form Multinucleate Giant Cells.

Monocytes are able to undergo homotypic fusion to produce different types of multinucleated giant cells, such as Langhans giant cells in response to M. tuberculosis infection or foreign body giant cells in response to implanted biomaterials. Monocyte fusion is highly coordinated and complex, with various soluble, intracellular, and cell-surface components mediating different stages of the process. Tetraspanins, such as CD9, CD63, and CD81, are known to be involved in cell:cell fusion and have been suggested to play a role in regulating homotypic monocyte fusion. However, peripheral human monocytes are not homogenous: they exist as a heterogeneous population consisting of three subsets, classical (CD14++CD16−), intermediate (CD14++CD16+), and non-classical (CD14+CD16+), at steady state. During infection with mycobacteria, the circulating populations of intermediate and non-classical monocytes increase, suggesting they may play a role in the disease outcome. Human monocytes were separated into subsets and then induced to fuse using concanavalin A. The intermediate monocytes were able to fuse faster and form significantly larger giant cells than the other subsets. When antibodies targeting tetraspanins were added, the intermediate monocytes responded to anti-CD63 by forming smaller giant cells, suggesting an involvement of tetraspanins in fusion for at least this subset. However, the expression of fusion-associated tetraspanins on monocyte subsets did not correlate with the extent of fusion or with the inhibition by tetraspanin antibody. We also identified a CD9High and a CD9Low monocyte population within the classical subset. The CD9High classical monocytes expressed higher levels of tetraspanin CD151 compared to CD9Low classical monocytes but the CD9High classical subset did not exhibit greater potential to fuse and the role of these cells in immunity remains unknown. With the exception of dendrocyte-expressed seven transmembrane protein, which was expressed at higher levels on the intermediate monocyte subset, the expression of fusion-related proteins between the subsets did not clearly correlate with their ability to fuse. We also did not observe any clear correlation between giant cell formation and the expression of pro-inflammatory or fusogenic cytokines. Although tetraspanin expression appears to be important for the fusion of intermediate monocytes, the control of multinucleate giant cell formation remains obscure.

Ex vivo expansion of alveolar macrophages with Mycobacterium tuberculosis from the resected lungs of patients with pulmonary tuberculosis.

Tuberculosis (TB), with the Mycobacterium tuberculosis (Mtb) as the causative agent, remains to be a serious world health problem. Traditional methods used for the study of Mtb in the lungs of TB patients do not provide information about the number and functional status of Mtb, especially if Mtb are located in alveolar macrophages. We have developed a technique to produce ex vivo cultures of cells from different parts of lung tissues surgically removed from patients with pulmonary TB and compared data on the number of cells with Mtb inferred by the proposed technique to the results of bacteriological and histological analyses used for examination of the resected lungs. The ex vivo cultures of cells obtained from the resected lungs of all patients were largely composed of CD14-positive alveolar macrophages, foamy or not, with or without Mtb. Lymphocytes, fibroblasts, neutrophils, and multinucleate Langhans giant cells were also observed. We found alveolar macrophages with Mtb in the ex vivo cultures of cells from the resected lungs of even those TB patients, whose sputum smears and lung tissues did not contain acid-fast Mtb or reveal growing Mtb colonies on dense medium. The detection of alveolar macrophages with Mtb in ex vivo culture as soon as 16–18 h after isolation of cells from the resected lungs of all TB patients suggests that the technique proposed for assessing the level of infection in alveolar macrophages of TB patients has higher sensitivity than do prolonged bacteriological or pathomorphological methods. The proposed technique allowed us to rapidly (in two days after surgery) determine the level of infection with Mtb in the cells of the resected lungs of TB patients and, by the presence or absence of Mtb colonies, including those with cording morphology, the functional status of the TB agent at the time of surgery.

Clinicopathologic Study of Granulomatous Lesions in the Bone Marrow

Introduction: Granulomatous lesion in the bone marrowis not a common finding and can be attributed to a variety of conditions ranging from infections to malignancies to drugs. Though tuberculosis is the most common etiology, bone marrow granulomas can be associated with a number of infections and other non infective conditions. The incidence of bone marrow granulomas has been increasing over the years due to the increasing surge of HIV infection. Aims: This study basically aims to study the prevalence of bone marrow granulomas, to identify the various causes and to study the pattern of granulomas in different conditions. Materials & Methods: This is a retrospective analysis of 100 cases of bone marrow granulomas conducted in the Clinical Laboratory of Kasturba hospital for a period of four and a half years from January 2009 to May 2013.The clinical details were collected from medical records and bone marrow biopsy slides were retrieved and studied. Results: Out of the 100 cases, 66% cases were diagnosed as tuberculosis. 17% cases were due to other infections like Typhoid fever (5%), Brucellosis (4%), Scrub typhus (2%), Hansen’s disease (1%), Cryptococcosis (2%) and HIV infection itself without any other opportunistic infections (3%). Malignancies accounted for 9% cases, Sarcoidosis (1%) and in 7% cases a definitive diagnosis was not reached. Among the 66 cases of tuberculosis, 40 (60%) cases were immunodeficient due to HIV infection. HIV positive cases predominantly showed single (52%), ill defined granulomas (73%), with caseation necrosis (52%), while HIV negative cases predominantly showed single (54%), small (50%), well defined or ill defined granulomas with plump epithelioid cells (58%) and Langhans giant cells (42%). Conclusion: There can be varied etiology for bone marrow granulomas with tuberculosis being the most common cause.The morphology and pattern of granulomas can aid in the diagnosis of the condition hence study of bone marrow for granulomas should be considered as an important diagnostic tool in such conditions.

Brown Shadow in Lichen Nitidus: A Dermoscopic Marker!

A 35-year-old male presented with asymptomatic multiple papular lesions over both forearms. Physical examination revealed multiple white-colored, flat-topped papules [Figure 1]. Based on the characteristic morphology of the lesions, a clinical diagnosis of lichen nitidus was established.Figure 1: Multiple white-colored flat-topped papules distributed bilaterally over forearmsDermoscopy (DermLite III; 3Gen; Polarized, 10×) of the lesions revealed multiple, white, well-circumscribed circular areas, 1–2 mm in diameter with a smooth surface [Figure 2a]. An indistinct brown shadow was reflected through each of these white circles [Figure 2b].Figure 2: (a) Dermoscopy demonstrates multiple, white, well-circumscribed, circular areas with a smooth surface along with an indistinct brown shadow reflected through these white circles (b) Magnified dermoscopic image of (a) demonstrating the brown shadow (black arrow) (DermLite III; 3Gen; Polarized, 10×)Histopathology revealed a circumscribed subepidermal dense focal lymphohistiocytic infiltrate along with occasional Langhans giant cells, flanked by collarettes of epidermal acanthosis on either side, which gave a “ball-in-clutch” appearance confirming the diagnosis of lichen nitidus. The overlying epidermis showed evidence of acanthosis and focal parakeratosis [Figure 3].Figure 3: Histopathology shows subepidermal foci of lymphohistiocytic infiltrate, encircled by acanthotic epidermal collarettes with parakeratosis of overlying stratum corneum (H and E stain 10×)The presence of multiple well-demarcated white circles on dermoscopy are known to correspond to epidermal acanthosis on histopathology.[12] An interesting observation made was the presence of a brownish shadow inside each of these white circles, which is in fact a reflection of the underlying dense foci of lymphocytes and epithelioid cells in the dermal papilla. This deduction concurs with the observation of the “peripilar sign” in cases of early androgenetic alopecia, wherein the superficial perifollicular lymphocytic infiltrate is seen as a brown halo around the hair follicles.[34] Hence, in lichen nitidus, the epidermal acanthosis corresponds to white circles and the central brownish shadow reflected through the white circles corresponds to the inflammatory infiltrate enveloped by the acanthotic rete ridges. This particular finding on dermoscopy establishes a strong dermoscopic and histopathological correlation in lichen nitidus, which enables us to differentiate it from other conditions mimicking it, such as pityriasis versicolor and lichen sclerosus et atrophicus. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Clinical-Morphological Aspects in Spinal Tuberculosis.

Osteoarticular tuberculosis (OATB) Aim: The authors made a clinical morphological assessment of tissue samples from patients admitted in Surgical Departments of the Emergency County Hospital of Craiova, Romania, between 1990 and 2015, proved as presenting tuberculous lesions of the spine in the Department of Pathology of the same Hospital. Materials and Methods: The studied material consisted of bone, joint and sometimes muscle tissue fragments resulted from biopsies or surgical excisions from 7 cases coming out of 54 patients investigated in the above-mentioned period of time, where the established histological diagnosis was tuberculosis (TB). For diagnostic confirmation, Ziehl-Neelsen staining has been used as a rule but, in some cases, immunohistochemistry was also used. Results: TB lesions have prevailed in men and around the age of 50 years. Thoracic segment of the spine was the most involved. Epithelioid and giant Langhans cells dominated the inflammatory cellular population. Necrosis was always present, usually in its classical acidophilic form. Fibrosis was almost always absent. On the whole, the granulomatous reaction was in almost half of the cases hyporeactive and disorganized. Conclusions: The clinical morphological profile of our series is fitting with data described in the literature. Because of its life threatening potential, spinal TB should be investigated thoroughly especially in its morphological features in order to obtain as quickly as possible an etiological diagnosis.

Progressive Pathological Changes in Sub-clinical Experimental Para-tuberculosis in Goats

An experiment was carried out to study the development of sequential histological lesions and efficacy of certain diagnostic tests in experimentally induced subclinical paratuberculosis infection in goats. Twelve goats of 8-12 weeks age were infected with 4.23 x 109 Mycobacterium avium subsp. Paratuberculosis on 8 occasions. Eight goats were kept as in-contact controls and 4 as uninfected controls. Diagnostic tests, gross and histopathological studies were carried out at 3, 6, 9 and 12 months post-infection. Two goats were positive in the AGID test at 12MPI. Three goats, one at 9 MPI and two at 12 MPI were positive in faecal culture. Tissue PCR detected one goat positive each at 9 and 12 MPI. Six (50%) of 12 infected goats had gross and histological lesions. Marked enlargements of the mesenteric lymph nodes were observed in the early stages (3 and 6 months post infection) of infection. Mucosal thickening and corrugation of the jejunal and ileal mucosae, enlargement and oedema of the mesenteric lymph nodes, dilatation of lymphatics and gelatinisation of mesenteric fat were observed in goats euthanised at 9 and 12 MPI. Histological lesions consisting of flat and broad villi with mild infiltration of lymphocytes and macrophages in the intestinal villi and crypts were common at 3 MPI and 6 MPI. Focal infiltration of macrophages in Peyer's patches and giant cells were found in the mesenteric lymph nodes at 6 MPI. Broadened villi and increased infiltration of lymphocytes and macrophages with Langhan's giant cells were observed in the villi and crypts at 9 MPI and 12 MPI goats. Acid-fast bacilli were detected in 3 goats, one each at 6, 9 and 12 MPI.

Female genital tuberculosis and infertility: serial cases report in Bandung, Indonesia and literature review

BackgroundFemale genital tuberculosis (FGTB) is a Mycobacterium infection in the reproductive organs which often leads to infertility. FGTB is either asymptomatic or causes uncharacteristic clinical presentations, making an early diagnosis is challenging. Our aims were to evaluate the clinical presentations, the process to confirm the diagnosis and followed-up the patients who had undergone laparoscopy at our center. FGTB has been reported from many countries, but has never been reported from Indonesia. Here we present case studies to document the presence of FGTB in Indonesia.Cases presentationThere were three patients admitted to our center; two patients were admitted with irregular menstrual cycle as their chief complaint, while one patient came due to infertility. The results from laparoscopy were suggestive of FGTB; including the presence of caseating granulomas surrounded by epithelioid cells, lymphocytes, plasma cells, and Langhans giant cells. Additionally, PCR testing confirmed presence of MTB. Subsequent to diagnosis, continuous TB medications was administered with excellent clinical outcome in two patients (pregnant in 18 months after under gone laparoscopy). The infertile patient remain in one of the treated patient above.ConclusionIn infertile patients who live in countries where Tuberculosis is an endemic disease, such as Indonesia, a comprehensive history taking, along with ultrasonography results can be used to diagnose FGTB. Confirmation of this diagnosis can be achieved through polymerase chain reactions result. Timely diagnosis and treatment are imperative to prevent any permanent injury to patient’s reproductive organs.

Tuberculose mammaire au Togo : à propos de 28 cas présumés

Our study aimed to describe the epidemiological, clinical and histological aspects of mammary tuberculosis in Togo. This is a descriptive cross-sectional study of breast tuberculosis for which the diagnosis was presumed on histological grounds in the pathology department (LAP) of the Lomé Tokoin university hospital from January 1995 to December 2016 (20 years). A total of 28 presumed cases of mammary tuberculosis were identified. There were 26 women and 2 men, with an average age of 34.2 ± 0.3 years. The clinical signs were nodule (84.1%), tumefaction (75%), abscess (63.6%) and tumefaction with cutaneous fistulization (59.1%). Breast involvement was isolated in 31.8% of cases and associated with pleuropulmonary tuberculosis in 54.5% of cases. Co-infection with HIV was found in 63.9 % of cases. Histology showed inflammatory granulomas made of Langhans giant cells, epithelioid cells and lymphocytes around the foci of caseous necrosis. Thoracic radiography was abnormal in 16 patients (57.1%).Mammary tuberculosis is not rare in our country. Clinical presentation is often misleading and is a diagnostic challenge, more particularly with breast abscess or cancer.