Miliary Infiltrates Research Articles

Disseminated histoplasmosis from western Mexico—rethinking our geographic distribution of endemic fungal species: a case report and review of literature

BackgroundHistoplasma is a fungal pathogen found in many parts of the world. In North America, its distribution is traditionally thought to be endemic to the Ohio and Mississippi River valleys. Development of histoplasmosis after Histoplasma exposure is related to degree of inoculum exposure and susceptibility, for example, immunocompromised status. Most exposed, healthy individuals are asymptomatic and few develop pulmonary symptoms. A limited number of infectious etiologies (that is, Histoplasma, Coccidioides, and Mycobacterium tuberculosis) can cause miliary pattern on chest imaging, and thus, histoplasmosis should be considered whenever a patient presents with pulmonary symptoms and these unique radiographic findings.Case presentationA previously healthy 13-year-old Hispanic male presented as a transfer from an outside hospital with fever and hypoxia in the setting of a progressive, subacute gastrointestinal illness. Given hypoxia, the concern for sepsis, and unclear etiology of his illness, broad-spectrum antimicrobial therapy and noninvasive ventilation were started. Initial evaluation demonstrated miliary pulmonary infiltrates, and travel history raised suspicion for coccidioidomycosis or tuberculosis. After a complete evaluation, lab studies confirmed a diagnosis of histoplasmosis, and the patient made a full recovery after the initiation and completion of antifungal therapy.ConclusionHerein, we present a patient who acquired histoplasmosis from an area of Mexico not currently acknowledged as endemic and review recently published data emphasizing new areas of Histoplasma endemicity in North America, particularly the southwest USA and most states of Mexico. Though limited surveillance data exist, mounting case reports/series and local epidemiologic studies illustrate the expanding worldwide endemicity of Histoplasma and underscore histoplasmosis as a growing global health concern.

A Rare Case of Charcot-Leyden Crystals In liver biopsy in a 14-Year-Old Boy with Persistent Fever and Miliary Infiltrates

The presence of Charcot-Leyden Crystals in liver biopsy is rare. A report case of a 14-year-old boy who presented with persistent fever and respiratory symptoms. Chest X-ray and CT thorax showed miliary infiltrates. The Mantoux test was positive and sputum for acid-fast bacilli (AFB) was negative. The patient started antitubercular therapy (ATT). There was no response and the patient still had fever. Further evaluation with an ultrasound of the abdomen revealed multiple small liver abscesses with septic emboli in the spleen. Since the patient was non-responsive to antibiotics, biopsy from the lesion in the liver was suggested. Biopsy report revealed Charcot-Leyden crystals with no granulomas. The Patient was diagnosed as a case of systemic parasitic infestation. Albendazole under steroid cover was prescribed and the patient was afebrile on follow-up. It was concluded that the presence of CLCs in a biopsy specimen is rare but may be a cause of an underlying parasitic infestation. Early diagnosis and treatment with antiparasitic drugs can lead to a favorable outcome.

1425. Changes in Clinical Presentation of TB due to the COVID-19 pandemic

Abstract Background In 2020/21, deaths due to active tuberculosis (TB) increased globally for the first time in decades with concomitant global decline in TB detection rates, suggesting that delay in TB diagnosis during the COVID-19 pandemic is associated with increased mortality. In the US and New York City, 20% decline in TB cases was reported in 2020/21. We aimed to compare symptom duration, sputum microscopy and radiographic findings in patients with newly diagnosed TB at Montefiore Medical Center (MMC) in the Bronx, New York, before and during the COVID-19 pandemic. We hypothesized that patients during the COVID-19 pandemic present with signs of more advanced TB than before. Methods Using a cross-sectional study design, we retrospectively reviewed medical records of TB patients identified through microbiology lab records from 11/1/2018 to 3/11/2022 and stratified by admission before (11/1/2018–2/29/2020) and during (3/1/2020–3/11/2022) the COVID-19 pandemic. Inclusion criteria were age ≥18 years, admission to an MMC hospital, and new diagnosis of culture-confirmed TB. Results We identified 24 TB patients who presented before and 24 during the pandemic. About 1.7 new TB cases were diagnosed monthly before vs 1.0 during the pandemic, an >40% decline. Patients had both pulmonary and/or extrapulmonary manifestations without differences between groups. There were no significant differences in demographics and comorbidities between the two groups aside from diabetes, which was higher in the pre-COVID group (p = 0.03). Two TB patients had a prior history of COVID and one developed nosocomial COVID during the admission. There was no difference in mortality between groups. Patients with pulmonary manifestations had higher sputum AFB smear positivity (p=0.14) and significantly higher occurrence of multilobar or miliary infiltrates on chest X-ray during compared to before COVID (p = 0.01; Table 1). Table 1.Symptoms and diagnostics on initial presentation of patients with pulmonary TB before and during the COVID-19 pandemic Depending on distribution, t-tests or Mann Whitney U tests were used for continuous and Chi-square tests or Fisher’s exact tests for categorical variables. Sputum AFB smears results are reported for the initial 3 smears. Conclusion Our findings show >40% decline in patients presenting with TB in the Bronx during vs before the COVID-19 pandemic and suggests patients presented with more advanced disease than before the pandemic. Whether COVID-19 could have contributed to this remains to be investigated. Our results have implications for public health and emphasizes the need for earlier identification of TB. Disclosures All Authors: No reported disclosures.

Metastatic Gastric Adenocarcinoma Mimicking Pulmonary Tuberculosis

Gastric Cancer is a leading cause of morbidity and mortality worldwide, which makes timely and accurate detection critical. The rare presentation of Gastric Adenocarcinoma (GA) with miliary pulmonary metastases, known as Bard's Syndrome, can be easily mistaken for more common primary pulmonary diseases, such as tuberculosis. We present a case of a 43 year old El Salvadorian male with persistent pleuritic chest pain and fevers despite treatment for disseminated infiltrates suggestive of TB. Diagnostic biopsies obtained after failed treatment confirmed GA which prompted initiation of palliative chemotherapy. A 43-year-old male from El Salvador with no significant PMH, presented with a two day history of fevers, chills and pleuritic chest pain. Chest imaging (Figures 1 and 2) revealed bilateral miliary infiltrates suggestive of TB as well as PE, which prompted initiation of RIPE therapy and anticoagulation. He returned two weeks later with worsening symptoms and repeat imaging of the chest raised suspicion for pneumonia. He improved and was discharged home on antibiotics. One week later, he developed severe abdominal pain and was found to have abdominal ascites. CT Abdomen revealed extensive clot formation throughout iliac venous system and omental caking, initially worrisome for TB peritonitis versus carcinomatosis. TB therapy was discontinued as prior AFB cultures came back negative. Omental biopsy was consistent with CK7 positive adenocarcinoma. Linitis plastica was observed on EGD (Figure 3) and EUS biopsy later confirmed malignant cells from primary gastric adenocarcinoma. The patient was initiated on palliative chemotherapy with Epirubicin, Oxaliplatin, Capecitabine (EOX). Given our patient's demographics, symptoms and radiographic imaging, a diagnosis of TB was initially made with differentials focused on primary pulmonary pathology. However, this limited differential caused an unintentional delay in detection and treatment of gastric adenocarcinoma, a disease of remarkable morbidity and mortality. Gastric carcinoma is the fourth leading cause of cancer worldwide, the second leading cause of cancer related death, and carries a significant cancer burden. GA has a 2:1 male predominance, and while incidence in North America has decreased there is a higher incidence in Hispanic populations. By adding Bard's Syndrome to the differential of miliary pulmonary infiltrates, the burden of this destructive and deadly disease can be decreased.2676_A Figure 1. Diffuse miliary pulmonary nodular opacities.2676_B Figure 2. Innumerable small bilateral pulmonary nodules with small bilateral pleural effusions.2676_C Figure 3. Linitis Plastica noted on Esophagogastroduodenoscopy

Unusual Presentation of Bronchiolitis Obliterans Organizing Pneumonia Mimicked Pulmonary Metastases: A Case Report

SESSION TITLE: Imaging SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: The radiological presentation of bronchiolitis obliterans organizing pneumonia (BOOP) is characterized by multiple air space consolidations with a subpleural distribution or areas of ground glass lung infiltration. We report a case of BOOP presenting with a multiple nodular pattern mimicking miliary metastasis lung infiltration. CASE PRESENTATION: A 47-year-old man presented with cough. He was a current smoker for 35 years. He had COPD and DM. Vital signs were normal. Chest X-ray showed bilateral nodular opacities. Thorax computed tomography; predominantly in the upper lobe, bilateral, multiple pulmonary nodules (the largest 20 mm) with variable border features were detected, some of which were frosted glass densities (Fig.1). Mediastinal (10 mm in diameter), right suprahiler (15 mm in diameter) and both axillar lymph nodes were present. Serological tests were normal. Mycobacterium tuberculosis was negative. PET/CT: Several millimetric lymph nodes without mediastinal pathologic FDG involvement were observed. A large number of nodules were observed in both lung parenchyma, some of which were calcified, with mildly elevated FDG uptake (Early SUV max: 2,18, Late SUV max: 3,14) (Fig.1). Lung biopsies with wedge resection were perfomed under video-assisted thoracoscopy(VATS). Histopathological analysis consistented with BOOP (Fig.2). The patient underwent steroid therapy at a dose of 48 mg / day with the diagnosis of BOOP. At 3 months of treatment, control CT completely removed. The steroid treatment was stopped at 4 months because of uncontrolled diabetes mellitus. The patient was followed-up for one year, and the disease did not relapse. DISCUSSION: Heterogenic radiologic features on X-ray and on CT scan make correct diagnosis difficult, sometimes resulting in ineffective therapy and unnecessary hospitalization. Most often, CT scan shows unilateral or bilateral airspace consolidation with a predominantly peripheral distribution in lower and middle zones. Contrary to the common radiological findings in our case, there were bilateral multifocal nodules with predominantly upper lobes. In pet ct; metastatic disease can not be excluded due to increased metabolic activity in late images. Therefore, histopathological confirmation is required. We did not find any reports that bronchiolitis obliterans organized pneumonia pet ct findings. It may be said that boop pet ct findings may interfere with malignancy. CONCLUSIONS: In conclusion, our patient had an unusual radiological pattern of bilateral pulmonary nodules associated with COP that mimicked pulmonary metastases. Its radiological and nuclear properties can lead to misdiagnosis like malignancy. Reference #1: American Thoracic Society/European Respiratory Society International Multidisciplinary Consensus Classification of the Idiopathic Interstitial Pneumonias. Am J Respir Crit Care Med. 2002;165:277-304. DISCLOSURE: The following authors have nothing to disclose: Demet Polat, Eylem Ozgur, Sibel Atis Nayci, Tuba Kara, Feramuz Apaydin, Pelin Özcan No Product/Research Disclosure Information

Clinical Features and Prognostic Significance of Limited and Diffuse Endobronchial Sarcoidosis

Aims: Airway involvement is a common feature of sarcoidosis and mucosal abnormalities may be evident in the respiratory tract. However, firm data establishing the clinical features and prognosis of sarcoidosis in these patients is lacking although the incidence of endobronchial disease is high. The purpose of this study was to evaluate the clinical features of the patients with limited, diffuse and no endobronchial involvement. Another aim was to investigate the prognostic differences between these patients. Methods: We conducted a retrospective study to evaluate the clinical and laboratory findings of 48 patients with endobronchial sarcoidosis and 50 patients without endobronchial involvement seen at our institution. The patients fulfilled the clinical, radiologic or both features of sarcoidosis supported by the histopathologic evidence of noncaseiting granulomas. Six to ten bronchial biopsies were taken from each patient. The sample was considered positive if it demonstrated noncaseiting Original Research Article Tetikkurt et al.; BJMMR, 11(6): 1-7, 2016; Article no.BJMMR.20786 2 granulomas with negative fungal and mycobacterial cultures. The patients were classified into three groups according to the histopathologic biopsy results: 1) No endobronchial involvement, 2) Limited endobronchial involvement: One biopsy site positive and 3) Diffuse endobronchial involvement: Two or more biopsy sites positive for noncaseaiting granulomas. Results: Bronchial biopsy was positive in 82% of the abnormal appearing airways while it was diagnostic in 36% of the normal appearing mucosa. The most frequent bronchoscopic appearence was miliary infiltration. Nodular, erythematous lesions and edematous mucosal swelling were other bronchoscopic findings. There were no significant differences between the three groups for FEV1, FVC, TLC, DLCO/VA serum and 24 h urinary calcium levels. Serum ACE levels were significantly higher (p<0.001) in patients with limited and diffuse bronchial involvement compared to patients with no endobronchial disease. The extrapulmonary organ involvement (p<0.001) and progressive disease incidence was more frequent (p<0.001) in patients with limited and diffuse endobronchial disease. Conclusions: Endobronchial involvement in sarcoidosis appears to be a significant predictive risk factor for progressive disease. Patients with limited or diffuse endobronchial disease have more severe extrapulmonary organ involvement and a worse prognosis than patients without endobronchial disease. Bronchoscopy may identify such patients carrying a risk factor for progressive sarcoidosis.

Congenital miliary tuberculosis in an 18-day-old boy

Congenital tuberculosis (TB) is a rare disease that is associated with high mortality. Mycobacterium tuberculosis, the causative agent, may be transmitted from the infected mother to the fetus by the transplacental route or by aspiration of infected amniotic fluid. Clinical symptoms and signs are not specific. Miliary patterns are the most common findings in the chest X-rays of many infants with congenital TB. In this case, an 18-day-old boy had jaundice on the fifth day of birth, and fever and respiratory distress appeared on the 18th day. Chest X-ray showed diffuse fine bilateral infiltration. Clinically, pneumonia or sepsis was suspected. Respiratory symptoms and chest X-ray findings worsened despite empirical antibiotic therapy. The lungs showed miliary infiltration suggestive of TB. Gastric aspirates were positive for M. tuberculosis. Respiratory distress and fever were gradually improved after anti-TB medication. Congenital TB is difficult to detect because of minimal or no symptoms during pregnancy and nonspecific symptoms in neonates. Hence, clinicians should suspect the possibility of TB infection even if neonates have non-specific symptoms. Early diagnosis and meticulous treatment are required for the survival of neonates with TB.

Diagnosis, treatment, and outcomes of coccidioidomycosis in allogeneic stem cell transplantation.

Allogeneic hematopoietic stem cell transplant (allo-HSCT) recipients have multiple risk factors for coccidioidomycosis, and previous reports of coccidioidomycosis in this patient population describe severe infections with poor outcomes. We performed a retrospective chart review of allo-HSCT recipients with active coccidioidomycosis to characterize the utility of diagnostic tests for coccidioidomycosis and to determine treatment outcomes. Eleven of 426 (2.6%) allo-HSCT recipients experienced active coccidioidomycosis after transplantation. Of these 11 patients, 1 (9%) had extrapulmonary infection, 9 (82%) patients were hospitalized, and 5 (45%) died. Culture or histology was positive in 33% (3/9) of the patients tested. Most (64% [7/11]) had at least 1 positive serologic test result, and the enzyme immunoassay immunoglobulin G test was positive most often (overall 55% [6/11]). Chest radiographs and chest computed tomography scans showed miliary or multifocal nodular infiltrates or consolidations, consistent with coccidioidomycosis, in 80% (8/10) and 100% (9/9), respectively, of patients tested throughout the course of active illness. Rapid polymerase chain reaction testing was positive in 71% (5/7) of the patients tested. Peripheral eosinophilia was present in 18% (2/11) of patients. Coccidioidomycosis is associated with high morbidity and mortality in allo-HSCT recipients in an area endemic for Coccidioides. Diagnosis of this infection can be difficult and often requires multiple and frequently invasive tests. Antifungal prophylaxis should be considered for patients at highest risk.

Acute Fibrinous Organizing Pneumonia: A Case Report and Literature Review

Acute fibrinous organizing pneumonia (AFOP) is a distinct histopathologic pattern of lung injury with the hallmark feature of intra-alveolar fibrin deposits with associated organizing pneumonia, type II pneumocyte hyperplasia, and a patchy lymphohistiocytic proliferation. We describe the case of a previously healthy 47-year-old man who presented with a 4-day history of worsening dyspnea, cough, and nocturnal fevers and miliary nodules on chest imaging. Subsequently, there was an indication of AFOP when he underwent open lung biopsy. AFOP has been associated with a variety of underlying conditions including rheumatologic diseases, medications, and infections, and several cases were idiopathic. This case highlights the importance for radiologists to be aware of this uncommon pattern of lung injury and to consider it in the differential when encountering bilateral miliary infiltrates on chest imaging.

Histopathology of Disseminated Mycobacterium bovis Infection Complicating Intravesical BCG Immunotherapy for Urothelial Carcinoma

Intravesical instillation of Bacillus Calmette-Guérin (BCG) is a mainstay of adjunctive therapy for superficial bladder cancer. Disseminated BCG infection ("BCG-osis") after this therapy is rare and potentially life-threatening; only isolated case reports detail the histopathologic findings thereof, few of which had a diagnosis confirmed by molecular testing. We report 3 additional cases of BCG-osis complicating BCG therapy, all confirmed by cultures and molecular assays, including the first cases of wedge biopsy-confirmed BCG pneumonia and BCG olecranon bursitis. When suggested by a relevant clinical history, recognition of randomly distributed granulomas in any organ should prompt consideration of BCG-osis and liberal performance of AFB stains, aided by targeted molecular assays. Physicians should maintain a high index of suspicion when miliary infiltrates arise after intravesical BCG instillation, and close multidisciplinary communication is essential. Pathologist awareness of this rare cause of granulomatous inflammation aids recognition of BCG-osis and facilitates prompt initiation of antimycobacterial therapy.

Clinical Features and Prognostic Significance of Endobronchial Sarcoidosis

Aims: Endobronchial involvement may occur in patients with sarcoidosis. Although the prevalence of bronchial abnormalities is high, there are no firm data establishing the clinical features and prognosis of sarcoidosis in these patients. The aim of our study was to define the clinical characteristics and prognosis of patients with endobronchial sarcoidosis. Methods: Clinical and laboratory findings of 44 patients with endobronchial sarcoidosis and 46 patients without endobronchial involvement seen at our institution, were evaluated retrospectively. The patients fulfilled clinical, radiologic or both features of sarcoidosis supported by the histopathologic evidence of noncaseating granulomas. Six to ten bronchial biopsies were taken from each patient. The sample was considered positive if it demonstrated noncaseiting granulomas with negative bacterial, fungal and mycobacterial cultures. Results: Bronchial biopsy was more positive in 84% of the abnormal appearing airways, biopsy provided diagnostic tissue in 32% of the normal appearing mucosa. The most frequent Original Research Article Yanardag et al.; BJMMR, 9(1): 1-7, 2015; Article no.BJMMR.18441 2 bronchoscopic finding was miliary infiltration followed by nodular and erythematous lesions. Serum ACE, serum and urinary Ca levels were higher (51.4±14.3 IU/L vs 37.3±15.1 IU/L, p<0.01; 8.42±3.6 mg/dL vs 10.8±2.9 mg/dL, p<0.01; 244.9±32.4 mg/day vs 379.6±36.8 mg/day, p<0.01) in patients with endobronchial involvement. There was no significant difference between FEV1, FVC, TLC and DLCO/VA. The extrapulmonary organ involvement (p<0.02) and progressive disease (p<0.03) was more frequent in patients with endobronchial disease. Conclusion: Endobronchial involvement in sarcoidosis appears to be a significant predictive risk factor for progressive disease. Extrapulmonary organ involvement was also higher in these patients contributing to a worse prognosis.

Miliary tuberculosis in an Indian lady: Looking beyond miliary tuberculosis.

Presence of miliary shadows in chest imaging in the appropriate clinical setting is often taken as a marker of miliary tuberculosis. If sputum is negative for acid -fast bacillus, empirical anti-tubercular therapy is given without securing a histological or microbiological diagnosis. We report a young female with human immunodeficiency virus infection who had miliary infiltrates on chest radiography. She was started on empirical anti-tubercular therapy. But an alternate diagnosis was achieved later with invasive sampling and ATT was stopped. This case illustrates the need for physicians to remain alert to diseases which mimic tuberculosis in presentation.

Miliary pulmonary cryptococcosis

A 32-year-old HIV positive male presents with fevers and a non-productive cough. Initial X-ray and subsequent computerised tomography of the chest shows a bilateral miliary pattern of pulmonary infiltration highly suggestive of disseminated tuberculosis. However subsequent results were consistent with disseminated cryptococcosis, including pulmonary involvement, with cryptococcus identified on transbronchial tissue biopsy, and on blood and cerebrospinal fluid cultures.Imaging features of pulmonary cryptococcosis are generally of well-defined pleural-based nodules and less commonly alveolar infiltrates, lymphadenopathy, pleural effusions or cavitating lesions. Miliary pulmonary infiltrates are an exceptionally rare presentation.

Characteristics of Central Nervous System Tuberculosis in a Low-Incidence Country: a Series of 20 Cases and a Review of the Literature

Central nervous system tuberculosis (CNS-TB) is a devastating manifestation of tuberculosis (TB) caused by the hematogenous spread of Mycobacterium tuberculosis. Here, I present a retrospective analysis of 20 CNS-TB cases in Israel, a country with a low incidence of TB over an 11-year period (2000-2010). Most of the cases were those of African migrants, with an increased prevalence in adult females and in those with HIV coinfections. Clinical manifestations were usually non-specific, and miliary infiltrates were rare. Lymphocytic meningitis was frequent with bacteriological confirmation in 50% of the cases. The yields of cerebrospinal fluid smear examinations were low (20%). Brain computed tomography revealed tuberculomas (45%) and hydrocephalus (15%). All patients received individual treatment on the basis of drug susceptibility patterns and adjunctive steroid therapy. However, 35% of the patients died within the first year and the mortality rate was strongly correlated to disease severity (90%), HIV coinfection (85%), and hydrocephalus (66%). Progress in new diagnostic tests and early treatment may improve the current high mortality and morbidity rates.

Multidrug-Resistant Disseminated Nocardia Farcinica Infection in a Systemic Lupus Erythematosus Patient

Herein, we present a 40-year-old female case who was admitted to our hospital with the complaints of fever and a painful left leg. She had a five-month history of treatment with azathioprine and prednisolone for lupus nephritis. The patient was diagnosed with disseminated nocardiosis (nodular cutaneous lesions, bacteremia, brain abscesses, and a reticulonodular miliary tuberculosis-like infiltration) associated with Nocardia farcinica and was treated using linezolid, netilmicin, and ceftriaxone. This case is important as treatment of Nocardia infections remains week particularly when they involve the central nervous system and when they are sustained by highly drugresistant species such as Nocardia farcinica.

Histoplasmose: ein ungewöhnliches Feriensouvenir

A 24-year-old woman (student of biology) was part of a study group in Uganda. She developed fever and headache, which was empirically treated as malaria. After she had returned to Switzerland, a chest x-ray showed bilateral miliary nodular infiltrates. In assumption of an atypical pneumonia, she was treated with levofloxacin, although without success. On admission, she was in a bad general condition and was markedly dyspneic. Rales were heard over both lungs. CRP, liver enzymes and LDH were elevated. A lung function test revealed a marked impairment of the diffusion capacity. The chest x-ray showed a progression of the lung infiltrates. The informal medical data exchange among the group members by a virtual social network abbreviated our diagnostic workup substantially, since we heard that histoplasmosis had been assumed in another group member. It turned out that the affected persons had visited a colony of bats living in a cave inside the trunk of a tree. Antibodies against Histoplasma capsulatum were positive. We began a treatment with itraconazole. The condition improved gradually; chest x-ray and lung function normalized after the 8 week treatment. Histoplasmosis with such a severe course is rare in immunocompetent humans, which indicates that the inoculum must have been very high. Soil contaminated with bats guano favours the proliferation of Histoplasma capsulatum. Our case is also an illustration of how the widespread use of electronic media can sometimes facilitate our work.

Tuberculome du cône médullaire : à propos d’un cas et revue de la littérature

Tuberculosis affecting the central nervous system is well recognized, but only rarely localizes to the medullary conus.We report the case of a 69 year old man who was admitted to our unit with cauda equina syndrome. The MRI demonstrated ring-enhanced necrotizing lesions involving the medullary conus, the cervical cord and the brain. His chest CT scan showed a miliary infiltrate. The clinical presentation was associated with an inappropriate secretion of antidiuretic hormone. Quadruple antituberculous therapy was initiated, with corticosteroids in the initial phase of the treatment. Evolution was favorable, and follow-up MRI imaging demonstrated complete resolution of the cervical cord and brain lesions.

Bacteriological analysis of induced sputum for the diagnosis of pulmonary tuberculosis in the clinical practice of a general tertiary hospital

To determine the diagnostic sensitivity of bacteriological analyses in induced sputum (IS) for the diagnosis of pulmonary tuberculosis (TB) and to identify the clinical characteristics associated with the confirmed diagnosis, as well as to determine the diagnostic yield of bronchoscopy carried out when IS tests negative for AFB in smear microscopy. A retrospective, cross-sectional study of patients suspected of having active pulmonary TB and referred to our clinic for sputum induction. We consecutively reviewed the laboratory data of all patients submitted to sputum induction between June of 2003 and January of 2006, as well as their electronic medical records. In addition, the results of the bacteriological analysis of bronchoscopic specimens collected from the patients whose AFB tests were negative in IS were reviewed. Of the 417 patients included in the study, 83 (19.9%) presented IS samples that tested positive for TB (smear microscopy or culture). In the logistic regression analysis, radiological findings of cavitation (OR = 3.8; 95% CI: 1.9-7.6) and of miliary infiltrate (OR = 3.7; 95% CI: 1.6-8.6) showed the strongest association with the diagnosis of pulmonary TB. In 134 patients, bronchoscopy was carried out after negative AFB results in IS and added 25 (64.1%) confirmed diagnoses of pulmonary TB. In our clinical practice, the frequency of confirmed diagnosis of pulmonary TB using IS (19.9%) was lower than that previously reported in controlled trials. Cavitation and miliary infiltrate increase the diagnostic probability of pulmonary TB using IS. The use of bronchoscopy when IS tests negative for AFB significantly increases sensitivity in the diagnosis of pulmonary TB.

Development of a clinical scoring system for the diagnosis of smear-negative pulmonary tuberculosis

This study developed a clinical score based on clinical and radiographic data for the diagnosis of smear-negative pulmonary tuberculosis (SNPT). SNPT was defined as a positive culture in Ogawa in a patient with two negative sputum smears. Data from patients admitted to the emergency ward with respiratory symptoms and negative acid-fast bacilli (AFB) smears was analyzed by means of logistic regression to develop the predictive score.Two hundred and sixty two patients were included. Twenty patients had SNPT. The variables included in the final model were hemoptysis, weight loss, age > 45 years old, productive cough, upper-lobe infiltrate, and miliary infiltrate. With those, a score was constructed. The score values ranged from -2 to 6. The area under the curve for the ROC curve was 0.83 (95% CI 0.74-0.90). A score of value 0 or less was associated with a sensitivity of 93% and a score of more than 4 points was associated with a specificity of 92% for SNPT. Fifty-two point twenty-nine percent of patients had scores of less than one or more than four, what provided strong evidence against and in favor, respectively, for the diagnosis of SNPT. The score developed is a cheap and useful clinical tool for the diagnosis of SNPT and can be used to help therapeutic decisions in patients with suspicion of having SNPT.

Comparative radiological features of disseminated disease due to Mycobacterium tuberculosis vs non-tuberculosismycobacteria among AIDS patients in Brazil

BackgroundDisseminated mycobacterial disease is an important cause of morbidity and mortality in patients with HIV-infection. Nonspecific clinical presentation makes the diagnosis difficult and sometimes neglected.MethodsWe conducted a retrospective cohort study to compare the presentation of disseminated Mycobacterial tuberculosis (MTB) and non-tuberculous Mycobacterial (NTM) disease in HIV-positive patients from 1996 to 2006 in Brazil.ResultsTuberculosis (TB) was diagnosed in 65 patients (67.7%) and NTM in 31 (32.3%) patients. Patients with NTM had lower CD4 T cells counts (median 13.0 cells/mm3 versus 42.0 cells/mm3, P = 0.002). Patients with tuberculosis had significantly more positive acid-fast smears (48.0% vs 13.6%, P = 0.01). On chest X-ray, miliary infiltrate was only seen in patients with MTB (28.1% vs. 0.0%, P = 0.01). Pleural effusion was more common in patients with MTB (45.6% vs. 13.0%, P = 0.01). Abdominal adenopathy (73.1% vs. 33.3%, P = 0.003) and splenic hypoechoic nodules (38.5% vs. 0.0%, P = 0.002) were more common in patients with TB.ConclusionMiliary pulmonary pattern on X-ray, pleural effusion, abdominal adenopathy, and splenic hypoechoic nodules were imaging findings associated with the diagnosis of tuberculosis in HIV-infected patients. Recognition of these imaging features will help to distinguish TB from NTM in AIDS patients with fever of unknown origin due to disseminated mycobacterial disease.