Miliary Pulmonary Tuberculosis Research Articles

Paradoxical tuberculous reaction to anti-tnfα discontinuation: a complex case of miliary tuberculosis and macrophagic activation syndrome with hepatic manifestations

Tuberculosis reactivation during anti-TNF-alpha therapy paradoxically worsened following reconstitution of pathogen-specific immune responses after cessation of TNFα antagonist treatment and initiation of anti-bacillary therapy. We report the case of a 46-year-old woman who was prescribed a tumor necrosis factor blocker (anti-TNF) for a relapse of Behçet's disease. The patient developed pulmonary miliary tuberculosis following the reactivation of latent tuberculosis, despite a normal pre-therapeutic work-up. Discontinuation of anti-TNF and initiation of anti-bacillary drugs triggered a paradoxical tubercular reaction (PTR). The diagnosis of paradoxical reaction to anti-tuberculosis drugs was evoked by the clinical and biological deterioration and the appearance of miliary cerebral tuberculosis and cerebral venous thrombosis after a period of clinical improvement. Although this phenomenon has been documented, it represents a major challenge for clinicians. The peculiarity of this case lies in its association with a macrophagic activation syndrome (MAS) with hepatic involvement, retained on clinical-biological and histological criteria. The overlap between MAS and PTR makes it difficult to diagnose these two entities with certainty. The patient responded favorably to moderate-dose systemic corticosteroid therapy with progressive degression, and the reintroduction of anti-tuberculosis drugs.This work aims to highlight the importance of close monitoring of TB patients on anti-TNFα therapy for early diagnosis and management of complications to improve the prognosis of these complex patients.

Miliary Pulmonary Tuberculosis After Intravesical BCG Instillation in a Patient with High-Grade Bladder Cancer

Intravesical administration of Bacillus Calmette-Guerin (BCG) vaccine is used in the treatment of superficial bladder cancer. In clinical practice, intravesical BCG immunotherapy after transurethral tumor resection is a highly effective treatment option in preventing tumor recurrence and progression in medium and high risk superficial bladder tumors. Since patients are given live tuberculosis (TB) bacillus, serious side effects such as pneumonia, sepsis and even death can be seen. Lung involvement occurs in less than 1% of patients and most commonly presents as interstitial pneumonia or miliary TB. Miliary TB is difficult to diagnose and is usually based on high clinical suspicion, as Mycobacterium bovis is not isolated in most cases. Treatment is not completely standardized. However, in severe cases, a combination of antituberculosis drugs and corticosteroids is recommended. In this report, a case of miliary tuberculosis, a very rare complication after instillation of BCG into the bladder in a patient with a diagnosis of superficial bladder cancer, was presented. A 73-year-old male patient diagnosed with bladder tumor underwent transurethral resection of bladder tumor, and then weekly intravesical injection of BCG-MEDAC for six weeks had no adverse effects. Three weeks of intravesical BCG supplementation was planned for the patient who had no signs of recurrence when checked three months later by cystoscopy. Two hours after the first dose, the patient, who applied to the emergency department with the complaint of chills and shivering, was hospitalized for further follow-up and treatment. Afterwards, repeat cultures were taken from the patient whose fever continued on the seventh day of treatment with broad-spectrum antibiotics (meropenem and teicoplanin). In addition, when abdominal and thorax computed tomography (CT) were performed, multiple miliary nodular lesions were detected in both lungs and were evaluated in favor of miliary TB. With these findings, the patient was started on miliary TB therapy [isoniazid (INH), rifampicin (RIF), ethambutol (EMB) and streptomycin (STM)] targeting Mycobacterium bovis, since it was an infection that developed after BCG injection. In the third week of the treatment, the patient's fever was under control, and he was discharged on the 25th day of his hospitalization because of significant improvement in infection markers [C-reactive protein(CRP)-procalcitonin]. At the end of two months, there was clear regression of pulmonary abnormalities on control thorax CT. In conclusion, miliary TB developing after intravesical BCG instillation is a very rare condition, the cause of which is not fully understood, the etiology of fever can be easily missed, and the diagnosis is difficult. In addition, this case is presented to draw attention to a critical disease that requires long treatment and follow-up and requires attention.

A case report about a child with drug-resistant tuberculous meningitis

BackgroundHematogenous disseminated tuberculosis predisposes to concurrent tuberculous meningitis (TBM), the most devastating and disabling form of tuberculosis. However, children often have atypical clinical symptoms, difficulty in specimen collection, low specimen content, and an increasing incidence of drug-resistant tuberculosis. Thus, the accurate diagnosis and timely treatment of childhood tuberculosis face monumental challenges.Case presentationThe 14-year-old female presented to the hospital with intermittent fever, headache, and blurred vision. Her cerebrospinal fluid (CSF) showed a lymphocytic pleocytosis, an elevated protein level, and a decreased chloride level. And her CSF tested positive for TB-RNA. Xpert MTB/RIF detected Mycobacterium tuberculosis in her CSF, but the rifampin resistance test was unknown. Subsequently, her CSF culture was positive for Mycobacterium tuberculosis. The drug sensitivity test (DST) revealed resistance to isoniazid, rifampin, and fluoroquinolones. A computed tomography (CT) of the chest showed diffuse miliary nodules in both lungs. Intracranial enhanced magnetic resonance imaging (MRI) showed “multiple intensified images of the brain parenchyma, cisterns, and part of the meninges.” The final diagnosis is miliary pulmonary tuberculosis and pre-extensive drug-resistant TBM. After 19 months of an oral, individualized antituberculosis treatment, she recovered with no significant neurological sequelae.ConclusionFor patients with miliary pulmonary tuberculosis, especially children, even if there are no typical clinical symptoms, it is necessary to know whether there is TBM and other conditions. Always look for the relevant aetiological basis to clarify whether it is drug-resistant tuberculosis. Only a rapid and accurate diagnosis and timely and effective treatment can improve the prognosis and reduce mortality and disability rates.

Disseminated tuberculosis: Clinical presentation, diagnosis, and outcomes in a tertiary-care hospital in Saudi Arabia.

Tuberculosis (TB) is the primary infectious cause of mortality worldwide. Although TB incidence and prevalence are declining, the use of immunosuppressive drugs and the growing prevalence of immunocompromising conditions such as comorbidities, malignancies, and the use of immunosuppressive agents are risk factors for disseminated TB (DTB). This study aims to identify the relevant clinical, laboratory, radiological, and histopathological features of DTB, as well as to assess the typical anatomical distributions and treatment outcomes of patients diagnosed with the disease at King Abdulaziz Medical City (KAMC). A retrospective chart review was conducted, including all patients diagnosed with miliary or DTB at KAMC with retrievable medical files. The study included 55 patients, of whom 35 (63.6%) were male and the median age was 64 years old. 35 (63.6%) of the infected patients were timely diagnosed and eventually cured from the illness. The most common comorbid conditions were diabetes, chronic kidney disease, and immunocompromising conditions, which were present in 37 (67.2%), 12 (21.8%), and 11 (20%) of the patients, respectively. The most common presenting symptoms were fever and cough, present in 31 (56.3%) and 26 (47.2%) of the patients, respectively, followed by weight loss in 25 (45.4%), night sweats in 15 (27.2%), and shortness of breath in 14 (25.4%). Approximately two-thirds of the patients had pulmonary miliary TB (MTB) (38; 69.1%), followed by TB lymphadenitis (21; 38.2%), central nervous system involvement (13; 23.6%), skeletal involvement (11; 20%), gastrointestinal involvement (5; 9.1%), pleural involvement (3; 5.5%), and urogenital TB (2; 3.6%). The mortality rate was 14 (25.5%) patients. MTB is challenging to diagnose due to nonspecific clinical, laboratory, and imaging findings. Clinicians dealing with patients who are at risk of developing DTB should be aware of the typical presentations and abnormal clinical findings. They should also have a low threshold to initiate specific investigations for the disease, as early diagnosis and effective treatment is critical in reducing morbidity and mortality rates.

A study of risk factors for tuberculous meningitis among patients with tuberculosis in China: An analysis of data between 2012 and 2019.

The present study aimed to explore the risk factors for tuberculous meningitis (TBM) among patients with tuberculosis (TB). This retrospective study was conducted on patients with TB who were hospitalized in Beijing Chest Hospital between January 2012 and December 2019. Demographic and clinical data of patients with TB were extracted from electronic medical records using a standardized data collection system. Logistic regression was used to analyze the risk factors associated with TBM. Of the total number of 22,988 cases enrolled, 3.1% were cases of TBM, which included 127 definite and 581 probable TBM, respectively. Multivariate analysis showed that definite TBM was significantly associated with patients aged < 30 years [adjusted odds ratio (aOR) = 3.015, 95% confidence interval (CI): (1.451-6.266)], who were farmers [aOR = 1.490, 95%CI: (1.020-2.177)], with miliary pulmonary TB [aOR = 105.842, 95%CI: (71.704-156.235)], and with malnutrition [aOR = 2.466, 95%CI: (1.110-5.479)]. Additionally, probable TBM was significantly associated with patients aged < 30 years [aOR = 2.174, 95% CI: (1.450-3.261)], aged 30-59 years [aOR = 1.670, 95% CI: (1.222-2.282)], who were farmers [aOR = 1.482, 95%CI: (1.203-1.825)], with miliary pulmonary TB [aOR = 108.696, 95%CI: (87.122-135.613)], and with a digestive system TB [aOR = 2.906, 95%CI: (1.762-4.793)]. An age of < 30 years, being a farmer, and having miliary pulmonary TB were risk factors for TBM among patients with TB. Further screening of patients with TB with aforementioned characteristics could facilitate clinicians to identify patients with TBM at an early stage.

Liver tuberculosis in children

Objective. The primary tuberculosis infection in childhood is manifested as a common disease. The diagnostics of liver tuberculosis is still a little-studied problem due to the absence of clinical manifestations.Purpose. To study clinical course, diagnostics and management of liver tuberculosis in children.Material and methods. 5 children, aged from 5 days to 16 years, with liver tuberculosis were under the observation. To put diagnosis, the researchers used the following parameters: anamnesis, examination, laboratory and specific tests, ultrasound, radiological methods including CT, biopsy of the surgical material.Results and discussion. Out of 5 children with liver tuberculosis, 3 had disseminated miliary pulmonary tuberculosis with liver damage; one had liver tuberculosis of the tuberculoma type and one had tumor-like liver tuberculosis. These three observations are described the article. In the diagnostics, basic indexes are CT of the abdominal organs, histological examination of the surgical material and positive Diaskin test.Conclusion. An isolated tuberculous liver damage is a rare case. More often, several anatomical regions are simultaneously involved in the specific process.

The profile of drug resistance of Mycobacterium tuberculosis and clinical features of extrapulmonary resistant tuberculosis among children living in Lviv region, Ukraine

Pediatric tuberculosis (TB) is a serious infectious disease that affects many children worldwide and is more likely to be extrapulmonary than adult TB. The purpose - to analyze the profile of drug resistance of Mycobacterium tuberculosis and clinical features of extrapulmonary resistant (EPR) TB among children from Lviv region, Ukraine. Materials and methods. We analyzed all cases of EPR TB (n=23) and extrapulmonary sensitive (EPS) TB (n=24) among 478 medical charts of children, who were hospitalized in the Lviv Anti-TB hospital during 2013-2020. Results. It was found out that EPR TB was diagnosed significantly more often at the age of 1 year and up to 3 years old than EPS TB and significantly less often - among children aged 4-7 years. The children with EPR TB were significantly more likely to live in rural areas and they were significantly more likely to be from families with less than 2 children, compared to EPS TB. The children with EPR TB were more often diagnosed with meningeal and central nervous system (CNS) TB, less often - with TB of the bones and joints, only they had TB of the intestine, compared to EPS TB. Miliary pulmonary TB and the predominance of bilateral process were more common at EPR TB. Among children with EPR TB, rifampicin-resistant TB was significantly more common found than the risk of multidrug-resistant TB (MDR-TB) and monoresistant TB. The resistance profile of MDR-TB showed that 17.4% are resistant to the combination of HR (H-isoniazid, R-rifampicin), 8.6% - to HRES (E-ethambutol, S-streptomycin), 4.3% - to НRS. Among 43.5% of children with EPR TB the contact with a TB patient was not established. At the same time, only a third of children who had came into contact with bacterial exсretors were under dispensary observation and only about 9% received chemoprophylaxis. Conclusions. In order to prevent the development of EPR TB, it is necessary to improve TB prevention measures among the most vulnerable segments of the population. The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of all participating institutions. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors.

Analysis of Clinical Features and Risk Factors in Pregnant Women With Miliary Pulmonary Tuberculosis After In Vitro Fertilization Embryo Transfer.

PurposeMiliary pulmonary tuberculosis (TB) among pregnant women after in vitro fertilization embryo transfer (IVF-ET) causes poor outcomes but is rarely reported. This study analyzed the clinical characteristics and risk factors of these patients to provide hints for further studies.MethodThe demographic characteristics, clinical manifestations, radiologic features, treatment, and outcomes of six patients diagnosed from May 2012 to August 2021 in Xiangya Hospital and 69 patients that were reported in English or Chinese literature from January 1980 to August 2021 were retrospectively analyzed. Continuous variables were compared between groups by t-test or Mann–Whitney U test, and categorical variables were compared between groups by chi-square test or Fisher exact test. Univariate and multiple logistic regression analyses were used to determine the predictors of respiratory failure.ResultsA total of 75 patients were included. The average age of patients was about 30 years. All patients had tubal obstruction; 5 of them were diagnosed with pelvic TB before. Thirteen cases had a history of pulmonary or extrapulmonary TB, six out of them without any antituberculosis treatment history. All patients were in their first or second trimester during the onset of symptoms. The average interval between onset of symptoms and radiologic examination was about 21 days. The most common abnormalities on chest computed tomography scan were multiple nodules, pulmonary infiltrate, and consolidation. Merely 10 patients obtained bacteriological diagnosis by Mycobacterium tuberculosis culture or polymerase chain reaction test. The other patients were clinically diagnosed. All the patients received antituberculosis treatment. Although 44% of patients had fatal complications, all cases were cured or improved after antituberculosis treatment. Unfortunately, only eight fetuses survived (10.6%). The most frequent and severe complication was type I respiratory failure (20%). Patients with expectoration, dyspnea, coarse breath sounds, ground-glass opacity, and pulmonary infiltrate or consolidation were more likely to have respiratory failure (P < 0.05). Ground-glass opacity (OR = 48.545, 95% CI = 2.366–995.974, P = 0.012) and pulmonary infiltrate or consolidation (OR = 19.943, 95% CI = 2.159–184.213, P = 0.008) were independent predictors for respiratory failure.ConclusionTube infertility with underscreened or untreated TB is a risk factor for miliary TB during pregnancy after IVF-ET. Ground-glass opacity and pulmonary infiltrate or consolidation are predictors of respiratory failure. We demonstrate risk factors for incidence and complications to supply clues for future intervention and improve patient prognosis.

CLINICAL CASES OF CONGENITAL TUBERCULOSIS IN THE PERM REGION

Abstract. Congenital tuberculosis is extremely rare, not a sufficiently carefully collected anamnesis, the presence of respiratory and intoxication complaints, contraindications to preventive X-ray examination, lack of registration at the dispensary observation of some pregnant women prevent the detection of the disease. Timely tuberculosis in a pregnant woman and her treatment can prevent not only infection with mycobacterium tuberculosis of the fetus, but also the disease. The purpose of this study was to present clinical cases of congenital tuberculosis in the Perm Region for 25 years. During this period of time, two cases of congenital tuberculosis in children with different forms of outcome were registered. A case of congenital miliary pulmonary tuberculosis with bacterial excretion realized already 1 month after the birth of a child from a mother with disseminated pulmonary tuberculosis and proceeding as a nonspecific respiratory disease. And a case of late-diagnosed congenital tuberculosis of internal organs and peripheral lymph nodes born from a tuberculosis patient and an HIV-infected mother. The following were studied: medical documentation of these patients, anamnesis of the disease, methods of X-ray, laboratory and clinical diagnostics, observation results that allowed reflecting the features of the clinical course of tuberculosis. Timely initiated chemotherapy, in the case of congenital miliary pulmonary tuberculosis with bacterial excretion, made it possible to achieve a clinical cure with an outcome of complete resorption without residual changes. Clinical observation of congenital tuberculosis of internal organs and peripheral lymph nodes in the patient demonstrated a case of late detection of the disease, however, thanks to the course of chemoprophylaxis of tuberculosis in non-vaccinated BCG immediately after birth, prevented the further development of severe tuberculosis. Proper organization of timely prevention, detection and treatment of congenital tuberculosis with its correction at all stages allows to achieve a clinical cure with small residual changes.

Lymphocytic interstitial pneumonia in an infant with diffuse cystic pulmonary tuberculosis

Background: Lymphocytic interstitial pneumonia (LIP) is a rare disorder causing diffuse involvement of the lung parenchyma, including cystic changes. It is generally associated with autoimmune diseases in adults and human immunodeficiency virus infection in children. Concurrent LIP with pulmonary tuberculosis (TB) is rare and has not been reported in the pediatric population. Clinical Description: An 8-month-old infant who was recently diagnosed with miliary pulmonary TB and on antitubercular treatment presented with fast breathing for 2 days. Salient examination findings were tachypnea, with oxygen saturation of 84% in room air. High-resolution computed tomography of the chest showed diffuse involvement of both lungs with bilateral cystic changes. Histopathological examination of a lung biopsy specimen was consistent with LIP. Management: First-line antitubercular therapy was continued as per the national guideline, and methylprednisolone pulse was administered for 3 days followed by maintenance prednisolone for 8 weeks. The child responded well clinically and was kept under close follow-up. Radiological improvement became apparent at 15-month follow-up. Conclusion: Presence of diffuse cystic lung disease in pulmonary TB should raise suspicion for LIP. Lung biopsy is diagnostic and should be considered in such cases.

Multifocal cutaneous tuberculosis coexisting with pulmonary tuberculosis

Tuberculosis (TB) is caused by Mycobacterium tuberculosis and it can affect multiple organ systems. Cutaneous TB, a less common type of extrapulmonary TB can coexist with TB of other organs. Here, we describe a case of multifocal cutaneous TB suggestive of two different morphological types with concomitant miliary pulmonary TB.

Dilemme diagnostic et rôle de l’imagerie dans la tuberculose pulmonaire miliaire en postpartum

Most tuberculosis (TB) infections in women of reproductive age occur around pregnancy and the postpartum period. Miliary TB is a disseminated form of the disease which is rare during pregnancy and postpartum but potentially fatal. The clinical presentation of miliary pulmonary TB is not specific and body specimens may be difficult to obtain or give a negative finding, leading to delayed diagnosis and treatment. The decision to investigate patients’ symptoms with imaging can be rewarding as the miliary pattern can be easily recognized. We report a case of postpartum miliary pulmonary TB in a client negative for human immunodeficiency virus infection that was diagnosed with chest computed tomography after prolonged illness and no certain clinical diagnosis.

Concurrent central nervous system involvement in immunocompetent adults with pulmonary miliary TB: a prospective analysis.

Wallgren's tuberculosis (TB) timetable demonstrated co-occurrence of miliary TB and tuberculous meningitis in children. To verify the same in immunocompetent adults, we prospectively evaluated the prevalence and spectrum of central nervous system (CNS) involvement in patients with pulmonary miliary TB. This was a tertiary care, University hospital-based, prospective evaluation performed from December 2018 to June 2020. Newly diagnosed patients with pulmonary miliary TB were subjected to a detailed clinical, laboratory and MRI-based evaluation. All patients received treatment as per WHO guidelines. Out of 342 patients with pulmonary TB, 53 patients met the eligibility criteria. The median age at presentation was 32 y and approximately two-thirds of patients were female. Clinically, only two-fifths of patients had features of CNS involvement. Cerebrospinal fluid (CSF) and imaging abnormalities were noted in 46 patients each. Twelve (23.5%) patients were diagnosed with definite-category tuberculous meningitis. Presence of an infarct significantly correlated with neurological features. Mantoux positivity correlated significantly with the presence of choroid tubercles, CSF changes and brain tuberculomas. This is the first study to endorse Wallgren's observations in immunocompetent adults. A high index of suspicion, even in asymptomatic patients, may uncover tuberculous lesions involving the CNS and guide optimal monitoring of patients.

Genitourinary tuberculosis in the structure of autopsy morphological findings in deceased patients at the late stages of HIV infection

Introduction. The problem of tuberculosis (TB) has not lost its significance due to the overlapping epidemic of HIV infection and the addition of specific lesions at its late stages. It is due to the lack of adherence to antiretroviral therapy in a large number of patients. The high mortality rate in HIV-associated TB requires an increase in the interest of all doctors for the early detection of various TB localizations against the background of HIV, allowing the patient to be cured. For urologists, information on the frequency of genitourinary TB in HIV patients is of interest to improve its diagnosis. Purpose of the study. To identify the proportion of genitourinary TB in the structure of the specific lesions in patients with HIV-associated TB. Materials and methods. The case-records of 115 deceased patients with a combination of HIV infection and TB were retrospectively analyzed using a continuous method. The number of men among them was 81.7 ± 3.6% (94). The average age of men was 37.1 ± 27.2 years, women — 31.9 ± 6.3 years. The research results were processed statistically. Results. The average period from the moment of HIV infection detection to the registration of a lethal outcome was 2.8 ± 1.3 years, from the moment of TB diagnosis — 6.96 ± 7.3 years. The majority of patients with HIV infection had a stage of secondary diseases (93.1 ± 2.4%). At the time of admission to the TB dispensary, the average CD4 + lymphocyte level was 131.06 ± 75.8 cells/pL, 10.03 ± 2.5%. Anti-retroviral therapy was observed only in 19 (16.5 ± 3.5%) patients. In deceased patients disseminated pulmonary TB was more often verified at autopsy — 52.2 ± 4.7%, miliary — 7.8 ± 2.5%, infiltrative — 11.3 ± 3.0%. In patients with disseminated and miliary pulmonary TB, foci of dropout were often observed in the spleen (71.7 ± 5.8% and 55.6 ± 16.6%) and liver (46.7 ± 6.4% and 33.3 ± 15,7%). The kidney damage occurred in 60.0 ± 6.3% of patients with disseminated and 44.4 ± 16.6% miliary pulmonary TB. Kidneys TB was confirmed by bacterioscopic urine examination in three cases only (2.6 ± 1.5%) during life. Prostate TB was confirmed by analysis of expressed prostatic secretion on Mycobacterium tuberculosis (2.6 ± 1.5%) and was combined with kidney TB. The lesions of the lymphatic system during life were exposed in 17.4 ± 3.5% of patients. A pathomorphological examination revealed TB of intrathoracic lymph nodes in 37.4 ± 4.5%, intra-abdominal lymph nodes — in 22.6 ± 3.9%, peripheral — 6.1 ± 2.2%, more often in miliary and disseminated pulmonary TB. TB meningitis was registered in 31 cases as well as meningoencephalitis in 32 patients during life and at autopsy, respectively. Intestinal TB was confirmed by autopsy in 9.6 ± 2.7% of patients; during life, it was accompanied by the detection of the pathogen in the feces. The pancreatic TB was detected in 2.6 ± 1.5%, TB spondylodiscitis in 1.7 ± 1.2%, myocardial TB in 0.9 ± 0.9% and pericardium TB in 0.9 ± 0.9% cases. Conclusion. Thus, generalized TB is diagnosed in patients in the late stages of HIV infection, in the structure of which kidney damage is in second place, yielded only to spleen damage. Obtaining this information should form the alertness of urologists in terms of detecting and diagnosing genitourinary TB in patients with HIV infection.

Clinical case of specific generalized lymphadenitis complicated by miliary tuberculosis of lungs

Adolescent A., aged 15 years and 10 months, was admitted to the Department of Oncohematology of the Regional Children’s Clinical Hospital in Ivano­Frankivsk urgently on 23rd of March, 2018; he was in a difficult clinical condition with generalized and conglomerate increase of many groups of peripheral lymphatic nodes with suspicion of lymphogranulomatosis. After a comprehensive examination and an open biopsy of the anterior­cervical lymph node rightward, on March 27th, 2018, granulomatous specific lymphadenitis of tubercular aetiology was confirmed pathohistologically. On April 5th, 2018, the patient was transferred for the treatment to the Children’s Department of the RPC (Regional Phthisiopulmonology Centre) with the FDPTB (First Diagnosed Primary Tuberculosis) (April 6th, 2018) of the lymph nodes, the generalized form, Destruction — MBT (Mycobacterium tuberculosis) — M– C (Culture)– Resistance 0 Histology+ (March 27th, 2018) Category 1 Cohort 2 (2018). He received antimycobacterial therapy H0.3, R0.3, Z1.5, Lfx0.5. In connection with the maintenance of the elevated level of several OncoMarkers in peripheral blood, he was distantly consulted by leading specialists of the Kyiv State Institution «National Institute of Phthisiology and Pulmonology named after F.H. Yanovsky of the AMS of Ukraine» on May 10th, 2018. Diagnosis of specific lymph nodes’ damage is confirmed, it is recommended to strengthen the treatment scheme with kanamycin. Having received the 90 doses of medicines, were noted: positive clinical dynamics, reduction of the size and conglomerate of peripheral lymph nodes and their absence in the retroperitoneal space according to the ultrasound study. On July 13th, 2018, the patient was discharged from the hospital for the outpatient treatment. After completing of the 120 doses of antimycobacterial medicines, on August 2nd, 2018, the miliary pulmonary tuberculosis was detected on the control MSCT (MultiSpiral Computed Tomography), and therefore the patient was rehospitalized with FTPTB (Failure of Treatment of Primary Tuberculosis) (August 6th, 2018) of the lymph nodes, generalized form Destruction– MBT– M– C– Resistance 0 Histology + (March 27th, 2018), complicated by miliary dissemination Category 2 Cohort 3 (2018). Treatment was continued according to the scheme 2H0.3, R0.45, Z1.5. E0.8, S0.75 with corticosteroid therapy with prednisolone of 20 mg with gradual decrease of the dose. On the control MSCT on October 4th, 2018, it was noted — positive dynamics — partial resorption of focal dissemination in both lungs, a significant reduction of the lymph nodes’ size of the mediastinum to normal. Subsequently, according to the MSCT on January 31, 2019, in both lungs throughout the course, an increasing focal (miliar) dissemination. February 20, 2019 a review of histological preparations of the biopsy of the lymph nodes of the neck, held consultation in the Kyiv State Institution «National Institute of Phthisiology and Pulmonology named after F.H. Yanovsky of the NAMS of Ukraine». The diagnosis of the specific nature of lymph nodes and lung lesions has been re­confirmed. On the 26th of February, 2019 according to the decision of the Central Medical Advisory Commission of Drug­Resistant TB of the Ivano­Frankivsk Regional Phthisiopulmonology Centre in connection with the negative dynamics of a specific process in the lungs, it is recommended to register a clinical incidence in 4 categories with the diagnosis: RMDR­TB (26.02.2019) pulmonary (miliary) Destruction– MBT– M– MG– C– Resistance 0 Histology + (March 27th, 2018), Category 4 (FTPTB) Cohort 1 (2019). The patient is prescribed treatment according to the scheme Cm0.6, Mfx0.4, Cs0.5, Pt0.5, Z1.6. Thus, the specific lymph nodes’ damage can clinically occur as a tumorous process. An important part in differential diagnosis is pathohistological study of the biopsy material of the lymph nodes. Further clinical observations, dynamic ultrasound study and MSCT­examination are necessary for controlling the course of the disease and correcting the treatment.

Spectrum of 18F-FDG Uptake in Bilateral Lung Parenchymal Diseases on PET/CT.

Bilateral lung parenchymal involvement is seen in infective as well as noninfective conditions, appearing as focal or diffuse lung disease. PET/CT with FDG helps in characterization (increased glucose utilization is seen by both inflammatory and neoplastic cells). In this article, we describe the spectrum of patterns of FDG uptake and associated CT changes involving bilateral lung parenchyma. Benign conditions described are aspiration pneumonia; pulmonary toxicity by bleomycin; infections, namely, sarcoidosis, miliary pulmonary tuberculosis, and pulmonary nocardiosis; and inflammatory conditions such as pulmonary Langerhans cell histiocytosis and pulmonary alveolar proteinosis. Neoplastic conditions described are bilateral pulmonary metastases and lymphangitic carcinomatosis.

A case of miliary pulmonary tuberculosis complicated by refractory hypercalcaemia following vitamin D replacement

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Asymptomatic choroidal tubercle in a patient with Crohn's disease on adalimumab treatment

Abstract Introduction Adalimumab, an anti-tumor necrosis factor alpha therapy for active Crohn's disease (CD), is associated with increased risks of tuberculosis infection. Case report The case is presented of a 48 year-old male with active CD on treatment with adalimumab. After three months, he developed a miliary pulmonary tuberculosis infection, with a solitary non-reactive choroidal tubercle temporal-superior to the optic disk being found in an ophthalmological study. Fluorescein angiography showed late hyperfluorescence in a staining pattern. Optic coherence tomography showed a flat mass without serous retinal detachment. The choroidal tubercle slowly regressed with antituberculosis therapy. Discussion Choroidal tubercles with no vitreo-retinal symptomatology can be present in patients with CD and on treatment with adalimumab.

Gastrointestinal (duodenum) tuberculosis associated with pancreatic pseudotumor and micronodular pulmonary infiltrate: a case report

We present the case report of a patient admitted to the Hospital Universitário Clementino Fraga Filho with suspected pancreatic neoplasm, with no histopathological diagnosis. A duodenal biopsy and CT scan of the thorax and abdomen were previously performed and the final presumptive diagnosis was pancreatic tuberculosis with pulmonary (Miliary tuberculosis) and confirmed duodenal involvement. In this manuscript we will discuss the main aspects of pancreatic tuberculosis, a rare entity with few cases described in the literature. We will discuss the importance of excluding some pathologies in the suspicion of pancreatic neoplasm.

Tubérculo coroideo asintomático en un paciente con enfermedad de Crohn en tratamiento con adalimumab

IntroductionAdalimumab, an anti-tumour necrosis factor alpha therapy for active Crohn's disease (CD), is associated with increased risks of tuberculosis infection. Case reportThe case is presented of a 48 year-old male with active CD on treatment with adalimumab. After three months, he developed a miliary pulmonary tuberculosis infection, with a solitary non-reactive choroidal tubercle temporal-superior to the optic disc being found in an ophthalmological study. Fluorescein angiography showed late hyperfluorescence in a staining pattern. Optic coherence tomography showed a flat mass without serous retinal detachment. The choroidal tubercle slowly regressed with antituberculosis therapy. DiscussionChoroidal tubercles with no vitreo-retinal symptomatology can be present in patients with CD and on treatment with adalimumab.