Rare Presentation Of Extrapulmonary Tuberculosis Research Articles

S3328 An Atypical Etiology of Chronic Abdominal Pain: Peritoneal Tuberculosis

Introduction: Peritoneal tuberculosis (TB) is a rare presentation of extra-pulmonary TB, comprising only 5% of extra-pulmonary TB cases. Patients oftentimes present with non-specific complaints and without typical Mycobacterium tuberculosis risk factors. Additionally, diagnostic testing lacks high sensitivity and specificity with further invasive methods frequently necessitated. We present an unusual case of peritoneal TB presenting as non-localized abdominal pain, facilitating insight into this uncommon disease. Case Description/Methods: A 53-year-old female with a past medical history of hypothyroidism presented with joint pain diagnosed as seronegative rheumatoid arthritis and subsequently began treatment with methotrexate and adalimumab for one year. Within the following year, she experienced chronic right lower quadrant (RLQ) abdominal pain, fevers, night sweats, fatigue, and ascites. Extensive work-up revealed a positive QuantiFERON gold TB test. A diagnostic laparoscopy with peritoneal biopsy successively demonstrated elevated CA-125 and large-volume ascites. Mycobacterium tuberculosis PCR and Grocott methenamine silver staining were negative. One of two acid-fast bacillus (AFB) smear and cultures yielded a positive result. Our patient was treated for peritoneal TB. She continued to have several years of chronic RLQ abdominal pain several months after RIPE treatment completion, undergoing a cholecystectomy and three adhesion lysis procedures with mild symptomatic improvement and subsequent worsening thereafter. An operative note highlighted the large amount of adhesions from the patient’s liver to her diaphragm and anterior abdominal wall, appearing similar to Fitz-Hugh-Curtis syndrome. She continues to have chronic abdominal pain and is followed closely by her treatment team. Discussion: Our patient was on immunosuppressive medications and had a history of travel to Mexico, a high TB burden country. Notably, AFB smear and culture has a poor sensitivity for peritoneal TB, oftentimes necessitating laparoscopic peritoneal biopsy for further diagnosis. Our patient was empirically treated for peritoneal TB before AFB culture yielded positive results, given her B symptoms and positive QuantiFERON test. She also had an elevated CA-125 value, which is associated with peritoneal TB and may be used in patients with a negative AFB stain. Our patient experienced recurrent adhesions, an unfortunate and persistent consequence of the inflammatory nature of peritoneal TB.

A cervical tuberculous abscess mimicking a fourth branchial cleft cyst in a child: PCR, the key to fast diagnosis

BackgroundAnterior cervical tuberculous abscess is a rare presentation of extrapulmonary tuberculosis even in endemic countries.Case presentationWe report a case of a 14-year-old girl with a 5 day history of an anterior mass. The diagnosis of an infected fourth branchial cleft cyst was first evoked. Fine-needle aspiration cytology was suggestive of tuberculosis. Polymerase chain reaction analysis was the key to the diagnosis of a tuberculous abscess.ConclusionsIn endemic countries, abscesses occurring in uncommon sites should be dealt with a high degree of suspicion for tuberculosis. Early diagnosis is essential to initiate specific and effective treatment. Pre-operative diagnosis avoids invasive surgery and related complications.

MON-482 Thyroid Tuberculosis - An Unlikely Diagnosis

Background: Mycobacterium tuberculosis (MTB) is an aerobic bacillus responsible for the most cases of tuberculous infection. Approximately one-third of the world’s population is infected. Tuberculosis (TB) of the thyroid gland is an unusual diagnosis with an estimated prevalence of 0.1 to 0.6%. The thyroid TB can mimic different pathologies (thyroid neoplasms, lymphoma, infectious or granulomatous thyroiditis, Graves’ disease or bacterial abscess) and the diagnosis can be easily disregarded, especially in non-endemic countries and if the patient doesn’t have systemic symptoms. The fine needle aspiration and histopathological examination, with acid-fast bacilli staining and TB culture, are the gold standard exams.Clinical Case: A 71-year-old female was referred to our Endocrinology department after a diagnosis of nodular thyroid disease. She had complaints of slight cervical discomfort, with 6 months of duration. She hadn’t personal or familiar relevant antecedents. At observation, a movable, elastic and non-tender nodule of 15mm at the right superior thyroid lobe was identified. Blood tests including a thyroid profile were normal. The neck ultrasound showed, at the right lobe of the thyroid, multiple solid nodules; the dominant had 18mm, was heterogeneous and had multiple calcifications. Moreover, lymph nodes with suspicious ultrasonographic features along the right internal jugular chain were reported. The patient underwent fine-needle aspiration (FNA) of the suspicious thyroid nodule and one lymph node. Results were respectively: non-diagnostic (Bethesda I) and reactive pattern. FNA was repeated on a different occasion and results were similar. Due to ultrasound suspicious of malignancy, a total thyroidectomy was performed and a lymph node from level IV was sampled for extemporaneous examination. Necrotizing granulomas were documented; the Ziehl-Neelson staining (ZNS) was negative; material was sent to microbiology. Following this finding, ganglion emptying was not performed. The thyroid histology showed tuberculoid type granulomas with lymphoid border and central necrosis. However, the ZNS was negative. The diagnosis was definitely established by a positive culture of the lymph node tissue and molecular detection, by polymerase chain reaction (PCR), of MTB. Pulmonary involvement was excluded and she started antituberculous agents planned for 9 months (rifampicin and isoniazid during 9 months and ethambutol and pyrazinamide for 2 months).Conclusion: Thyroid TB is a rare presentation of extrapulmonary tuberculosis. In presence of systemic or specific complaints or history of exposition the diagnosis may be suspected and confirmatory tests requested in order to ensure an adequate treatment. However, sometimes, histopathology remains a key step and the use of cultures improves the sensitivity and specificity of TB tests.

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.
 
 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.
 
 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.
 
 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.
 
 Keywords: Mastitis tuberculosis, diagnosis, treatment.

Peritoneal Tuberculosis: A Challenging Diagnosis

Abdominal tuberculosis (TB) is a rare extra-pulmonary presentation of TB representing about 5% of all cases of extra-pulmonary TB. It is ranked sixth in incidence after lymphatic, pleural, osteoarticular, genitourinary and meningeal. It is usually secondary to reactivation of latent TB or ingestion of contaminated food. In cases of active pulmonary TB, abdominal involvement is usually due to hematogenous spread. The diagnosis is often delayed due to the nonspecific presentation and the poor yield of the conventional diagnostic techniques.An 88-year-old male from Nepal with history of end-stage renal disease on hemodialysis presented with subjective fevers, decreased appetite, early satiety and abdominal distention for 3 months. Physical examination was positive for ascites. Laboratory work up was significant for WBC 4.3 and elevated sedimentation rate at 41. Computed tomography (CT) abdomen showed large ascites. Paracentesis showed ascitic fluid (AF) with total nucleated cells 2400 with 5% neutrophils and 87% lymphocytes and his SAAG was <1.1. AF cytology was negative for malignancy. Three AF acid fast bacilli (AFB) smears and culture were negative, however serum QuantiFERON gold was positive. AFB sputum cultures were sent and came back positive for mycobacterium TB. CT thorax showed moderate right and small left pleural effusions. Thoracentesis was tried but was unsuccessful. He was started on isoniazid, rifampin, pyrazinamide and ethambutol and was discharged with a close follow up. Thoracentesis was done after discharge and pleural fluid AFB culture was negative.Abdominal TB can involve any part of the gastrointestinal tract with the most common sites being peritoneum, intestines and liver. A number of risk factors have been associated with peritoneal TB including cirrhosis, peritoneal dialysis, diabetes and malignancy. It often presents with ascites, abdominal discomfort and fevers. CT usually shows ascites, thickening of the peritoneum and lymphadenopathy. AF analysis usually shows elevated WBC with lymphocytosis and SAAG <1.1. AF stain and culture for AFB has poor sensitivity while adenosine deaminase testing has better sensitivity and is used to support the diagnosis in noncirrhotic patients. If AF analysis is nondiagnostic, peritoneal biopsy is pursued via laparoscopy. Treatment is similar to pulmonary TB with anti-TB medications for at least 6 months. Empiric treatment can be started in patients with high suspicion and negative diagnostic testing.

Tuberculous Tonsillitis in a Patient Treated with an Anti-TNF Agent.

Tuberculosis remains a concern in patients receiving anti-TNF therapy as these individuals have a higher incidence of extrapulmonary and disseminated tuberculosis. Tuberculous tonsillitis is an unusual presentation of extrapulmonary tuberculosis, which is diagnosed mostly in immunodeficient patients. We report the case of a 33-year-old woman, diagnosed with Behçet’s syndrome, immunosuppressed with adalimumab, cyclosporine and prednisolone. She had odynophagia for 2 weeks, fever and a hypertrophied, ulcerated left tonsil. A tonsil biopsy revealed a granulomatous inflammatory process. Ziehl-Neelsen staining was positive for acid-fast bacilli. The chest x-ray revealed a milliary pattern. Gastric juice was positive for Mycobacterium tuberculosis complex DNA. A diagnosis of tonsillar and pulmonary tuberculosis was established. This case report highlights the low threshold for a tuberculosis diagnosis in unusual locations in patients treated with anti-TNF therapy.LEARNING POINTSTuberculosis is a concern in patients receiving anti-TNF therapy as these individuals have a higher incidence of disseminated and extrapulmonary tuberculosis despite previous screening and treatment of latent disease.Tuberculous tonsillitis is a rare presentation of extrapulmonary tuberculosis and is thought to occur mostly in immunodeficient patients.Tonsillar tuberculosis commonly presents with sore throat and cervical lymphadenopathy which with abnormal tonsillar findings (such as ulcerations, masses and white patches) makes the differential diagnosis with other tonsillar infections or neoplasms challenging.

Rare presentation of intractable tuberculous panophthalmitis with intraocular and intraorbital abscesses: a case report

BackgroundWe report a rare presentation of extrapulmonary tuberculosis.Case presentationA 29-year-old Burmese woman with human immunodeficiency virus infection and known pulmonary tuberculosis who had been treated for 5 months presented to our hospital with unilateral progressive painful visual loss of 1 month’s duration. She was diagnosed with tuberculous panophthalmitis with subretinal and intraorbital abscesses, conjunctival abscess, and extraocular muscle tuberculoma. The diagnosis was confirmed by a conjunctival pus swab with a positive result for acid-fast bacilli and a positive result for a mycobacterial culture. There was high suspicion of multidrug-resistant tuberculosis. Despite receiving ongoing aggressive treatment with conventional antituberculous medications, this patient required subtotal orbital exenteration to control her infection and prevent further progression. Second-line antituberculous medications were added to the first-line therapy, with satisfactory results achieved.ConclusionsTuberculous panophthalmitis with intraocular and intraorbital abscesses is a rare presentation of extrapulmonary tuberculosis. Patients who do not respond to first-line antituberculous therapy might be infected with either single-drug or multidrug-resistant Mycobacterium tuberculosis. Patient compliance is one of the key factors that can alter the course of treatment. Careful patient monitoring can improve disease progression, outcome, and prognosis.

Lichen Scrofulosorum in a Patient with Tuberculous Cervical Lymphadenopathy: A case report

Introduction: Cutaneous tuberculosis (CTB) is a rare presentation of extrapulmonary tuberculosis (TB) with various clinical manifestations. Tuberculids, a type of CTB, are probably the result of hyperergic immune reaction induced by Mycobacterium tuberculosis. Lichen scrofulosorum (LS) is a rare tuberculid mostly seen in children and young adults with or without other manifestations of tuberculosis. Case report: We present a 30 year old patient presented with a papular eruption on his trunk and upper extremities. The patient had recently started on a 4 drug-regimen treatment for a diagnosed tuberculous cervical lymphadenitis and he was under investigation for pulmonary TB. Histopathology of the papular lesions showed epithelioid granulomas strongly indicating lichen scrofulosorum. The eruption responded to antitubercular therapy with complete clearance of the lesions. Discussion: The tuberculids are a form of CTB caused by hypersensitivity reactions to Mycobacterium tuberculosis. The diagnosis of LS is problematic and frequently delayed because of its rarity and clinical similarity to many other more common skin conditions.

Rare presentation of extra-pulmonary tuberculosis of the cheek

Extra- pulmonary tuberculosis (EPTB) has become a rising health problem aided by a pandemic of Human Immunodeficiency Virus infection (HIV). It occurs in about 15%-20% of HIV negative immunocompetent individuals and a greater propensity to occur in those with HIV infection. It predominantly affects the lymphatics and other organ systems like – central nervous system, skeletal, pleural etc. Tuberculosis of the cheek is uncommon, and is usually associated with a concomitant oral lesion. Extra-oral Tuberculosis in the absence of an oral lesion, is a unique occurrence. Hence, it can pose a diagnostic challenge especially in a young immunocompetent individual. We therefore report a rare presentation and management of Extra-pulmonary Tuberculosis of the Cheek in an immunocompetent 26 year old male.

Twenty-nine cases of lupus vulgaris

Cutaneous tuberculosis (TB) is a rare presentation of extrapulmonary TB. Lupus vulgaris (LV) is a common presentation of cutaneous TB. ObjectiveWe aimed to describe the epidemiological, clinical, paraclinical, therapeutic, and outcome features of LV in the region of Sfax, Tunisia. Patients and methodsWe conducted a retrospective and descriptive study of LV case patients observed at the dermatology department of the Hédi Chaker Hospital (Sfax) over a 34-year period. ResultsA total of 88 cutaneous TB case patients were identified during the study period, including 29 patients presenting with LV. All patients had clinical features of the most common presentation of LV. The results of skin biopsies indicated tuberculoid granulomas without caseous necrosis. Patients received TB treatment. LV progressed to squamous cell carcinoma in one patient. ConclusionIn Tunisia, endemic country for TB, LV should be considered in patients presenting with an old skin lesion.

A Rare Case of Peritoneal Tuberculosis

Peritoneal tuberculosis (TB) is a rare extra-pulmonary presentation of TB, caused by strains of mycobacteria, usually Mycobacterium tuberculosis . The clinical presentation of peritoneal TB can be extremely varied, making it a huge diagnostic challenge. Herein, we report a case of a 62-year-old Chinese female with no previous exposure to TB, presenting with 1-day history of per-rectal bleeding and abdominal pain. The diagnosis was eventually made with a combination of blood investigations, computerized tomography scans and histological analysis of peritoneal nodules found on diagnostic laparoscopy, which confirmed necrotizing granulating inflammation. She was subsequently started on anti-TB medications promptly without any further complications and recovered uneventfully. J Med Cases. 2016;7(4):130-132 doi: http://dx.doi.org/10.14740/jmc2449w

Tuberculosis of talus: a case report

Tuberculosis is still a major cause of mortality and morbidity in the world and especially in developed countries where it has been causing major disability. Relating to this we present a case report of 42yr old male patient with h/o pain and swelling of left foot and ankle from 2 years which after preliminary investigation was diagnosed as tuberculosis and was confirmed by biopsy. Under cover of anti-tubercular treatment (ATT) patient was treated with debridement and curettage of talonavicular joint with arthrodesis. Patient was continued on anti-tubercular treatment for 12 months after which patient was able to walk without pain and able to do his routine daily activities. My aim is to present a case of isolated tuberculosis of talonavicular joint which is a rare presentation of extrapulmonary tuberculosis and consideration of this diagnosis in chronic ankle and foot pain.

Extrapulmonary tuberculosis at an unusual site

Tuberculosis remains a major public health problem. One-third of the cases diagnosed with tuberculosis have extrapulmonary disease. Here, we report a rare presentation of extrapulmonary tuberculosis involving the spleen. This isolate was a sensitive one and hence the patient responded to the standard regime. Traditional methods of diagnosis are time-consuming but accurate and should be mandatorily followed by drug susceptibility testing to rule out multidrug and extensively drug-resistant tuberculosis.

Obstructive pseudotumor of tuberculosis in a young woman: a rare presentation.

Retroperitoneal pseudotumor is an extremely rare presentation of extrapulmonary tuberculosis. The diagnosis of this paucibacillary disease is difficult which is usually misdiagnosed as a malignant tumor. High index of suspicion is required for early diagnosis and treatment of retroperitoneal pseudotumor which can affect prognosis of this disease. Because of its rarity and difficult diagnosis, we report an 18-year-old immunocompetent girl who presented with abdominal pain and vomiting. Upper endoscopy showed an exudative mass between the second and third parts of duodenum. Abdominal computed tomography (CT) revealed a large retroperitoneal mass with extension into small bowel. Exploratory laparotomy and histopathological examination of tissue showed calcified granuloma. Ziehl-Neelsen staining and PCR confirmed the tuberculosis. The patient was successfully treated with standard antituberculosis therapy.

Tuberculous Otitis Media and Lupus Vulgaris of Face: An Unusual Association

Tuberculous otitis media is a rare extra-pulmonary presentation of tuberculosis. Tuberculous otitis media is usually associated with pulmonary tuberculosis or tuberculosis involving nasopharynx and oropharynx. Lupus vulgaris is the most common morphological variant of cutaneous tuberculosis. The disease often affects the face and may be associated with nasal or nasopharyngeal tuberculosis. Lupus vulgaris associated with tuberculous otitis media is not reported in English literature. We report a case of 40year old female patient who presented with symptoms of chronic suppurative otitis media and non-healing skin lesion of face. The biopsy of skin lesion showed granulomatous pathology and helped us to reach a diagnosis of tuberculous otitis media.

Isolated metacarpal bone tuberculosis-A case report

SUMMARYTuberculous involvement of the metacarpals and phalanges is a rare presentation of extrapulmonary tuberculosis in adult. Here is a case of tubercular dactylitis in a 27 year old female presenting as discharging sinus over proximal part of third metacarpalbone of left hand.

Tonsillar and lymph node tuberculosis revealing asymptomatic pulmonary tuberculosis

Sir, Tonsillar tuberculosis is a rare presentation of extrapulmonary tuberculosis. Although tuberculosis of the tonsils is nowadays an uncommon finding, tonsillar granulomas are occasionally seen by histopathologists, and can sometimes contain tuberculous organisms. Occasionally, tonsillar tuberculosis may precede the diagnosis of pulmonary tuberculosis.1 We present the case of a 40-year-old patient admitted for evaluation of hoarseness and difficulty in swallowing, firstly diagnosed as recurrent angina. He had also had chronic bilateral cervical lymphadenopathy for the last three years. All preceding investigations were normal. Clinical examination was …

Primary nasolacrymal tuberculosis diagnosed after dacryocytorhinostomy

Although tuberculosis (TB) is common and well recognized in many countries, unusual presentations of the disease sometimes raise difficulties in differential diagnosis. Primary tuberculosis of the lacrimal sac and the nasolacrimal duct is an extremely rare presentation of extra-pulmonary tuberculosis. Dacryocystorhinostomy alone is not sufficient for the treatment of these patients and an anti-tuberculous therapy has to be added. Here we present a patient with primary tuberculosis, which is limited to the inferior meatus and filled the entire lacrimal sac on the left side. The patient underwent endoscopic dacryocystorhinostomy due to obstruction of the nasolacrimal duct and culture of the granulation tissue, taken from the lacrimal sac revealed mycobacterial tuberculosis. The patient was improved with anti-tuberculous therapy that was added to the surgery. Primary tuberculosis is a rare granulomatous disease of the nasolacrimal system, which should be considered in the differential diagnosis to plan the effective treatment.