Tuberculin Research Articles

Case Report: A Case of Tuberculosis with Psoriasiform Lichen Scrofulosorum Exhibiting Koebner’s Phenomenon followed by Scrofuloderma

Lichen scrofulosorum is the most common tuberculid in the Indian population and the second most common form of cutaneous tuberculosis. We discuss an uncommon presentation of lichen scrofulosorum, with psoriasiform morphology and koebnerization at tuberculin test site, associated with cervical lymphadenitis in a 17-year-old girl. Although the cutaneous lesions resolved completely after 3 months of antitubercular treatment (ATT), she developed scrofuloderma in the left cervical region at 4 months. In the absence of rifampicin resistance, ATT was continued for another 6 months, with no further evidence of disease activity. This case represents an infrequent occurrence of lichen scrofulosorum followed by scrofuloderma, which necessitated a prolonged course of first-line ATT.

The distribution of tuberculin reaction among children at school entry in Madaba, Jordan

The present study reports the results of a tuberculin test survey of a representative sample of BCG unvaccinated children at school entry age in the Madaba district in Jordan in 1991-92. Preschool household contacts of positive schoolchildren and a 5% random sample of negative schoolchildren were also screened by the same test. Three out of the 746 children screened by the initial school survey were found to be positive giving a prevalence rate of 0.4%. The overall prevalence rate of infection among preschool contacts was found to be 10.1% [28.6% among the contacts of the positive schoolchildren compared to 8.1% among contacts of the negative children]

Effect of the Inoculation Site of Bovine and Avian Purified Protein Derivatives (PPDs) on the Performance of the Intradermal Tuberculin Test in Goats From Tuberculosis-Free and Infected Herds.

The single and comparative intradermal tuberculin (SIT and CIT) tests are used for the ante-mortem diagnosis of caprine tuberculosis (TB). The tuberculin injection site has been associated with a different performance of the test in cattle. In contrast to that required in cattle in Europe (cervical injection), it can be carried out in the scapular region in goats. Nevertheless, there are no previous data concerning the effect of the injection site on the performance of the test in goats. The aim of the present study was to evaluate the effect of two different inoculation sites (cervical and scapular) on the performance of the SIT/CIT tests. This was done by intradermally inoculating 309 goats from two infected herds and one TB-free herd with both avian and bovine PPDs in the mid-cervical and scapular regions. None of the animals from the TB-free herd had positive reactions, and the number of reactors was not significantly higher, regardless of the inoculation site, in the high and low prevalence herds. However, significantly higher increases in skin fold thickness were observed on the cervical site when compared to the scapular site after the avian and bovine PPD inoculations in the TB-free herd (p < 0.001) and after the bovine PPD injection in the high prevalence herd (p = 0.003). The presence of clinical signs was also more evident on the cervical site when using avian and bovine PPDs in the high prevalence herd (p < 0.01). In contrast, increases in higher skin fold thickness were observed on the scapular site when compared to the cervical site after the bovine and avian PPD inoculations were employed in the low prevalence herd (p < 0.01). These results suggest that the cervical injection of PPDs may improve the sensitivity of the intradermal tuberculin test in high TB prevalence caprine herds, mainly owing to the increased presence of local clinical signs and a better performance of the CIT test. Moreover, specificity was not affected when using standard interpretations, although further analyses in a great number of herds are required in order to confirm these findings.

Field evaluation of specific mycobacterial protein-based skin test for the differentiation of Mycobacterium bovis-infected and Bacillus Calmette Guerin-vaccinated crossbred cattle in Ethiopia.

Bovine tuberculosis (bTB) challenges intensive dairy production in Ethiopia and implementation of the test and slaughter control strategy is not economically acceptable in the country. Vaccination of cattle with Bacillus Calmette–Guerin (BCG) could be an important adjunct to control, which would require a diagnostic test to differentiate Mycobacterium bovis (M. bovis)‐infected and BCG‐vaccinated animals (DIVA role). This study describes an evaluation of a DIVA skin test (DST) that is based on a cocktail (DSTc) or fusion (DSTf) of specific (ESAT‐6, CFP‐10 and Rv3615c) M. bovis proteins in Zebu–Holstein–Friesians crossbred cattle in Ethiopia. The study animals used were 74 calves (35 BCG vaccinated and 39 unvaccinated) aged less than 3 weeks at the start of experiment and 68 naturally infected ‘TB reactor’ cows. Six weeks after vaccination, the 74 calves were tested with the DSTc and the single intradermal cervical comparative tuberculin (SICCT) test. The TB reactor cows were tested with the DSTc and the SICCT test. Reactions to the DSTc were not observed in BCG‐vaccinated and unvaccinated calves, while SICCT test reactions were detected in vaccinated calves. DSTc reactions were detected in 95.6% of the TB reactor cows and single intradermal tuberculin positive reactions were found in 98.2% (95% confidence interval, CI, 92.1–100%). The sensitivity of the DSTc was 95.6% (95% CI, 87.6–99.1%), and significantly (p < .001) higher than the sensitivity (75%, 95% CI, 63.0–84.7%) of the SICCT test at 4 mm cut‐off. DSTf and DSTc reactions were correlated (r = 0.75; 95% CI = 0.53–0.88). In conclusion, the DSTc could differentiate M. bovis‐infected from BCG‐vaccinated cattle in Ethiopia. DST had higher sensitivity than the SICCT test. Hence, the DSTc could be used as a diagnostic tool for bTB if BCG vaccination is implemented for the control of bTB in Ethiopia and other countries.

Evaluation of P22 ELISA for the Detection of Mycobacterium bovis-Specific Antibody in the Oral Fluid of Goats.

The ante-mortem diagnosis of tuberculosis (TB) in ruminants is based mainly on the intradermal tuberculin test and the IFN-γ assay. Antibody (Ab)-based tests have emerged as potential tools for the detection of TB infected animals using serum, plasma, or even milk samples. Oral fluids have also been evaluated as alternative samples with which to detect specific Abs against Mycobacterium bovis in pigs or wild boars, but not in ruminants. The objective of this study was, therefore, to evaluate the performance of an in house-ELISA for TB diagnosis (P22 ELISA) in goats as an experimental model for the diagnosis of TB using oral fluid samples. Oral fluid samples from 64 goats from a TB-infected herd (n = 197) and all the animals from a TB-free herd (n = 113) were analyzed using the P22 ELISA. The estimated sensitivity (Se) and specificity (Sp) were 34.4% (95% CI: 22.4–45.6) and 100% (95% CI: 97.4–100), respectively. The optimal cut-off point was set at 100% according to the ROC analysis. Those animals with a higher level of Abs in their oral fluid attained a higher lesion score (p = 0.018). In fact, when taking into account only the setting of the animals with severe lesions (n = 16), the ELISA showed a Se of 75% (95% CI: 53.7–96.2). Results of the present study suggest that the P22 ELISA is highly specific but has a limited value detecting infected animals in oral fluid samples. Nevertheless, its performance is significantly higher in the presence of severe lesions.

Exacerbation of generalized plaque psoriasis after tuberculin test.

Koebner phenomenon, also known as isomorphic response, is the appearance of active skin lesions in sites of epidermal injury. This manifestation is characteristic of different dermatological diseases, such as lichen planus, vitiligo and psoriasis. We present the case of a psoriatic patient who experienced Koebner phenomenon after Mantoux test, followed by eruption of generalized plaque psoriasis.

Aptamer-Based Diagnostic Systems for the Rapid Screening of TB at the Point-of-Care.

The transmission of Tuberculosis (TB) is very rapid and the burden it places on health care systems is felt globally. The effective management and prevention of this disease requires that it is detected early. Current TB diagnostic approaches, such as the culture, sputum smear, skin tuberculin, and molecular tests are time-consuming, and some are unaffordable for low-income countries. Rapid tests for disease biomarker detection are mostly based on immunological assays that use antibodies which are costly to produce, have low sensitivity and stability. Aptamers can replace antibodies in these diagnostic tests for the development of new rapid tests that are more cost effective; more stable at high temperatures and therefore have a better shelf life; do not have batch-to-batch variations, and thus more consistently bind to a specific target with similar or higher specificity and selectivity and are therefore more reliable. Advancements in TB research, in particular the application of proteomics to identify TB specific biomarkers, led to the identification of a number of biomarker proteins, that can be used to develop aptamer-based diagnostic assays able to screen individuals at the point-of-care (POC) more efficiently in resource-limited settings.

Evaluation of the Efficacy of BCG in Protecting Against Contact Challenge With Bovine Tuberculosis in Holstein-Friesian and Zebu Crossbred Calves in Ethiopia.

Bovine tuberculosis (bTB) is prevalent in intensive dairy farms in Ethiopia. Vaccination could be an alternative control approach given the socio-economic challenges of a test-and-slaughter control strategy. The efficacy of the BCG was evaluated on 40 Holstein-Friesian (HF) and zebu crossbred calves recruited from single intradermal cervical comparative tuberculin (SICCT) test negative herds and randomly allocated into two groups. Twenty-two calves were vaccinated within 2 weeks of age, and 18 were kept as a control. Six weeks post-vaccination, the two groups were exposed and kept mixed with known SICCT test positive cows for 1 year. Immune responses were monitored by interferon gamma (IFN-γ) release assay (IGRA), SICCT test, and antibody assay. Vaccinated calves developed strong responses to the SICCT test at the sixth week post-vaccination, but did not respond to ESAT-6/CFP-10 peptide antigen-based IGRA. During the exposure, IFN-γ response to the specific peptide cocktail [F(2.44, 92.67) = 26.96; p < 0.001] and skin reaction to the specific proteins cocktail [F(1.7, 64.3); p < 0.001] increased progressively in both groups while their antibody responses were low. The prevalence of bTB was 88.9% (95% CI: 65.3–98.6) and 63.6% (95% CI: 40.7–83.8) in the control and vaccinated calves, respectively, based on Mycobacterium bovis isolation, giving a direct protective efficacy estimate of 28.4% (95% CI: −2.7 to 50.1). The proportion of vaccinated calves with lesion was 7.0% (34/484) against 11.4% (45/396) in control calves, representing a 38% (95% CI: 5.8–59.4) reduction of lesion prevalence. Besides, the severity of pathology was significantly lower (Mann–Whitney U-test, p < 0.05) in vaccinated (median score = 2.0, IQR = 0–4.75) than in control (median score = 5, IQR = 3.0–6.25) calves. Moreover, survival from M. bovis infection in vaccinated calves was significantly (log-rank test: χ2 = 6.749, p < 0.01) higher than that of the control calves. In conclusion, the efficacy of BCG was low, but the reduced frequency and severity of lesion in vaccinated calves could suggest its potential role in containing onward transmission.

Effect of Bovine Tuberculosis on Selected Productivity Parameters and Trading in Dairy Cattle Kept Under Intensive Husbandry in Central Ethiopia.

Bovine tuberculosis (BTB) has substantial impact on fertility, milk, and meat productivity in cattle. However, these assumptions are based on outdated data. Recent global studies on the impact of BTB on cattle productivity are scarce and show sometimes inconclusive and/or contradicting results. This pilot study is the first longitudinal study performed in urban upgraded dairy cattle in Ethiopia that are kept under intensive husbandry. We assessed whether BTB has an impact on various animal productivity parameters and animal movement. Animals (N = 890) included in the study were tested for BTB at least once using the comparative intradermal tuberculin test (CIDT). Fertility, mortality, and offtake were assessed in 21 dairy farms where herd follow-ups over 3 years were performed. In addition, an independent abattoir survey was conducted to assess carcass weight and visible TB-like lesions upon meat inspection. Animal movements (purchasing and offtakes) were documented for each farm. The impact of BTB status on the intervals been birth, service, and calving times and the intercalving intervals was analyzed using a Cox proportional hazards model. The hazard ratio associated with BTB-positive animals was smaller than 1 for all fertility parameters, suggesting that BTB status increases the time between events; however, the effect was small and only statistically significant (95% level) for the time between calving and service. Offtakes included a higher percentage of reactor animals (58%) as compared with non-reactor animals (42%) (p = 0.0001). Overall, reactors were eliminated from the farms within 238.6 days after receiving test results, which was 54.9 days faster than for negative animals. The majority of owners purchased animals within their town or its surrounding. Nearly a quarter of reactors were sold directly to other farms. Animals were also sold further away, including other regions, raising the question of disease spread and the need for an animal tracing mechanism. In the abattoir survey, a total of 349 carcasses were weighed, of which 8% showed visible TB-like lesions and 53.6% had fasciolosis. Negative adult bull carcasses were 7.5 kg heavier than reactor bulls.

Pathology, immunohistochemistry and molecular study of cattle screened by comparative tuberculin test for diagnosis latent form of Johne’s disease

Mycobacterium avium subsp. paratuberculosis causes Johne’s disease in cattle and other ruminants. It is one of the most widespread in terms of prevalence and one of the most important diseases in the livestock industry in terms of economic importance. In the latent form of the disease, animals can act as carriers. The main purpose of this study was to evaluate avian tuberculin in a single intradermal comparative tuberculin test (SICTT), histopathology, immunohistochemistry, and molecular methods for diagnosis of infected cows with the latent form of the disease. Twenty-three asymptomatic cows and without post-mortem signs of the disease were selected using the single intradermal comparative tuberculin test and were tested.In this study, avian tuberculin in SICTT was able to in diagnosing the latent form of the disease. The results confirm immunohistochemistry and real-time PCR as a sensitive and reliable diagnostic complementary approach for detecting latent forms of Paratuberculosis.

Using of Gamma Interferon γ-IFN and Multiplex PCR (m-PCR) for Detection of Bovine Tuberculosis in Dairy Herds in Egypt

Many diagnostic tools are essential for Mycobacterium bovis (M. bovis) eradication program. This study aimed to apply γ-IFN assay to detect bovine tuberculosis and multiplex PCR (m-PCR) for rapid identification of Mycobacterial isolates. A total no. of 150 cattle in 10 small farms at different Governorates in Egypt, were previously gave suspected results with comparative cervical tuberculin test (SICCT), they retested after 60 days later again with SICCT and bovine gamma-interferon (γ-IFN) immunoassay. Eighty-seven (58%) out of total 150 animals were +ve reactors by SICCT test while 80 (53.3%) animals gave +ve γ-IFN assay. The isolated M. bovis by conventional culturing and identification tests were +ve 55 (63.2%) out 87. The γ-IFN assay sensitivity and specificity gave 82.9% and 93.8% respectively. For rapid identification of different mycobacterial isolates using m-PCR two set of primers were used. The first set gave 123bp DNA PCR product expressing IS6110 insertion element for Mycobacterium tuberculosis (MTBC). The other one gave 500bp from RvD1Rv2031c genomic sequence definite to M. bovis. M-PCR findings were in a concordance with results of conventional culturing and identification tests with high sensitivity and specificity (100%). From this study, it is concluded that diagnosis of bovine tuberculosis (BTB) used tuberculin test and γ-IFN assay with m-PCR for rapid identification M. bovis isolates in living herds.

Lichen scrofulosorum in an 18-year-old patient.

Tuberculides are cutaneous hypersensitive reactions triggered by M. tuberculosis or its antigens. The concept of tuberculides was first given by Darier in 1896 (1). The diagnosis of tuberculides is difficult and depends on the features as follows (3): a strongly positive tuberculin test, tuberculoid histology on skin biopsy, absence of M. tuberculosis in the smear, negative culture, and resolution of the skin lesions with anti-tubercular therapy. Lichen scrofulosorum is a rare entity and it presents with minute, skin colored, and grouped papules, usually seen in annular arrangement on the trunk. Differential diagnosis should consider lichenoid sarcoidosis, keratosis pilaris, keratosis spinulosa, papular secondary syphilis and pityriasis rubra pilaris. Histopathology shows in the upper dermis epitheloid granulomas with few, occasionally found giant cells. Extensive screening is required in these patients to rule out extra cutaneous TB infection (2). However, up to 30% of patients may have no obvious underlying focus of tuberculosis (3).

The variable prevalence of bovine tuberculosis among dairy herds in Central Ethiopia provides opportunities for targeted intervention.

Bovine tuberculosis (bTB) is an important disease for dairy productivity, as well as having the potential for zoonotic transmission. Previous prevalence studies of bTB in the dairy sector in central Ethiopia have suggested high prevalence, however, they have been limited to relatively small scale surveys, raising concerns about their representativeness. Here we carried out a cross sectional one-stage cluster sampling survey taking the dairy herd as a cluster to estimate the prevalence of bTB in dairy farms in six areas of central Ethiopia. The survey, which to date is by far the largest in the area in terms of the number of dairy farms, study areas and risk factors explored, took place from March 2016 to May 2017. This study combined tuberculin skin testing and the collection of additional herd and animal level data by questionnaire to identify potential risk factors contributing to bTB transmission. We applied the single intradermal cervical comparative tuberculin (SICCT) test using >4mm cut-off for considering an individual animal as positive for bTB; at least one reactor animal was required for a herd to be considered bTB positive. Two hundred ninety-nine dairy herds in the six study areas were randomly selected, from which 5,675 cattle were tested. The overall prevalence of bTB after standardisation for herd-size in the population was 54.4% (95% CI 48.7-60%) at the herd level, and it was 24.5% (95% CI 23.3-25.8) at the individual animal level. A Generalized Linear Mixed Model (GLMM) with herd and area as random effect was used to explore risk factors association with bTB status. We found that herd size, age, bTB history at farm, and breed were significant risk factors for animals to be SICCT positive. Animals from large herds had 8.3 times the odds of being tuberculin reactor (OR: 8.3, p-value:0.008) as compared to animals from small herds. The effect of age was strongest for animals 8-10 years of age (the oldest category) having 8.9 times the odds of being tuberculin reactors (OR: 8.9, p-value:<0.001) compared to the youngest category. The other identified significant risk factors were bTB history at farm (OR: 5.2, p-value:0.003) and cattle breed (OR: 2.5, p-value: 0.032). Our study demonstrates a high prevalence of bTB in central Ethiopia but with a large variation in within-herd prevalence between herds, findings that lays an important foundation for the future development of control strategies.

Study of Latent Tuberculosis among Type 1 Diabetic Children in Zagazig University Pediatric Hospital

Background: In certain places, tuberculosis (TB) and diabetes mellitus (DM) are strongly linked as frequent comorbidities and might be termed epidemics combined. Objective: The present work aimed to detect relationship between type 1 DM (T1DM) and latent TB. Patients and Methods: This comparative cross-sectional study was conducted over the period from October 2019 to October 2020. It included 81 cases had type 1 DM and 81 healthy children as control group. This study was conducted at Zagazig University Pediatric Hospital. All patients were subjected to the following: Full history taking, full general examination, and investigation (Tuberculin test and chest X ray). Results: In the current study, 42% were male and (58%) were female. In the present work, there was no statistically significant difference between cases group and controls group regarding anthropometric measurements. This study showed that, the percentage of positive tuberculin test was higher among cases group than controls group (32.1%, 7.4%) p value< 0.001. OR estimate for DM on risk of TB was 5.9 (95% CI 2.27 to 15.33). Conclusion: There was no statistically significant difference between diabetic group and control group regarding sex, age, weight, and height. There was no statistically significant difference between diabetic and control group regarding contact with patient with TB and passive smoking. The percentage of positive tuberculin test was higher among diabetic group than control group.

Indirect hemagglutination reaction in the differential diagnosis of bovine tuberculosis

The main problem of improving the health of farms from tuberculosis is diagnosis, in particular, differential diagnosis. Despite the comprehensive study and a fairly impressive number of proposed diagnostic methods, including on the molecular genetic level, the problem of differentiation of non-specific reactions remains topical today. About effectiveness of serological methods of research, in particular, indirect hemagglutination reactions, in the literature there are scattered and polar data. In the methods of setting up reactions, in the variety of antigens, methods of adsorption of agglutinins, stabilization of red blood cells, etc., the researchers ' opinions differ. Four methods of stabilization of sheep erythrocytes sensitized with polysaccharide antigen (Feeli, Weinbach, Ling, RES) have been comparatively studied. The maximum antibody titer was established for the stabilization of red blood cells by Feeli. A total of 1911 blood samples from four farms with different relationships to tuberculosis were studied in the reaction of indirect hemagglutination with diagnostics from Mycobacterium bovis and Mycobacterium fortuitum. Relatively high positive indicators of the reaction of indirect hemagglutination were revealed in animals in farms with tuberculosis problems, in which the diagnosis was confirmed by pathoanatomic method in 87.5% of cases. The results of the tuberculin test coincided with the results of indirect hemagglutination reactions in 37.07% of cases. Diagnostic antibody titers were detected in 201 anergic animals of the treated herd and in 5 from the isolation unit. During the slaughter of 20 heads from a dysfunctional farm and 5 from the overexposure group, tuberculosis was established in 15 and 5, respectively. The practical significance of the reaction of indirect hemagglutination with different diagnostics in the detection of homologously infected animals is shown.

&lt;p&gt;&lt;strong&gt;Interferon gamma and IP 10 mRNA quantitative real time PCR in whole blood culture of guinea pig and cattle to multi-antigen recombinant protein cocktail and PPD of &lt;em&gt;Mycobacterium bovis &lt;/em&gt;(3/86Rv)&lt;/strong&gt;&lt;/p&gt;

In vivo tuberculin skin test and in vitro IFNγ assays are the most explored diagnostics for Mycobacterium bovis infection (Bovine Tuberculosis) in animals. However, there are other potential biomarkers like IP10 which may allow diagnosis of tuberculosis. In this study, IFNγ and IP10 mRNA responses in guinea pig and cattle were determined by quantitative RT-PCR in whole blood samples stimulated PPDs and recombinant protein cocktail containing eight purified rCFP2, rESAT6, rCFP10, rMTC28, rMPB53, rMPB63, rMPB64 and rMPB83 proteins. Blood samples were obtained from M. bovis sensitised guinea pigs and tuberculin test positive cattle. Both guinea pigs and cattle blood cultures produced a significant increase in mRNA level of IFNγ and IP10 when stimulated with protein cocktail as compared to that of bovine PPD. Upon different antigenic stimulations, IP10 mRNA responses were followed the similar kinetics to those of IFNγ with high correlation (r = 0.97 for guinea pig and 0.96 for cattle).

A Case of Tuberculous Spondylitis in Child with Undernourish

Tuberculous spondylitis accounts for around 2% of all cases of Tuberculosis (TB) and around 15% of extrapulmonary TB cases. It has been reported that a 17 years old boy with a complaint of a bump on the lumbar region and felt low back pain since two years before admission with a history of back trauma. There was a decrease of body weight. There was no paraesthesia nor paralysis. Defecation and micturition were normal. Basic immunization was incomplete. On physical examination found palpable lymph nodes 0,5x0,5x0,5 cm, multiple et regio colli. There was no BCG scar. Impression nutritional status was undernourished. There was fixed palpable mass at back size about 5x4x5 cm, hard, no fluctuations, no rebound tenderness. Lung examination was normal. Tuberculin test showed induration sized 20 mm. Gene Xpert result Micobacterium Tuberculosis (MTB) not detected. On chest X-ray examination found L1-2 corpus destruction. MRI Spine was suggestive of compressive fractures and suggestive of a bilateral psoas abscess. Decompression and lumbar stabilization surgery were performed. The histopathology examination results were consistent to spondylitis TB characteristics. The patient was discharged on 6th hospitalization and given anti-tuberculous drug.Keywords: bump, extrapulmonary, fracture, spondylitis, tuberculosis

P088 Neurotuberculosis in a patient with Ulcerative Colitis using adalimumab for a long period in Brazil

Abstract Background Immunobiological antibodies to tumor necrosis factor alpha (TNFα), act by decreasing the proinflammatory cytokine TNFα. In this context, patients using these biologicals may develop an immunocompromised state (1). TNFα is important in the activation, differentiation and recruitment of different immune cells, with an important role in the formation and maintenance of granulomas, in response to intracellular organisms (2), such as tuberculosis (TB), whose reports occur, on average, 12 weeks after onset of the biological (1). Neurotuberculosis (NT) is the most severe form of TB (3), being responsible for 5 to 7% of cases of extra-pulmonary involvement (4,5). Its diagnosis being based on suspicious symptoms, biochemical analysis of the cerebrospinal fluid (CSF) and confirmed by the detection of the TB bacillus in the CSF. TB in the central nervous system (CNS) is usually due to the spread of pulmonary infection, and rarely occurs in isolation as in this case we are reporting. Methods This study aims to report a case of NT was described in patient with Ulcerative Colitis (UC), 4 years after the start of therapy with biological, and discuss clinical aspects, diagnosis, management and prognosis. Results 34-year-old woman with UC since the age of 20, using adalimumab for 4 years, presented with progressive headache for 20 days, associated with daily afternoon fever (38⁰C). She denied any contact or familiar with TB. Analysis of CSF revealed TB culture positive. On brain MRI, there were small cortical lesions in the left frontal lobe and two larger lesions, with post-contrast enhancement, in the left temporal lobe and in the right frontal lobe, both measuring about 10 mm (Figure 1). She was in sustained deep remission with adalimumab for 4 years (Figure 2). She has had a chest X-ray and a tuberculin test every year, all of which are negative for TB. The initial management was discontinuing adalimumab, treatment with rifampicin, isoniazid, ethambutol, pyrazinamide and prednisone. The patient showed clinical and neurological improvement. Currently, 12 months after the diagnosis, she is asymptomatic and without neurological sequelae. Conclusion The reported case assumes importance because this patient has isolated TB in the CNSDigitar texto without pulmonary involvement who has UC and was using adalimumab. Screening tests for TB can ignore latent infection, especially in patients undergoing immunosuppression (anti-TNF, steroids and HIV). The possibility of TB should always be considered in the presence of fever of unknown origin in patients on anti-TNFα therapy, even for a long period. Early recognition, suspension and appropriate treatment are important steps towards therapeutic success, avoiding neurological sequelae and mortality.

Miliary tuberculosis: an atypical presentation

Miliary tuberculosis (TB) is a severe form of disseminated TB. In developing countries childhood miliary TB is a significant health problem. Pulmonary TB is the most common type of TB in children. Of all TB cases miliary TB accounts for about 1%. We report a case of paediatric miliary TB with acute presentation in a eleven years old female who presented with fever and cough since 3 days and rapid breathing since one day. Clinical examination showed hepatosplenomegaly, on auscultation chest was clear and air entry bilateral equal, chest x-ray was suggestive of miliary shadows suggestive of TB and it was confirmed by HRCT chest. Laboratory studies revealed anaemia and elevated erythrocyte sedimentation rate (ESR). Tuberculin test was negative, gastric lavage for acid-fast bacilli Gene-Xpert was positive for mycobacterium tuberculosis. Fundus examination revealed bilateral small, white sub retinal opacities with the classical appearance of choroidal tubercles. The diagnosis of Miliary TB was confirmed and the patient was started on anti TB therapy.

Bilateral Adrenal Adenomas Attributed to Extrapulmonary Mycobacterium Tuberculosis

Introduction: Adrenal infections are rare, with the Mycobacterium tuberculosis (MTB) being the most common causative agent in the developing world. MTB usually spreads to the adrenal glands hematogenously where it may be clinically manifested years after systemic infection. Here, we present a case of bilateral adrenal MTB infection associated with MTB peritonitis. Case Presentation: A 46-year-old male, from Ecuador, without significant medical history and no medical follow-up presented to the emergency room with a two-week history of abdominal pain, nausea, diarrhea, and significant weight loss. He denied fever, cough, or night sweats. No smoking, alcohol, or illicit drug use. He works as a construction worker without a history of sick contacts. Vital signs were stable, with abdominal distension and fluid shifting dullness on exam. Blood work revealed leucocyte count of 5.58K (4-11K), INR 1.2 (0.9–1.1), Sodium 132 mEq/L (136–145 mEq/L) with albumin 3.3 mg/dL (3.5–5.2 mg/dL), total bilirubin level, 1.3 mg/dL (0–1.2 mg/dL), and AST and alkaline phosphatase levels, 73 U/L (0–40 U/L) and 186 U/L (40–129 U/L) respectively. Computerized tomography (CT) of the abdomen showed large ascites, omental nodularity, calcified gall bladder, bilateral adrenal nodules, and multiple abdominal lymphadenopathies. Chest CT revealed right apical reticulonodular densities. A diagnostic paracentesis revealed an exudative effusion with serum ascites albumin gradient of 0.7, and negative acid fast bacilli (AFB) and adenosine deaminase enzyme. Ascitic cellular analysis was negative for malignant cells. AFB blood and sputum cultures were negative, though Quantiferon gold test was positive and a skin tuberculin test was 13x13mm. Tumor markers CA19-9, CEA, and alpha-fetoprotein came back negative. Additionally, serum aldosterone, plasma metanephrines, DHEA-S, AM Testosterone, ACTH, and morning cortisol levels were normal. The patient had a negative 1-mg dexamethasone suppression test. Positron emission tomography (PET) scan showed a hypermetabolic left adrenal mass (4.9x3.2 cm) and nodular peritoneum with no fluorodeoxyglucose (FDG) uptake in the enlarged abdominal lymph nodes. Peritoneal biopsy analysis revealed non-caseating granuloma positive for MTB. The adrenal biopsy was not performed given the extensive intra-abdominal disease. The patient was started on anti-MTB treatment (Isoniazid, rifampicin, pyrazinamide, and ethambutol) with significant clinical improvement and a slight decrease in the adrenal masses following abdominal imaging. Conclusion: Extrapulmonary MTB should be part of a differential diagnosis for bilateral adrenal masses. Adrenal glands could be infected by a variety of pathogenic microorganisms either by direct contact or hematogenous dissemination. A high index of suspicion is required for the diagnosis of MTB in patients with atypical presentation.