Tuberculosis In Immunocompetent Patient Research Articles

Disseminated Tuberculosis on an Otherwise Healthy Pediatric Patient

SESSION TITLE: Tuberculosis Global Case Reports SESSION TYPE: Global Case Report Poster PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM INTRODUCTION: Disseminated tuberculosis (TB) can involve several organs and clinically presents itself with multiple signs and symptoms. Pulmonary infection is generally the primary focus. The development of TB disease depends on inherent immunologic status of the host. Miliary disease and tubercular (TB) meningitis are the earliest and most deadly complications of primary TB. Genitourinary TB (GU TB) is the second most common form of extrapulmonary disease after peripheral lymphadenopathy. Despite it comprises 20% of nonpulmonary TB form, it is still misdiagnosed. CASE PRESENTATION: We report a case of an otherwise healthy, 11-year-old boy with disseminated tuberculosis who exhibited a wide spectrum of extrapulmonary involvement. He had nonspecific symptoms such as fever, weight loss (10 kg), fatigue, malaise, asthenia, anorexia, headache, and recurrent urinary infections for 4 months. Thereafter, a painful swelling appeared in his left scrotum and treated as a nonspecific abscess with drainage and antibiotics before admission at the tertiary hospital. His physical examination showed an extremely thin boy, palpable masses on left hypochondrium and flank, and a painful and erythematous scrotal mass ipsilateral. Urine analysis revealed hematuria and sterile pyuria but the urine was positive for acid-fast bacilli (AFB) on the third sample. Cerebrospinal fluid (CSF) yielded normal results. Bronchoalveolar lavage (BAL) smear produced a negative response for AFB.. Tuberculin Skin Test (TST) was anergic. There were no associated systemic disorders and HIV infection was not detected. A Chest Computed Tomography (CT) scan displayed well-defined randomly distributed nodules. Head CT scan showed hypoattenuating lesions on white matter. On a contrast, enhanced abdominal CT scans revealed intraluminal calcifications in the left kidney, hydronephrosis degree V, and a heterogeneous mass adjacent to left testis. A treatment with standard fixed-dose-combination tablets containing 4 drugs (RHZE) was initiated during the intensive care phase (2 months), R 150/H75/Z400/E275and 2 drugs (RH) during the continued treatment (7 months) and an oral corticosteroid (prednisone at a dose of 1mg/kg/day for 4 weeks). The patient showed marked recovery after initiation of anti-TB therapy and the scrotal mass had gradually subsided. DISCUSSION: Miliary tuberculosis (TB) is the widespread dissemination of Mycobacterium tuberculosis via hematogenous spread. It is estimated that it accounts for approximately less than 2% of all cases of TB in immunocompetent patients. In addition, miliary TB may mimic many diseases. GU TB comprises approximately 15-20% of extrapulmonary cases of TB in some developing countries, which is roughly twice that in developed areas. It is very uncommon in children. Persistent sterile pyuria and hematuria are the most classical findings in GU TB. In the case of epididymal TB, pain swelling, heaviness or mass lesion in the scrotum are the common presenting complaints, as observed in our case. Serial early-morning urine cultures (at least 3) for acid-fast bacilli (AFB) are still considered the criterion standard for evidence of active tubercular (TB) disease with a sensitivity of 65% and a specificity of 100%. Although microbiologic staining has a low sensitivity, our case presented AFB positive in the urine smear. Nonspecific clinical presentations may mimic other pathologic lesions. In this case, the patient was initially treated for the scrotal mass as a nonspecific abscess with drainage and usual antibiotics. Therefore, a high index of clinical suspicion for TB on a severely debilitated patient allowed prompting initiation of empirical therapy anti-TB. CONCLUSIONS: Tuberculosis (TB) is the most common cause of infection-related death worldwide. Therefore, a high index of clinical suspicion is important to obtain an early diagnosis and to ensure improved clinical outcomes. Early empirical treatment for possible but not yet definitive miliary TB increases the likelihood of survival and should never be withheld while test results are pending. Reference #1: Manual de Recomendações para o controle da tuberculose no Brasil. Ministério da saúde, 2010. Reference #2: Wise GJ, Marella VK. Genitourinary manifestation of tuberculosis.Urol Clin North Am 2003, 30:111-121 Reference #3: Klaus-Dieter Lessnau: Miliary Tuberculosis. Updated: Sep 13, 2013 http://emedicine.medscape.com/article/221777-overview#aw2aab6b2 (accessed in March 22, 2015) DISCLOSURE: The following authors have nothing to disclose: Lilian Pereira, Erica Cavalcante, Bernadete Silva, Waldonio Vieira, Roseana Sovano No Product/Research Disclosure Information

Cutaneous tuberculosis revealing multifocal tuberculosis in immunocompetent patients

Multifocal tuberculosis (TB) is rare. It occurs especially in immunocompromised patients. Association with skin involvement is rarer, and few cases are reported in the literature. The present study reports 7 cases of multifocal TB with cutaneous localization in immunocompetent patients. Cutaneous forms of TB included in this series are: gummas, scrofuloderma, vasculitis TB and lupus TB. The patients had at least two extra skin locations, namely: osteoarticular, lung, pleural, scrotal, muscular, digestive, laryngeal, nodal and splenic locations. These patients had no context of immunosuppression which is uncommon, but should be kept in mind, especially in endemic countries.

Disseminated Tuberculosis in Immunocompetent Patients: Case Reports

Disseminated Tuberculosis in Immunocompetent Patients: Case Reports

Chest imaging in immunosuppressed patients

• Bacterial pneumonias have similar radiographic patterns in immunocompetent and immunosuppressed patients. Chest radiographs and CT show consolidation, which may be focal (segmental or lobar), patchy or diffuse.• Tuberculosis in immunocompetent patients most frequently manifests as the reactivation (secondary) pattern, whereas immunosuppressed patients present the primary pattern of the disease.• If a neutropenic febrile patient presents with pulmonary nodules or consolidation surrounded by ground-glass opacities (“halo sign”), angioinvasive fungal infection must be the first diagnosis.• Pneumocystis jiroveci pneumonia should be the main diagnosis when ground-glass attenuation is seen in patients with human immunodeficiency virus with CD4+ <200 cells per cubic millimetre.• High-resolution CT features in viral infections are similar and show small poorly defined centrilobular nodules and consolidation foci and/or ground-glass attenuation with peribronchial distribution, and are multifocal and often bilate...

Role of Whole-Body Magnetic Resonance Imaging in the Evaluation of Extrapulmonary Tuberculosis in Immunocompetent Patients

The aim of this study was to evaluate the role of whole-body magnetic resonance imaging (WB-MRI) in imaging of extrapulmonary tuberculosis. Eighteen patients with single-site extrapulmonary tuberculosis were evaluated with contrast-enhanced dedicated MRI of the clinically symptomatic site followed by WB-MRI using contrast-enhanced 3-dimensional (3D) modified DIXON technique (m-DIXON) and diffusion-weighted WB imaging with background body signal suppression (DWIBS) sequences. Studies were read by 2 experienced radiologists, and additional lesions seen on WB-MRI were separately charted. Of 18 patients, 14 were found to have asymptomatic involvement of other organs on WB-MRI. In 5 patients, the information was helpful in choosing an easily accessible site for biopsy/aspiration. Postcontrast 3D m-DIXON was better in picking up brain and lymph nodal lesions, whereas DWIBS was better in detecting vertebral lesions. Whole-body MRI may be used for assessing the asymptomatic involvement of other body organs in tuberculosis. The combination of postcontrast 3D m-DIXON and DWIBS is complementary and may provide a road map for biopsy of accessible lesions.

Molecular typing of mycobacteria isolated from extrapulmonary tuberculosis patients at Debre Birhan Referral Hospital, central Ethiopia

Extrapulmonary tuberculosis (EPTB) constitutes about 10% to 20% of all cases of tuberculosis in immunocompetent patients and more than 50% of the cases in HIV-positive individuals worldwide. Little information is available on the clonal diversity of Mycobacterium species in Ethiopia from EPTB. This study was carried out on smear-negative EPTB patients to molecularly characterize Mycobacterium tuberculosis complex strains. A questionnaire, smear staining, culture, deletion typing, and spoligotyping were employed. The proportional distribution of EPTB and isolates did not vary substantially (p > 0.05) amongst the socio-demographic parameters considered in the current investigation. Out of 98 fine needle aspirates processed for culture, 36.7% (36/98) were positive for mycobacterial growth. Further speciation of those culture-positive isolates showed that 88.9% were M. tuberculosis and the remaining could be non-tuberculous mycobacterial species. Spoligotyping revealed 16 clusters out of which 2 were new to the SITVIT database. The most dominant spoligotypes were SIT54, SIT53, and SIT149 in decreasing order. SIT54, SIT134, SIT173, SIT345, SIT357, SIT926, SIT91088, and SIT1580 were reported for the first time in Ethiopia. The family with the highest frequency identified was M. tuberculosis family T1, followed by family 33. Most of the strains belonged to Euro-American (61.4%) and Indo-Oceanic (36.3%) lineages. The present study shows the importance of M. tuberculosis as a major cause of EPTB in the study area. Moreover, the majority of isolates of M. tuberculosis were found in clusters, suggesting the possibility of the existence of recent transmission. This warrants strengthening of the control programs for EPTB in the study area.

Pancreatic and peripancreatic nodal tuberculosis in immunocompetent patients: report of three cases.

Pancreatic and peripancreatic tuberculosis in immunocompetent patients is extremely rare. It often mimics pancreatic malignancy. Majority of the cases are diagnosed after an image guided biopsy or after an operation.We report three cases of pancreatic tuberculosis in immunocompetent patients. All three cases were diagnosed without laparotomy. Diagnosis was made by contrast enhanced computed tomography or endoscopic ultrasound guided fine needle aspiration of the peripancreatic mass and all three cases were treated successfully with antituberculous drugs.Pancreatic and peripancreatic tuberculosis should be considered in the differential diagnosis of a peripancreatic mass when the patient is young, residing in the endemic zone of tuberculosis or had past history of tuberculosis. Extensive necrosis of peripancreatic lymph nodes with rim enhancement further supports the diagnosis of tuberculosis. Every attempt should be made to diagnose the cases before start of therapy to prevent unnecessary operation.

Adjuvant interferon-γ treatment in two cases of refractory tuberculosis of the brain

Tuberculosis (TB) of the brain is often refractory and has the highest morbidity and mortality among the mycobacterial infections. A recent report suggests that interferon-γ may be of help since it can modulate the host inflammatory response against mycobacteria in the brain. Here, we report on a 44-year-old woman with multiple tuberculomas in the brainstem and a 40-year-old man with two large TB abscesses in the brain, both of whom had no response to anti-TB medications for 5 and 7 months, respectively, but with near-complete resolution with adjuvant interferon-γ therapy (50μg/m2, subcutaneously, three times per week). Our cases show that refractory brain TB in immunocompetent patients can be successfully treated with adjuvant interferon-γ therapy, without any significant side effects.

Primary gastric fundus tuberculosis in immunocompetent patient: a case report and literature review

We report on a 29-year-old Pakistani man who presented to the clinic with epigastric pain, of one-month duration. He did not report fever, cough, vomiting blood, passing black stools, loss of appetite or diarrhea. However, he had lost 7 kg since his symptoms had begun. Clinical examination was unremarkable. Laboratory results were within normal limits. An abdominal CT scan showed a mass with enhancement in the stomach. Gastric endoscopy revealed an ulcerative mass in the fundus. An endoscopic-biopsy specimen revealed caseating granulomas with acid-fast bacilli. The patient was diagnosed to have primary gastric tuberculosis, and antituberculous medications were initiated. Cultures of the gastric mass subsequently grew Mycobacterium tuberculosis sensitive to isoniazid and rifampcin. Follow-up after six months showed a good response to treatment; an upper gastrointestinal tract endoscopy after six months was normal.

Common and uncommon complications of reactivation tuberculosis in immunocompetent patients

Common and uncommon complications of reactivation tuberculosis in immunocompetent patients

Prophylaxis for tuberculosis in Europe--ongoing research.

The incidence of tuberculosis (TB) in patients with human immunodeficiency virus (HIV) infection has increased in recent years, raising issues regarding preventive therapy for TB in this high-risk patient population. To determine if an HIV-positive individual is at risk for reactivation of latent infection, testing with purified protein derivative (PPD) is recommended; however, many people with impaired cell-mediated immunity due to HIV are anergic. Strategies regarding PPD testing and criteria for HIV-positive patients are presented. Isoniazid has been the accepted drug for use as prophylaxis for TB in immunocompetent patients, and there is evidence that isoniazid is also effective in HIV-positive, PPD-positive patients. Data from efficacy and feasibility trials and the risks and benefits of preventive therapy with isoniazid are discussed. Because of toxicity and compliance problems with isoniazid, there is a continuing need for development of alternative therapies. The results of some preliminary studies of newer therapies are presented here.