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Disseminated tuberculosis in a non immun compromised patient with a complicated diagnosis.

Sahin H, Isık H, Uygun Ilıkhan S, Tanrıverdi H, Bilici M - Respir Med Case Rep (2014)

Bottom Line: The long time period between the exposure to TB bacillus and the onset of symptoms cause a delay in diagnosis.On the fourth month of the medical treatment the patient clinically recovered.Since the diagnosis of TB is difficult, high grade suspicion, combination of the radiologic, microbiologic and histopathological examinations are needed to achieve a diagnosis.

View Article: PubMed Central - PubMed

Affiliation: Bülent Ecevit University School of Medicine, Department of Internal Medicine, Zonguldak, Turkey.

ABSTRACT
Tuberculosis (TB) has become a global emergency worldwide. The long time period between the exposure to TB bacillus and the onset of symptoms cause a delay in diagnosis. Herein, we report a case of 64-year-old female patient suffering from dyspepsia, anorexia, weight loss and abdominal pain for the last 8 months. Physical examination, ascites fluid evaluation, chest radiography, ultrasonographic and tomographic scans, histopathological analysis of the lymphadenopathy (LAP) and endometrial tissue revealed TB. A fourfold antituberculous treatment with isoniazid, pyrazinamide, rifampicin and ethambutol was prescribed for two months and for four months maintenance therapy with isoniazid and rifampicin was given. On the fourth month of the medical treatment the patient clinically recovered. Since the diagnosis of TB is difficult, high grade suspicion, combination of the radiologic, microbiologic and histopathological examinations are needed to achieve a diagnosis.

No MeSH data available.


Related in: MedlinePlus

A: Multiple LAPs were observed in paraaortic region (white arrow). Also ascites (asterix) and ventral abdominal mesenteric heterogenity and thickness (black arrow) were seen on transverse abdominal CT image. B: Granulomas of epithelioid like histiocytes containing Langhans cells (blue arrow) and eosinophilic debris with caseification necrosis (white arrow) in endometrial stroma (H&E, ×50).
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fig2: A: Multiple LAPs were observed in paraaortic region (white arrow). Also ascites (asterix) and ventral abdominal mesenteric heterogenity and thickness (black arrow) were seen on transverse abdominal CT image. B: Granulomas of epithelioid like histiocytes containing Langhans cells (blue arrow) and eosinophilic debris with caseification necrosis (white arrow) in endometrial stroma (H&E, ×50).

Mentions: On the abdominal USG, there was a LAP of 2 cm in the hepatic hilum and ascites, but no hepatosplenomegaly. The USG scans of the axillary, inguinal, and cervical regions also revealed hypoechoic, lobulated, and heterogenous multiple LAPs. Ground-glass density areas in both lungs, especially in the left one, were seen on thoracic CT (Fig. 1B). On abdominal computed tomography (CT) multiple LAPs were observed in paraaortic region. Ascites, ventral abdominal mesenteric heterogenity and thickness were seen on CT image as well (Fig. 2A). For the exclusion of an occult malignancy, an upper gastrointestinal system endoscopy was performed, and reflux esophagitis was seen. She was consulted to our Gynecology Department to rule out gynecologic malignancies since the serum level of CA-125 was high. A gynecologic examination revealed no pathological finding so a screening PAP smear test and an endometrial curettage were performed. No pathological finding was found in mammographic scan. A supraclavicular lymphadenectomy was performed for a diagnosis. The pathology of the lenfoid tissue and endometrial biopsy showed caseification necrosis in some granulomas. Her PAP smear showed a negative result for malignancy. The intradermally performed purified protein derivative (PPD) test was 15 mm. The direct microscopic examining of induced sputum acid-resistant bacilli (ARB) was negative and sputum cultures for MTB were performed. After all of the diagnostic tests, genital TB became suspicious. A tetrad treatment with isoniasid 300 mg/day, rifampycin 600 mg/day, pyrazinamide 1500 mg/day, etambuthol 1500 mg/day was started. Sputum culture before the treatment was positive for MTB. Four months after the initiation of the treatment, her hemoglobin and CA-125 levels turned to normal. The ascites had disappeared, the diameters of the LAPs had significantly decreased, and the symptoms of the patient had all regressed.


Disseminated tuberculosis in a non immun compromised patient with a complicated diagnosis.

Sahin H, Isık H, Uygun Ilıkhan S, Tanrıverdi H, Bilici M - Respir Med Case Rep (2014)

A: Multiple LAPs were observed in paraaortic region (white arrow). Also ascites (asterix) and ventral abdominal mesenteric heterogenity and thickness (black arrow) were seen on transverse abdominal CT image. B: Granulomas of epithelioid like histiocytes containing Langhans cells (blue arrow) and eosinophilic debris with caseification necrosis (white arrow) in endometrial stroma (H&E, ×50).
© Copyright Policy - CC BY-NC-ND
Related In: Results  -  Collection

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Show All Figures
getmorefigures.php?uid=PMC4356042&req=5

fig2: A: Multiple LAPs were observed in paraaortic region (white arrow). Also ascites (asterix) and ventral abdominal mesenteric heterogenity and thickness (black arrow) were seen on transverse abdominal CT image. B: Granulomas of epithelioid like histiocytes containing Langhans cells (blue arrow) and eosinophilic debris with caseification necrosis (white arrow) in endometrial stroma (H&E, ×50).
Mentions: On the abdominal USG, there was a LAP of 2 cm in the hepatic hilum and ascites, but no hepatosplenomegaly. The USG scans of the axillary, inguinal, and cervical regions also revealed hypoechoic, lobulated, and heterogenous multiple LAPs. Ground-glass density areas in both lungs, especially in the left one, were seen on thoracic CT (Fig. 1B). On abdominal computed tomography (CT) multiple LAPs were observed in paraaortic region. Ascites, ventral abdominal mesenteric heterogenity and thickness were seen on CT image as well (Fig. 2A). For the exclusion of an occult malignancy, an upper gastrointestinal system endoscopy was performed, and reflux esophagitis was seen. She was consulted to our Gynecology Department to rule out gynecologic malignancies since the serum level of CA-125 was high. A gynecologic examination revealed no pathological finding so a screening PAP smear test and an endometrial curettage were performed. No pathological finding was found in mammographic scan. A supraclavicular lymphadenectomy was performed for a diagnosis. The pathology of the lenfoid tissue and endometrial biopsy showed caseification necrosis in some granulomas. Her PAP smear showed a negative result for malignancy. The intradermally performed purified protein derivative (PPD) test was 15 mm. The direct microscopic examining of induced sputum acid-resistant bacilli (ARB) was negative and sputum cultures for MTB were performed. After all of the diagnostic tests, genital TB became suspicious. A tetrad treatment with isoniasid 300 mg/day, rifampycin 600 mg/day, pyrazinamide 1500 mg/day, etambuthol 1500 mg/day was started. Sputum culture before the treatment was positive for MTB. Four months after the initiation of the treatment, her hemoglobin and CA-125 levels turned to normal. The ascites had disappeared, the diameters of the LAPs had significantly decreased, and the symptoms of the patient had all regressed.

Bottom Line: The long time period between the exposure to TB bacillus and the onset of symptoms cause a delay in diagnosis.On the fourth month of the medical treatment the patient clinically recovered.Since the diagnosis of TB is difficult, high grade suspicion, combination of the radiologic, microbiologic and histopathological examinations are needed to achieve a diagnosis.

View Article: PubMed Central - PubMed

Affiliation: Bülent Ecevit University School of Medicine, Department of Internal Medicine, Zonguldak, Turkey.

ABSTRACT
Tuberculosis (TB) has become a global emergency worldwide. The long time period between the exposure to TB bacillus and the onset of symptoms cause a delay in diagnosis. Herein, we report a case of 64-year-old female patient suffering from dyspepsia, anorexia, weight loss and abdominal pain for the last 8 months. Physical examination, ascites fluid evaluation, chest radiography, ultrasonographic and tomographic scans, histopathological analysis of the lymphadenopathy (LAP) and endometrial tissue revealed TB. A fourfold antituberculous treatment with isoniazid, pyrazinamide, rifampicin and ethambutol was prescribed for two months and for four months maintenance therapy with isoniazid and rifampicin was given. On the fourth month of the medical treatment the patient clinically recovered. Since the diagnosis of TB is difficult, high grade suspicion, combination of the radiologic, microbiologic and histopathological examinations are needed to achieve a diagnosis.

No MeSH data available.


Related in: MedlinePlus