Tuberculosis of pancreas and peripancreatic lymph nodes in immunocompetent patients: experience from China.
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AIM: To determine the clinical, radiographic and laboratory characteristics, diagnostic methods, and therapeutic variables in immunocompetent patients with tuberculosis (TB) of the pancreas and peripancreatic lymph nodes. METHODS: The records of 16 patients (6 male, 10 female; mean age 37 years, range 18-56 years) with tuberculosis of the pancreas and peripancreatic lymph nodes from 1983 to 2001 in the Southwest Hospital were analyzed retrospectively. In addition, 58 similar cases published in Chinese literature were reviewed and summarized. We reviewed the clinical, radiographic and laboratory findings, diagnostic methods, therapeutic approaches, and outcome in the patients. Criteria for the diagnosis of pancreatic tuberculosis were the presence of granuloma in histological sections or the presence of Mycobacterium tuberculosis DNA by polymerase chain reaction (PCR). RESULTS: Predominant symptoms consisted of abdominal nodule and pain (75 %), anorexia/weight loss (69 %), malaise/weakness (64 %), fever and night sweats (50 %), back pain (38 %) and jaundice (31 %). Swelling of the head of the pancreas with heterogeneous attenuation echo was detected with ultrasound in 75 % (12/16). CT scan showed pancreatic mass with heterogeneous hypodensity focus in all patients, with calcification in 56 % (9/16) patients, and peripancreatic nodules in 38 % (6/16) patients. Anemia and lymphocytopenia were seen in 50 % (8/16) patients, and pancytopenia occurred in 13 % (2/16) patients. Hypertransaminasemia, elevated alkaline phosphatase (AP) and GGT were seen in 56 % (9/16) patients. The erythrocyte sedimentation rate (ESR) was elevated in 69 % (11/16) cases. Granulomas were found in 75 % (12/16) cases, and in 38 % (6/16) cases caseous necrosis tissue was found. Laparotomy was performed in 75 % (12/16) cases, and ultrasound-guided fine needle aspiration (FNA) was done in 63 % (10 of 16). The most commonly used combinations of medications were isoniazid/rifampin/streptomycin (63 %, n=10) and isoniazid/rifampin pyrazinamide/streptomycin or ethambutol (38 %, n=6). The duration of treatment lasted for half or one year and treatment was successful in all cases. The characteristics of 58 cases from Chinese literature were also summarized. CONCLUSION: Tuberculosis of the pancreas and peripancreatic lymph nodes should be considered as a diagnostic possibility in patients presenting with a pancreatic mass, and diagnosis without laparotomy is possible if only doctors are aware of its clinical features and investigate it with appropriate modalities. Pancreatic tuberculosis can be effectively cured by antituberculous drugs. (+info)
Pseudotumoral form of primary progressive tuberculosis: a diagnosis to be considered.
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The diversity of clinical presentations of primary progressive tuberculosis (TB) and the difficulty in establishing the diagnosis of paucibacillary forms is the subject of painstaking research, as well as a cause of delay in therapy. We report the case of a 10-year-old black child who presented with chest pain and progressive widening of the upper mediastinum. Computerized tomography of the chest revealed multiple calcifications that were not identified with X-rays. Biopsy through mediastinoscopy was compatible with a diagnosis of tuberculosis. Despite exhaustive investigation that included direct examination, culture for mycobacteria and PCR (Polymerase Chain Reaction) of tissue samples, the etiologic agent was not revealed. Tuberculin conversion was observed during the follow-up and resolution period of the lesion, after administration of isoniazid, rifampicin and pyrazinamide. The nodal pseudotumoral form of tuberculosis is rare in immunocompetent children and it may simulate neoplastic disease; therefore, it should be included in the list of differential diagnoses of masses located in the anterosuperior mediastinum. (+info)
The ulcerating tuberculous hilar gland.
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In primary infection tuberculosis, the infected hilar gland(s) may cause involvement of peripheral lung tissue not only by pressure but also by rupture and discharge of caseous material into a bronchus. Atelectasis or lung infection or both may result and bronchiectasis may ensue.Early bronchoscopy is required when this form of tuberculosis fails to subside promptly under treatment.Bronchography is indicated to detect residual bronchiectasis which should be removed surgically.Three of six proved cases of Group A tuberculous tracheobronchitis caused by an ulcerating hilar gland required pulmonary resection for removal of residual bronchiectasis; two of these were complicated by atelectasis. All six patients are alive and well. (+info)
Bacteriological survey of tuberculous lymphadenitis in southeast England, 1981-1989.
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STUDY OBJECTIVE: The aim was to detect any changing trends in the nature and incidence of tuberculous lymphadenitis in southeast England and to determine whether there is any evidence for an increase in this disease that could be related to HIV infection. DESIGN: Mycobacteria isolated from patients with lymphadenitis in the years 1981 to 1989 were identified. Information was available on the age, sex, and ethnic origin of the patients and the anatomical site from which the mycobacterium was isolated. SETTING: The Public Health Laboratory Service Regional Tuberculosis Centre at Dulwich, which receives over 95% of mycobacteria isolated in southeast England. MAIN RESULTS: From 1980 to 1989, cultures were received from 1817 patients with mycobacterial lymphadenitis: 1677 were M tuberculosis, 25 M bovis, 21 M africanum, and 94 were other (environmental) species. In comparison with a survey conducted in the same region in 1973-80, the number of ethnic Indian subcontinent patients with lymphadenitis due to M tuberculosis had dropped by 30% and the number of European patients had dropped by 43% and showed a continuing decline and a shift towards an older age group. By contrast, there was a 20% increase in the number of cases due to environmental mycobacteria. The number of species causing such infections had increased and a greater proportion of patients were adults. Three patients infected by environmental mycobacteria were known to be HIV positive. CONCLUSIONS: The incidence of lymphadentis due to M tuberculosis is declining but cases due to environmental mycobacteria are increasing, with a greater diversity of species and more adult patients. There is no conclusive evidence for an impact of HIV infection on the incidence and nature of mycobacterial lymphadenopathy in southeast England, but this cannot be ruled out. (+info)
Mycobacterial cervical lymphadenitis in childhood.
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A study of 190 children of chronic cervical lymphadenitis showed tuberculous etiology on histopathological examination in 92 (48.4%) and bacteriological evidence of mycobacterial infection (smear and/or culture) in 42 (22.1%). Of these 42, twelve (28.6%) showed histopathological diagnosis of non-specific lymphadenitis. Positive culture for mycobacteria was obtained in 40, of which 30 (75%) were typical M. tuberculosis and 10 (25%) were atypical mycobacteria. The most predominant species of typical mycobacteria was M. scrofulaceum (60%) followed by M. avium intracellulare (40%). There was no remarkable difference in the histopathological pattern of those in which M. tuberculosis was grown and those in which bacterial growth was that of atypical mycobacteria. The diagnosis of chronic cervical lymphadenitis should therefore be taken a step beyond histopathology, up to complete bacteriological examination, especially to confirm the cases of mycobacterial lymphadenitis caused by atypical mycobacteria. (+info)
Detection of extrapulmonary tuberculosis with gallium-67 scan and computed tomography.
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We evaluated 23 patients with extrapulmonary tuberculosis (TB) with 67Ga imaging to assess its usefulness in the diagnosis of this condition. We performed computed tomography (CT) in 17 patients to assess CT features of extrapulmonary TB in comparison with findings from 67Ga scans. Nineteen of 23 patients (83%) had positive findings on 67Ga scans. One of five patients with tuberculous mediastinal lymphadenopathy, two patients with cervical lymphadenitis and a patient with renal TB had negative 67Ga scans. It was observed that the detection of previously unrecognized primary foci of TB, without concomitant pulmonary TB, was possible using 67Ga imaging in five patients (22%). The 67Ga scan was relatively sensitive for the localization of extrapulmonary TB. It is suggested that the 67Ga scan could serve as a screening method, when followed by CT and ultrasonography, for the initial detection of occult tuberculous lesions, especially in patients with prolonged fever. (+info)
Unopposed matrix metalloproteinase-9 expression in human tuberculous granuloma and the role of TNF-alpha-dependent monocyte networks.
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Tuberculosis is characterized by granuloma formation and caseous necrosis, but the factors causing tissue destruction are poorly understood. Matrix metalloproteinase (MMP)-9 (92-kDa gelatinase) secretion from monocytes is stimulated by Mycobacterium tuberculosis (M. tb) and associated with local tissue injury in tuberculosis patients. We demonstrate strong immunohistochemical MMP-9 staining in monocytic cells at the center of granuloma and adjacent to caseous necrosis in M. tb-infected patient lymph nodes. Minimal tissue inhibitor of MMPs-1 staining indicated that MMP-9 activity is unopposed. Because granulomas characteristically contain few mycobacteria, we investigated whether monocyte-monocyte cytokine networks amplify MMP-9 secretion. Conditioned medium from M. tb-infected primary human monocytes or THP-1 cells (CoMTB) stimulated MMP-9 gene expression and a >10-fold increase in MMP-9 secretion by monocytes at 3-4 days (p < 0.009, vs controls). Although CoMTB stimulated dose-dependent MMP-9 secretion, MMP-1 (52-kDa collagenase) was not induced. Anti-TNF-alpha Ab but not IL-1R antagonist pretreatment decreased CoMTB-induced MMP-9 secretion by 50% (p = 0.0001). Anti-TNF-alpha Ab also inhibited MMP-9 secretion from monocytic cells by 50%, 24 h after direct M. tb infection (p = 0.0002). Conversely, TNF-alpha directly stimulated dose-dependent MMP-9 secretion. Pertussis toxin inhibited CoMTB-induced MMP-9 secretion and enhanced the inhibitory effect of anti-TNF-alpha Ab (p = 0.05). Although chemokines bind to G protein-linked receptors, CXCL8, CXCL10, CCL2, and CCL5 did not stimulate monocyte MMP-9 secretion. However, the response to cholera toxin confirmed that G protein signaling pathways were intact. In summary, MMP-9 within tuberculous granuloma is associated with tissue destruction, and TNF-alpha, critical for antimycobacterial granuloma formation, is a key autocrine and paracrine regulator of MMP-9 secretion. (+info)
A comparative study of clinical manifestations caused by tuberculosis in immunocompromised and non-immunocompromised patients.
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OBJECTIVE: To characterize the differences between clinical manifestations in immunocompromised patients (ICPs) and non-immunocompromised patients (non-ICPs) with tuberculosis. METHODS: Underlying diseases, clinical presentations, misdiagnosis, treatment and prognosis, etc, were analyzed retrospectively in 115 tuberculosis patients, including 39 ICPs and 76 non-ICPs. RESULTS: Compared with non-ICPs, the individuals who were ICP had more expectoration (64.1% vs 35.5%), pulmonary moist rale (41.0% vs 9.2%), miliary pulmonary tuberculosis (30.8% vs 2.6%), pleural effusion (48.7% vs 25.0%) and lymphadenopathy (18.0% vs 4.0%). ICPs had less lung cavity (15.4% vs 22.4%) and pleural thickening (15.4% vs 23.7%) compared to non-ICPs. Pulmonary tuberculosis in ICPs was prone to be misdiagnosed as pneumonia (23.1% vs 6.6%). Pulmonary tuberculosis was found in the apicoposterior segment (SI + SII) in more cases in non-ICPs (21.7%, 10/46) than ICPs (10.3%, 3/29). The diagnostic value of tuberculin skin test and adenosine deaminase in pleural effusions was limited in ICPs. ICPs had significantly poorer prognoses than non-ICPs. CONCLUSION: The clinical manifestations of ICPs with tuberculosis are atypical, misdiagnosis often occurs, resulting in a worse prognosis. (+info)