Brachial plexus tuberculosis: A unique neurological variant of a common clinical disease

Isolated primary tuberculous involvement of the brachial plexus has not been reported in the past. Here, we report the case of a 29-year-old male who developed neck pain and radiculopathy for 3 months. Weakness in the left shoulder-elbow (2/5 MRC grade) and wrist (4/5 MRC grade) was present with numbness to pain and temperature along the C4–C5 dermatome. Magnetic resonance imaging (MRI) revealed a T2 hyperintense heterogeneously contrast-enhancing lesion involving the upper trunk of the brachial plexus. Under suspicion of malignancy, surgical exploration was undertaken. Intraoperatively, pus was noticed with unhealthy granulation tissue extending along the left-sided C4–5 lamina and transverse process. The frozen section suggested granulomatous infection and histopathology confirmed tuberculosis (TB). After 18 months of antituberculous treatment, the patient gradually recovered complete strength in the left upper limb. Follow-up brachial plexus MRI showed near-complete resolution of the lesion. We describe a unique case of a young patient clinically suggestive of the rapid progressive lesion (mimicking malignancy) affecting brachial plexus, turning out as TB on histopathology.

Epithelioid haemangioendothelioma – A rare cause of pleural effusion

We present the case of a 44-year-old patient, with a history of lymphatic tuberculosis, diagnosed with a pleural effusion associated with pulmonary consolidations. Pleural effusions are frequent in the general population, presenting an incidence of 3–4 cases/1000 people. The etiological diagnosis can be difficult, as they can be secondary to a variety of diseases. Numerous extrapulmonary disorders can explain fluid accumulations in the pleural space with elevated protein level (exudates). However, more frequently they are the result of pulmonary diseases – inflammatory, infectious or neoplastic. The case entailed a differential diagnosis between pulmonary and pleural tuberculosis and neoplastic diseases. Despite receiving antituberculous treatment, the patient’s initial symptoms worsen, the patient starts presenting new signs and symptoms, and the fluid’s characteristics change – expression of an unfavourable evolution. Establishing the diagnosis proved to be difficult as invasive procedures were necessary. We diagnosed an extremely rare tumour, of vascular origin as the cause of the pleural effusion. Epithelioid haemangioendothelioma (EHE) presents an incidence of 1 in 1 million people. In conclusion, when treating a patient for pleural effusion, the lack of improvement entails reconsidering the initial diagnosis and performing more extensive tests.

DIAGNOSING NTM IN IMMUNOCOMPETENT CHRONIC LYMPHADENITIS: AN EMERGING ENITITY

Introduction: Cervical lymph node infection due to nontuberculous mycobacteria in a immunocompetent patients are emerging problem globally. It is presented as chronic enlargement of gland with pain and pus discharge sometimes. Traditionally diagnosis is done through clinical examination, lymph node aspirated samples pathological finding or ZN microscopy, which altogether indicate mycobacterial infection only, unable to differentiate MTB from NTM infection.Increasing incidence of LNTB cases not responding to antituberculous treatment prompted us to pinpoint the etiological agent by doing liquid culture of FNA samples in microbiology laboratory. Materials and Methods: In this study 154 cases were recruited having chronic cervical lymph node swelling of suspicion of mycobacterial infection during January - December, 2014. Therein detailed history and thorough clinical examination of patients were reviewed. All patients were subjected for fine needle aspiration (FNA) using 10 ml syringe fitted with 21 G needle. The aspirated samples were subjected to smear microscopy byZiehlNeelsen (ZN) stain examination, May Grunwald - Giemsa stain and MGIT culture. Positive cultures were primarily identified by cord formation in ZN smear examination, detection of MPT-64 antigen by immuno-chromatographic test (Capilia test). Results: A total 154 lymph node samples were received and processed for culture during the study period. Out of total suspects 7/154 (4.5%) were identified as non-tuberculous mycobacterial lymphadenitis. Clinical examination showed that all the seven cases were presented with lymph node swelling and fever and previous ATT history. Other features seen were pain (2/7 28%), pus discharge (3/7 42%) and montoux positive (3/7 42%). The most common species identified was M. chelonae (3/7, 42%) followed by M. fortuitum (2/7, 28%), M. abscessus (1/7, 14%) and M.terricomplex (1/7, 14%). Four patients were managed surgically, one with surgical resection and medical treatment and 2 patients were lost tofollowup. Conclusion: Definitive and detailed microbiological examination is vital for diagnosing the nontuberculous lymphadenitis. M.chelonae is an important etiological agent.NTMs are important definitive etiological agents in cervical lymph node swelling. Clinical and pathological findings help in suspecting the infection.

The utility of point-of-care urinary lipoarabinomannan testing for the diagnosis of tuberculosis in critically ill patients: a prospective observational study

Background Tuberculosis is a major global public health concern. Patients with tuberculosis who require critical care have a high mortality and delay in initiating antituberculous therapy is associated with increased mortality. Lipoarabinomannan (LAM) is a lipopolysaccharide found in the cell wall of Mycobacterium tuberculosis. Urinary LAM may be used as a bedside diagnostic test for tuberculosis. Methods The study was a single centre, prospective observational study that compared the utility of urinary LAM with conventional tuberculosis diagnostic modalities in patients with suspected tuberculosis who required intensive care admission. Urinary LAM testing was performed using the Alere Determine TB LAM Ag lateral flow assay test strips. A patient was classified as having confirmed tuberculosis if they met the following criteria: a clinical presentation compatible with tuberculosis, with either a positive TB culture, a positive GeneXpert, or a histological diagnosis of tuberculosis. Results Fifty patients were included in the study, with 12 having confirmed tuberculosis. All patients received mechanical ventilation, and the ICU mortality was 60%. Urinary LAM had a sensitivity of 50.0% (95% CI, 21.1 to 78.9%) and a specificity of 84.2% (95% CI, 68.8 to 94.0%) for confirmed tuberculosis. Conclusion Urinary LAM allows for rapid bedside diagnosis of tuberculosis in critically ill patients. A positive urinary LAM should prompt consideration to initiate antituberculous treatment while the results of further diagnostic testing are awaited.

Laparoscopic Diagnosis of Peritoneal Tuberculosis

Peritoneal tuberculosis is a rare form of tuberculosis, which involves parietal and visceral peritoneum, omentum, and intestinal mesentery. Its incidence is increasing in developed countries due to HIV infection and immigration. We present a case of peritoneal tuberculosis in a twenty two-year-old patient misdiagnosed with appendicitis. A laparoscopic surgery was performed showing multiple implants on serosal surfaces and adhesions. Laparoscopic appendectomy and peritoneal biopsies were performed. As peritoneal tuberculosis was suspected, an early antituberculous treatment was initiated. A pathological examination of the samples revealed epithelioid granulomas with a centrale caseous necrosis and acid-fast bacilli. Peritoneal tuberculosis is a challenging diagnosis that can mimic other pathologies and should be kept in mind to establish an early antituberculosis treatment avoiding the high morbidity and mortality associated with a late treatment initiation. In case of suspicion of peritoneal tuberculosis, laparoscopy with guided biopsies is useful for the establishment of a correct diagnosis.

Tuberculous granuloma of maxillary antrum and ethmoid sinus mimicking malignancy and trigeminal neuralgia: A case report and review of the literature

Tuberculosis is a multi-system disease, but paranasal sinuses involvement is uncommon, and most cases occur secondary to pulmonary tuberculosis. Tuberculous granuloma of the paranasal sinuses is rare and only a few cases are reported. Due to non-specific ways of clinical presentations, diagnosis of paranasal tuberculosis can be missed, delayed or confused with other entities like malignancy. We present an uncommon case of tuberculous granuloma of the left maxillary antrum and ethmoid sinus in a 56-year-old man which mimicked trigeminal neuralgia and malignancy. Medial maxillectomy and anterior ethmoidectomy with clearance of the lesion followed by antituberculous treatment prevented permanent loss of his vision. Depending on the chief complaints, patients may present to various specialties. Early cross-referral is important for early diagnosis, appropriate management and prevention of complications.

The utility of point-of-care urinary lipoarabinomannan testing for the diagnosis of tuberculosis in critically ill patients: a prospective observational study

Background: Tuberculosis is a major global public health concern. Patients with tuberculosis who require critical care have a high mortality and delay in initiating anti-tuberculous therapy is associated with increased mortality. Lipoarabinomannan (LAM) is a lipopolysaccharide found in the cell wall of mycobacterium tuberculosis. Urinary LAM may be used as a bedside diagnostic test for tuberculosis.Methods: The study was a single centre, prospective observational study that compared the utility of urinary LAM with conventional tuberculosis diagnostic modalities in patients with suspected tuberculosis who required intensive care admission. Urinary LAM testing was performed using the Alere Determine TB LAM Ag lateral flow assay test strips. A patient was classified as having confirmed tuberculosis if they met the following criteria: a clinical presentation compatible with tuberculosis, with a positive TB culture, or 1 positive GeneXpert, or a histological diagnosis of tuberculosis.Results: Fifty patients were included in the study, with 12 having confirmed tuberculosis. Urinary LAM had a sensitivity of 50.0% and a specificity of 84.2% for confirmed tuberculosis. This compared with a sensitivity of 72.7% and a specificity of 100% for GeneXpert. There was no association between HIV status and CD4 count and urinary LAM results.Conclusion: Urinary LAM allows for rapid bedside diagnosis of tuberculosis in critically ill patients. A positive urinary LAM should prompt consideration to initiate antituberculous treatment while the results of further diagnostic testing are awaited.