Linfadenitis tuberculosa en niños: Revisión sistemática de reportes de caso

Objetivo: Realizar una revisión sistemática de casos de linfadenitis tuberculosa en niños publicados en la literatura hasta abril de 2022. Materiales y Métodos: Se buscó reportes de casos de linfadenitis tuberculosa por M. tuberculosis en niños, en las bases de datos de Scopus, PubMed, Science Direct, Web of Science, LILACs, Ovid MEDLINE, EBSCO y BMJ Case Reports. Resultados: Se seleccionó 41 reportes, que informaron 46 pacientes. La mayoría fueron varones (52,2%), de 8,5 (5-12) años, con tiempo de enfermedad de 2 (1-5) meses. Las manifestaciones clínicas más frecuentes fueron linfadenopatía palpable (60,9%), fiebre (52,2%) y tos (26,1%). También se encontró pérdida de peso (17,4%), escrófula (15,2%), dificultad respiratoria (13%), hiporexia (13%), dolor localizado (13%), exantema cutáneo (13%), sudoración nocturna (4,3%), dolor abdominal (4,3%) e ictericia (2,2%). Los ganglios cervicales fueron los más comprometidos (71,4%). Solo 17,4% tuvo compromiso pulmonar asociado. El PPD fue positivo en 77,1%, la baciloscopia en 17,2%, la histopatología en 94,1% y el cultivo en 58,8%. Conclusiones: La linfadenitis tuberculosa en niños fue más frecuente en varones, entre 5 y 12 años, inmunizados por BCG y sin contacto conocido de tuberculosis. Los síntomas más frecuentes fueron linfadenopatía palpable, fiebre y tos. Además, se presentaron cuadros atípicos con dificultad respiratoria, dolor localizado, exantema cutáneo, dolor abdominal e ictericia. Los ganglios cervicales fueron los más afectados. El estudio histopatológico fue la prueba con mayor sensibilidad diagnóstica detectando el 94,1% de casos.

Objective: To conduct a systematic review of tuberculous lymphadenitis cases in children published until April 2022. Materials and methods: Case reports of tuberculous lymphadenitis by M. tuberculosis in children were searched in Scopus, PubMed, Science Direct, Web of Science, LILACs, Ovid MEDLINE, EBSCO, and BMC Case Reports databases. Results: Forty-one reports were selected and a total of 46 patients were included. The majority were males (52,2%) of 8,5 (5-12) years old. The time of disease was 2 (1-5) months. The most frequent clinical manifestations were palpable lymphadenopathy (60,9%), fever (52,2%) and cough (26,1%). Weight loss (17,4%), scrofula (15,2%), respiratory distress (13%), hyporexia (13%), localized pain (13%), skin rash (13%), night sweats (4.3%), abdominal pain (4.3%) and jaundice (2,2%) were also founded. Cervical nodes were most frequently involved (71,4%). Only 17,4% were associated with lung involvement. PPD was positive in 77.1%, bacilloscopy in 17.2%, histopathology in 94,1% and culture in 58,8%. Conclusions: Tuberculous lymphadenitis in children was more frequent in boys, between 5 and 12 years, immunized by BCG and without known contact with tuberculosis. The principal symptoms were palpable lymphadenopathy, fever and cough. However, atypical symptoms were respiratory difficulty, localized pain, skin rash, abdominal pain, and jaundice. Cervical nodes were the most affected. The test with greatest sensitivity was the histopathological study which detected 94,1% of cases.

Tuberculosis miliar y meningitis multidrogorresistente (MDR) en paciente pediátrico: Reporte de un caso / Complicated multidrug-resistant tuberculosis (MDR) in a pediatric patient: Case report

Objetivo: Presentar el caso de un paciente pediátrico con cuadro inicial de tuberculosis (TB) ganglionar con abandono de tratamiento en 2 ocasiones que evolucionó a la forma miliar y meningitis tuberculosa multidrogorresistente. Reporte del caso: Varón de 4 años con diagnóstico inicial de tuberculosis ganglionar, que abandonó el esquema sensible de tratamiento en dos ocasiones. Tres meses después, se evidenció compromiso bilateral sugestivo de TB miliar y durante la hospitalización desarrolló tuberculosis meníngea e hidrocefalia. Por el antecedente de abandono de tratamiento, se solicitó un estudio de sensibilidad en aspirado gástrico, identificándose como multidrogorresistente; pasando al esquema EZLfxKmEtoCs y manejo de complicaciones, consiguiendo mejoría. Conclusiones: El abandono de tratamiento es una de las principales causas de resistencia a fármacos antituberculosos y de complicaciones. Es necesario reforzar la detección temprana y tratamiento efectivo de esta infección en niños, poniéndose énfasis el seguimiento de casos para evitar abandonos de tratamiento y las complicaciones consecuentes.

Objetive:To describe a pediatric case with initial diagnosis of lymph node tuberculosis (TB) that became multidrug resistant miliar and meningeal tuberculosis (TB-MDR) due to treatment dropout twice. Case report: a 4-year-old boy with initial diagnosis of lymphnode tuberculosis who had two episodes of dropout from the sensitive scheme treatment. Three months later, there was evidence of bilateral involvement suggestive of miliary TB. During hospitalization, he developed meningeal tuberculosis and hydrocephalus. Due to the history of treatment dropout, a sensitivity of gastric aspirate study was requested, identifying it as multidrug-resistant TB. He started the EZLfxKmEtoCs treatment scheme and complications management, achieving improvement. Conclusions: Treatment dropout is one of the main causes of drug resistance in tuberculosis and its complications. It is necessary to reinforce the early detection and effective treatment of this infection in children, focusing on the follow-up of cases to avoid treatment dropout and the consequent complications.

Escrofuloderma: tuberculosis cutánea y pulmonar asociada a coinfección COVID-19: reporte de caso / Scrofuloderma, cutaneous and pulmonary tuberculosis associated with COVID-19: report of one case

Cutaneous tuberculosis represents 1-1.5% of extrapulmonary tuberculosis, including a variety of clinical conditions. Scrofuloderma and lupus vulgaris are the most common forms. We report a 49-year-old woman who sought medical attention through tele-dermatology concerning a cervical nodule associated with suppuration and cutaneous involvement. The diagnoses of scrofuloderma and pulmonary tuberculosis were confirmed, and during her evolution she presented a coinfection with SARS-CoV-2. The possible associations between tuberculosis and COVID-19 were reviewed.

Scrofuloderma: a diagnostic challenge

Abstract: Cutaneous tuberculosis is a rare form of extrapulmonary tuberculosis, comprising 1-2% of cases. Caused by Mycobacterium tuberculosis or related strains, it presents a wide range of clinical manifestations, mimicking other chronic dermatoses and leading to delayed diagnosis. A case of scrofuloderma is reported, whose diagnosis and treatment were only made six years after onset of the disease.

A retrospective analysis of first confirmed tubercular lymphadenitis in 129 cases / 中华传染病杂志

Objective@#To analyze and summarize the clinical characteristics of tubercular lymphadenitis, and to improve the ability of diagnosis. @*Methods@#Clinical records of 129 patients first confirmed with tubercular lymphadenitis were collected retrospectively from Nanfang Hospital of Southern Medical University between January 2012 and December 2016. The categorical variables were described with the percentage (%) and compared with the chi-squaue test. Non-normal distribution data were described with M(P25, P75) and compared with rank sum test.@*Results@#The disease courses were different in all cases, mostly of 1-3 months (45.7%). Among the cases, 83 cases (73.6%) complained of lymph node enlargement. The predominant involved lymph node site was cervical (56.6%) with main presentation of single lymph node (61.2%). Only a few cases presented with fever (34.1%). The positive rate of histological examinations was 94.3%, while the positive rate of T cell spot test of tuberculosis infection (T-SPOT.TB) test was 93.3% and purified protein derivative (PPD) test was 69.6%. In the diagnosis of tubercular lymphadenitis, 100 cases (77.5%) were confirmed by histological examinations, 27 cases (20.9%) were given diagnostic treatment, and only 2 case (1.6%) was confirmed by culture. The average period of diagnosis was (10.4±6.5) days. The median age of patients with fever was 50.5 years old with a median disease course of 2.5 months, while the median age of patients fever was 35(24, 49) years old with a median disease course of 1.2(0.5, 6.0) months. The differences between two groups were statistically significant (Z=-3.118 and -2.982, respectively, both P<0.05). Patients with fever had higher proportion of swollen deep lymph nodes (54.5% vs 11.8%), elevated white blood cell counts (34.1% vs 7.1%) and neutrophils (31.8% vs 1.8%), elevated erythrocyte sedimentation rate (97.1% vs 56.1%), elevated C-reactive protein (95.0% vs 40.0%) and received diagnostic treatment (47.7% vs 7.1%) than patients with no fever (χ2=27.337, 15.545, 13.567, 19.347, 25.410 and 28.974, respectively, all P<0.05). @*Conclusions@#Most patients of tubercular lymphadenitis do not present with typical symptoms which might lead to misdiagnose in early stage. The histological examinations and T-SPOT.TB test are especially essential, and histological examinations is the most important diagnostic method. Patients without symptoms of tuberculous poisoning are more common in young people, and the confirmation of diagnosis are mainly based on histological examinations. Patients with symptoms of tuberculous poisoning are more common in middle-aged, with longer duration and deep lymph node involved, which is more serious and nearly half of which are confirmed with diagnostic treatment.

Clinical analysis of cervical lymph node tuberculosis / 中国耳鼻咽喉头颈外科

OBJECTIVE To analyze the clinical manifestation,diagnosis and treatment of cervical lymph node tuberculosis.METHODS The clinical data of 100 patients with cervical lymph node tuberculosis admitted in our hospital from 2007 to 2015 were retrospectively analyzed.RESULTS Most of the patients with cervical lymph node tuberculosis presented with cervical mass alone,only 8 cases associated with fever,night sweats,fatigue and other systemic symptoms of poisoning.Ninety five patients were diagnosed by postoperative pathological examination,while 15 patients were diagnosed with fine needle aspiration preoperatively.Ninety five patients received surgical treatment with postoperative systemic anti-tuberculosis treatment for 6 months,the remaining 5 patients given standard antituberculosis treatment.All of the patients got satisfactory results.There were three operative methods:simple cervical lymph node resection(31 cases),cervical lymph node dissection(53 cases),and abscess incision debridement(ll cases).All patients had no recurrence.CONCLUSION The clinical manifestation of cervical lymph node tuberculosis are complicated,the positive rate of fine needle aspiration biopsy is low.Postoperative pathological examination can help to further confirm the diagnosis.Surgical treatment combined with postoperative systemic standard anti-tuberculosis therapy can be used to cervical lymph node tuberculosis.

Video-assisted Thoracoscopic Surgery for the Treatment of Mediastinal Lymph Node Tuberculous Abscesses / 华中科技大学学报（医学）（英德文版）

The mediastinal lymph node tuberculous abscesses (MLNTAs) are secondary to mediastinal tuberculous lymphadenitis.Surgical excision is often required when cold abscesses form.This study was aimed to examine video-assisted thoracoscopic surgery (VATS) for the treatment of MLNTA.Clinical data of 16 MLNTA patients who were treated in our hospital between December 1,2013 and December 1,2015 were retrospectively analyzed.All of the patients underwent the radical debridement and drainage of abscesses,and intrathoracic lesions were removed by VATS.They were also administered the intensified anti-tuberculosis treatment (ATT),and engaged in normal physical activity and follow-up for 3 to 6 months.The results showed that VATS was successfully attempted in all of the 16 MLNTA patients and they all had good recovery.Two patients developed complications after surgery,with one patient developing recurrent laryngeal nerve injury,and the other reporting poor wound healing.It was concluded that VATS is easy to perform,and safe,and has high rates of success and relatively few side-effects when used to treat MLNTA.

Xpert MTB/RIF assay in rapid diagnosis of tuberculous lymphadenitis / 中华临床感染病杂志

Objective To assess the application of Xpert MTB/RIF assay in rapid diagnosis of tuberculous lymphadenitis.Methods Lymph node samples were collected from 1 02 clinically diagnosed patients with lymph node tuberculosis and 65 patients with other lymph node diseases from Zhejiang Provincial Hospital of Traditional Chinese and Western Medicine during January 201 4 and February 201 5. Xpert MTB/RIF,pathological examination and mycobacterium tuberculosis culture were conducted in all specimens of two groups.Taking clinical comprehensive diagnosis as the gold standard,the diagnostic sensitivity,specificity,positive predictive value,negative predictive value and diagnosis efficacy of three detection methods were assessed.The sensitivity of Xpert MTB/RIF in determining rifampicin resistance was analyzed using drug susceptibility testing as gold standard.Results The mean detection time of Xpert MTB/RIF was (2.2 ±0.2)h.Among 1 02 patients,Xpert MTB/RIF achieved higher sensitivity (96.1 %, 98 /1 02 ) than pathological examination (76.5%,78 /1 02 ) and mycobacterium tuberculosis culture (33.3%,34 /1 02)(χ2 =1 6.558 and 87.91 9,both P <0.01 ).Among 65 patients with other lymph node diseases,the specificity of all three detection methods was 1 00%.The receiver-operating-characteristic curve analysis demonstrated that diagnostic performance of Xpert MTB/RIF was better than that of other two methods.In 8 patients resistant to rifampicin confirmed by drug susceptibility testing,Xpert MTB/RIF detected 6 resistant-resistant patients.Conclusion Xpert MTB/RIF shows higher sensitivity and specificity in diagnosis of lymph node tuberculosis with the advantages of easy and rapid performance.

Tuberculosis axillary lymph node coexistent breast cancer in adjuvant treatment: case report / Tuberculose linfonodal axilar coexistente com carcinoma mamário em tratamento adjuvante: relato de caso

Coexistence of breast cancer and tuberculosis is rare. In most cases, involvement by tuberculosis occurs in axillary lymph nodes. We report a case of a 43-years-old patient who had undergone adenomastectomy and left sentinel lymph node biopsy due to a triple negative ductal carcinoma. At the end of adjuvant treatment, the patient had an atypical lymph node in the left axilla. Lymph node was excised, and after laboratory analysis, the diagnosis was ganglion tuberculosis. The patient underwent treatment for primary tuberculosis. The development of these two pathologies can lead to problems in diagnosis and treatment. An accurate diagnosis is important to avoid unnecessary surgical procedures.

A coexistência de câncer de mama e tuberculose é rara. Na maioria das vezes, o acometimento pela tuberculose ocorre nos linfonodos axilares. Relatamos caso clínico de paciente de 43 anos submetida à adenomastectomia e à biópsia de linfonodo sentinela à esquerda devido a um carcinoma ductal triplo negativo. Ao final do tratamento adjuvante, a paciente apresentou linfonodomegalia atípica em axila esquerda. Foi realizado exérese do linfonodo e, após análises laboratoriais, diagnosticou-se tuberculose ganglionar. A paciente foi submetida a tratamento para tuberculose primária. O desenvolvimento dessas duas patologias pode acarretar problemas quanto ao diagnóstico e ao tratamento. O diagnóstico acurado é importante para evitar procedimentos cirúrgicos desnecessários.

Tuberculosis extrapulmonar. Presentación de un caso / Extrapulmonary Tuberculosis. A Case Report

Se presenta el caso de una paciente de 49 años de edad, que presentó manifestaciones generales de cinco meses de evolución, dadas por pérdida de peso y astenia, acompañados de aumento de volumen en ganglios del cuello. Al examen físico presentó aumento de volumen en ganglios de cadena cervical lateral derecha, que formaban una masa de aproximadamente dos centímetros, sin signos de inflamación. Los exámenes complementarios tuvieron como hallazgo principal varias adenopatías, la mayor de ellas de 16 × 14 mm, hipoecogénica, por detrás del lóbulo derecho del tiroides. Se realizó extracción de ganglio para estudio anatomopatológico, el cual informó una adenitis granulomatosa tuberculoide, altamente sugestiva de tuberculosis, cultivo en Lowenstein- Jensen positivo de mycobacterium tuberculosis. Aunque la tuberculosis es en la actualidad una enfermedad curable, aún no es un problema resuelto. Es importante mantener la vigilancia, y un determinado índice de sospecha no solo ante enfermedades pulmonares, sino aquellas que comprometen a otros órganos sistemas.

The case of a 49-year-old patient with a 5-month history of general manifestations such as weight loss and weakness, accompanied by enlargement of the lymph nodes in the neck is presented. The physical examination showed an increased volume in the right lateral cervical lymph nodes, forming a mass of approximately two centimeters, without signs of inflammation. Complementary tests revealed several enlarged nodes; the largest was 16 × 14 mm, hypoechoic and behind the right lobe of the thyroid. The node was removed for pathological study, which found a tuberculous lymphadenitis, highly suggestive of tuberculosis (culture positive for mycobacterium tuberculosis on Lowenstein-Jensen medium). Although tuberculosis is now curable, it is not a solved problem. It is important to maintain surveillance and a certain degree of suspicion regarding lung diseases and those affecting other organs.

Combination of Jiehe pellet and the standardized anti-tuberculosis therapeutic regimen for pulmonary tuberculosis complicating cervical lymph node tuberculosis in the aged / 国际中医中药杂志

Objective To assess the efficacy of combination of Jiehe pellet and the standardized anti-tuberculosis therapeutic regimen for pulmonary tuberculosis complicating cervical lymph node tuberculosis in the aged. Methods A total of 103 aged patients with pulmonary tuberculosis complicating cervical lymph node tuberculosis were enrolled and randomly allocated to either a standardized anti-tuberculosis therapeutic regimen group (control group with 51 patients) or a standardized anti-tuberculosis therapeutic regimen plus Jiehe pellet group (treatment group with 52 patients). The patients in the control group and the treatment group received the treatment with 2HRZE/4HR and 2HRZE/4HR plus Jiehe pellet for 6 months, respectively. The abscessed lymph nodes were treated by either total excision or incision and drainage after 4 weeks of medicine treatment in both groups. Sputum smear was examined for acid-fast bacilli. The CD8 cells expressing natural killer T cells receptors NKG2A, NKG2D in peripheral blood were detected by flow cytometry. The treatment outcome was measured at the end of treatment. Results The rates of lesion resolution (78.85%vs. 58.82%;χ2=4.439, P<0.05) and cavity closure (62.86% vs. 35.48%;χ2=3.893, P<0.05) in the treatment group were significantly higher than those in the control group. In the end of 2, 4 and 6 months of treatment, cumulative rates of sputum conversion from positive to negative in the treatment group were significantly higher than those in the control group (χ2 were 5.343, 5.067 and 4.118,all P<0.05). The CD8 cells expressing NKG2A after treatment in the treatment group were significantly lower than those before treatment in the treatment group (t=9.510, P<0.01) and after treatment in the control group (t=9.832, P<0.01);the CD8 cells expressing NKG2D after treatment in the treatment group were significantly higher than those before treatment in the treatment group (t=10.622, P<0.01) and after treatment in the control group (t=10.433, P<0.01). The serum levels of IL-6 and TNF-αafter treatment were significantly lower than those before treatment in both groups (t were 17.344 and 21.142 in the treatment group, 10.984 and 12.203 in the control group;all P<0.01 );the serum levels of IL-6 and TNF-α after treatment in the treatment group were significantly lower than those after treatment in the control group (t were 7.832 and 5.478,all P<0.01). The serum IL-10 levels after treatment were significantly higher than those before treatment in both groups (t were 12.454 in the treatment group, 7.934 in the control group; all P<0.01 ); and the serum IL-10 level after treatment in the treatment group was significantly higher than that after treatment in the control group (t=4.720, P<0.01). The effective rate for cervical lymph node tuberculosis in the treatment was significantly higher than that in the control group (88.5%vs. 64.7%;χ2=6.855, P<0.01). Conclusion Combination of Jiehe pellet and the standardized anti-tuberculosis therapeutic regimen may improve immune function, increase the rate of sputum conversion from positive to negative, and facilitate lesion resolution in aged patients with pulmonary tuberculosis complicating cervical lymph node tuberculosis.

Dual Energy CT Imaging in Diagnosis of Cervical Squamous Cell Carcinoma Metastatic Lymph Nodes and Lymph Node Tuberculosis / 中国医学影像学杂志

PurposeTo explore the significance of dual energy CT in differential diagnosis of squamous cell carcinoma metastatic lymph nodes and lymph node tuberculosis in the neck.Material and Methods Twenty-five patients with a total of 62 cervical enlarged lymph nodes confirmed with squamous cell carcinoma metastasis or lymph node tuberculosis by pathology underwent dual energy enhanced CT scan. Iodine coverage value of two different kinds of pathological properties of lymph nodes was measured. The trend of the spectrum curve was observed and the energy spectrum curve slope of two kinds of lymph nodes were compared. The sensitivity, specificity and accuracy of energy spectrum curve slope in differential diagnosis were analyzed. Results Of all 62 lymph nodes, there were 32 squamous cell carcinoma metastatic lymph nodes and 30 lymph node tuberculosis. There were statistic significance in the iodine coverage between the squamous cell carcinoma metastatic lymph nodes and lymph node tuberculosis (t=3.806 and 3.698,P<0.05). In the range from 60 keV to 180 keV, CT value of the two kinds of lymph nodes decreased with increase of keV value. It showed the higher the keV value the less CT value decreased, with the energy spectrum curve of drop type. The area of the iodine coverage was 0.756 with the differential diagnostic sensitivity of 56% and the specificity of 80%. The area of energy spectrum curve slope was 0.898 with the differential diagnostic sensitivity of 76% and the specificity of 85%.Conclusion The iodine coverage value and the energy spectrum curve slope have significance in differential diagnosis of the cervical squamous cell carcinoma metastatic lymph nodes and lymph node tuberculosis. The energy spectrum curve slope is superior to the iodine coverage value in differential diagnosis.

Cutaneous tuberculosis: diagnosis, histopathology and treatment - Part II

The evolution in the knowledge of tuberculosis' physiopathology allowed not only a better understanding of the immunological factors involved in the disease process, but also the development of new laboratory tests, as well as the establishment of a histological classification that reflects the host's ability to contain the infectious agent. At the same time, the increasing bacilli resistance led to alterations in the basic tuberculosis treatment scheme in 2009. This article critically examines laboratory and histological investigations, treatment regimens for tuberculosis and possible adverse reactions to the most frequently used drugs.

Linfadenitis axilar primaria tuberculosa, dificultades en el diagnóstico: presentación de un caso / Tuberculous primary axillary lymphadenitis: their difficulties in diagnosis

La linfadenitis axilar primaria tuberculosa sin otra enfermedad asociada, es una enfermedad infrecuente.Objetivo: presentar un caso de linfadenitis axilar primaria de origen tuberculoso en una paciente.Caso Clínico: paciente de 25 años, femenina, de piel blanca, con antecedentes de haber sido ingresada hace tres años por síndrome adenico por lo cual fue estudiada, al año de su egreso presenta adenopatías en la región lateral derecha del cuello, es estudiada por consulta externa donde se le realizó múltiples exámenes, estudio histopatológico de ganglio, imagenológicos etc., diagnosticándole una adenitis inespecífica. Es ingresada por presentar una tumoración en axila derecha de más o menos 4,5 a 5cm, de aproximadamente un año de evolución, con crecimiento lento, lobular que no ocasiona ningún tipo de molestias.Conclusiones: la tuberculosis extrapulmonar es infrecuente. La afectación ganglionar es mayormente reportada pero sobre todo en los ganglios del cuello, muy rara en la región axilar. La presentación clínica por lo regular es asintomática. El diagnóstico definitivo viene dado por la epidemiología, prueba de tuberculina, la imagenología y fundamentalmente la histopatología, ya que esta enfermedad tiene un gran número importante de diagnósticos diferenciales

Tuberculous primary axillary lymphadenitis without other associate manifestation is a rare disease.Objective: to present a case of primary axillary lymphadenitis caused by tuberculosis in a patient.Clinical case: 25 years-old, female, white skin patient admitted three years ago by adenic syndrome, after a year of being discharge she presented adenopathy in the right lateral region of the neck, she was studied by external consultation where multiple tests were carried out like: histopathological study of the ganglion, imaging etc., diagnosing a nonspecific adenitis. She is admitted by presenting a right axillary tumor of 4.5- 5 cm, approximately with one year of evolution, with slow, lobular growth that does not cause any kind of discomfort.Conclusions: extrapulmonary tuberculosis is uncommon. The ganglionic form is the most reported, particularly those in the neck, very rare in the axillary region. The clinical presentation usually has no symptoms. The epidemiology, tuberculin test, imaging and mainly histopathology give the definitive diagnosis; because this disease has a great number of differential diagnoses

Abordagem diagnóstica da tuberculose pleural, ganglionar, renal e de sistema nervoso central / Diagnostic Approach to Tuberculosis in the Pleura, Lymph Nodes, Kidneys, and Central Nervous System

O objetivo do presente artigo foi relatar a abordagem diagnóstica da tuberculose pleural, ganglionar, renal e do sistema nervoso central. A forma mais frequente entre essas formas de tuberculose no Brasil é a tuberculose pleural, cujo diagnóstico na prática clínica baseia-se no exame histopatológico, com uma alternativa relatada nos últimos anos: a dosagem da enzima adenosina desaminase. A maioria dos achados laboratoriais encontrados implica na condição paucibacilar dessas formas extrapulmonares

The objective of this study was to report the diagnostic approach to tuberculosis of the pleura, lymph nodes, kidneys, and central nervous system. In Brazil, the most common extrapulmonary form of tuberculosis is that afecting the pleura. In clinical practice, pleural tuberculosis is typically diagnosed on the basis of the histopathological examination. However, in recent years, the determination of adenosine deaminase levels has been used as an alternative. Most laboratory indings indicate that these extrapulmonary forms are paucibacillary

Manifestações clínicas da tuberculose pleural, ganglionar geniturinária e do sistema nervoso central / Clinical Manifestations of Tuberculosis in the Pleura, Lymph Nodes,Urogenital System, and Central Nervous System

A tuberculose persiste como uma importante causa de morbidade e mortalidade mundial. Apesar de a forma pulmonar ser a apresentação mais importante e frequente, o acometimento extrapulmonar ocorre em aproximadamente 10-20% dos casos e em até 60% nos imunocomprometidos. Revisamos as principais manifestações clínicas dos mais importantes acometimentos extrapulmonares da tuberculose em nosso meio. O comprometimento pleural, ganglionar e urogenital são os mais comuns em nosso meio, além da importância do comprometimento do sistema nervoso central. A tuberculose costuma manifestar-se clinicamente como enfermidade subaguda a crônica, com sinais sistêmicos clássicos de febre baixa vespertina, emagrecimento e astenia, além daqueles que são dependentes do órgão afetado. Algumas dessas manifestações são revistas e descritas, lembrando, porém, que não existe quadro clínico patognomônico da enfermidade e que essa deve ser sempre lembrada no diagnóstico diferencial em nosso meio

Tuberculosis persists as a major cause of morbidity and mortality worldwide. Although the pulmonary form is more common and severe, the extrapulmonary form occurs in 10-20% of all cases and in up to 60% of cases in which the host is immunocompromised. This paper reviews the principal clinical manifestations of the most common types of extrapulmonary tuberculosis. Extrapulmonary tuberculosis most often afects the pleura, lymph nodes, urogenital system, and central nervous system, the last being the most common. In most cases, extrapulmonary tuberculosis is a clinically subacute or chronic disease, with symptoms speciic to the afected organ, as well as systemic signs, including a low fever, weight loss, and asthenia. Although some of these manifestations have been described, there is no pathognomonic clinical proile of the disease, which should always be included in the diferential diagnosis

Recurrent nodules in the calves: A sign of tuberculosis / Recurrent nodules in the calves: A sign of tuberculosis

Aims: To describe a case of erythema induratum of Bazin, classified as a tuberculid, or skin lesion with similar histological features to true cutaneous tuberculosis, in which the relation with Mycobacterium tuberculosis cannot be easily demonstrated.Case Description: A 60-year-old woman presented with recurrent multiple nodules in the legs. Skin examination revealed violaceous painless nodules, some of them ulcerated, with a serous fluid, located on both legs in an asymmetric way, predominantly in the calves. Lesions disappeared spontaneously for brief periods. Skin biopsies revealed septal and lobular panniculitis with epithelioid granulomata and vascular necrosis. Tuberculin skin test was positive. Culture of the cutaneous lesions and polymerase chain reaction to Mycobacterium tuberculosis were negative, but mediastinal lymph nodes collected through mediastinoscopy were cultivated and positive to Mycobacterium tuberculosis. Therapy with isoniazid, rifampicin, pyrazinamide and ethambutol were administered. After two months under therapy the skin lesions healed. The clinical and histopathological features and the strong positive tuberculin skin test have strongly suggested the diagnosis of erythema induratum of Bazin. Positive culture for Mycobacterium tuberculosis and the remission of the lesions with antituberculosis therapy confirmed the diagnosis.Conclusions: Clinicians must be aware of the differential diagnosis of recurrent skin lesions, including the erythema induratum of Bazin. In this case, association with tuberculosis was confirmed by positive culture of mediastinal lymph nodes for Mycobacterium tuberculosis and remission of the lesions with antituberculosis therapy.

Objetivos: descrever um caso de eritema induratum de Bazin, classificado como tubercúlide, lesão cutânea com características histológicas semelhantes à tuberculose cutânea, mas na qual a relação entre o Mycobacterium tuberculosis não é facilmente demonstrada.Descrição do Caso: uma mulher de 60 anos de idade apresentou-se com múltiplos nódulos recorrentes nos membros inferiores. O exame da pele revelou nódulos indolores, violáceos, alguns deles ulcerados, com um líquido seroso, localizados em ambas as pernas, de forma assimétrica e com predomínio nas panturrilhas. As lesões apresentavam um aparecimento paroxístico, com remissão espontânea por breves períodos. Foi realizada biópsia cutânea que revelou paniculite septal e lobular com granulomas epitelióides e necrose vascular. O teste tuberculínico foi positivo. A cultura das lesões cutâneas e a reação em cadeia da polimerase para Mycobacterium tuberculosis foram negativos, mas foi realizada biópsia de linfonodos por mediastinoscopia, cuja cultura foi positiva para Mycobacterium tuberculosis. Foi iniciada terapêutica específica com isoniazida, rifampicina, pirazinamida e etambutol. Após dois meses de tratamento houve remissão das lesões. As características clínicas e histopatológicas e o teste tuberculínico fortemente positivo sugeriram o diagnóstico de eritema indurado de Bazin, sendo este confirmado pela cultura de linfonodos positiva para Mycobacterium tuberculosis e pela remissão das lesões com a terapêutica antituberculose.Conclusões: o clínico precisa estar atento para o diagnóstico diferencial de lesões cutâneas recorrentes, incluindo neste o eritema induratum de Bazin. Neste caso, a associação com a tuberculose ficou confirmada pela cultura dos linfonodos mediastinais positiva para Mycobacterium tuberculosis e remissão das lesões com a terapêutica antituberculose.

HIV-associated tuberculous lymphadenitis: the importance of polymerase chain reaction (PCR) as a complementary tool for the diagnosis of tuberculosis - a study of 104 patients / Linfadenite tuberculosa associada ao HIV: a importância da reação em cadeia de polimerase (PCR) como ferramenta complementar para o diagnóstico da tuberculose - estudo de 104 pacientes

BACKGROUND: Lymphadenitis is common in HIV-positive patients. Diagnosis of the infections associated with this condition is complex, particularly in the case of tuberculosis. Rapid and specific detection of Mycobacterium tuberculosis (M. tuberculosis) is fundamental in ensuring adequate treatment. In addition, frequent causes of lymphadenitis such as those associated with lymphoma and histoplasmosis, among others, must be eliminated as possible causes. OBJECTIVES: To evaluate the accuracy of polymerase chain reaction as a tool for the diagnosis of lymphadenitis resulting from M. tuberculosis. METHODS: In this study, a protocol was developed using the following procedures: direct microscopy using Ziehl-Neelsen staining, culture in Lowenstein-Jensen medium, histology and polymerase chain reaction. RESULTS: A total of 104 patients were included in the study. According to histopathology, 38 patients (36 percent) were found to have nonspecific chronic lymphadenitis, 27 (26 percent) had tuberculous lymphadenitis, 11 patients (10.5 percent) had lymphoma and 9 (8.7 percent) had histoplasmosis. When Lowenstein-Jensen culture was performed, positive tests for tuberculous lymphadenitis increased by 30 percent. With polymerase chain reaction, M. tuberculosis DNA was detected in 6 out of 38 samples of non-specific chronic lymphadenitis. Three of these patients were followed up, developed symptoms of tuberculosis and were cured following specific treatment. CONCLUSION: The data obtained in this study suggest that all cases of lymphadenopathies should be submitted to histopathology, Lowenstein-Jensen or Ogawa culture and polymerase chain reaction. Polymerase chain reaction may prove to be useful in providing an early and accurate detection of cases of extrapulmonary tuberculosis in HIV-positive patients with lymphadenopathies, avoiding empirical treatment and the possible development of resistant strains.

FUNDAMENTOS: A linfadenite é comum em pacientes HIV-positivos. O diagnóstico das infecções associadas a essa condição é complexo, especialmente em relação à tuberculose. A detecção rápida e específica do Mycobacterium tuberculosis (M. tuberculosis) é essencial para o tratamento adequado. Além disso, frequentes causas de linfadenites tais como as relacionadas a linfoma, histoplasmose, e outras, devem ser afastadas. OBJETIVOS: Avaliar a importância da biópsia cirúrgica excisional das linfadenites e realização dos exames histopatológicos, exames baciloscópicos (Ziehl-Neelsen), cultura (Lowenstein-Jensen) e reação em cadeia da polimerase (PCR) com finalidade diagnostica MÉTODOS: Desenvolveu-se um protocolo para biópsias excisionais de linfonodos, adotando-se os seguintes procedimentos: exame direto de esfregaços corados pelo método de Ziehl-Neelsen, cultura em meio de Lowenstein-Jensen, exame anátomo-patológico e PCR. RESULTADOS: Ao todo foram incluídos 104 pacientes, e o exame histopatológico evidenciou 36 por cento (n = 38 pacientes) de casos de linfadenite crônica inespecífica, 26 por cento (n = 27) de linfadenite tuberculosa, 10,5 por cento (n =11) de linfoma e 8,7 por cento (n = 9) de histoplasmose. Através da cultura no meio de Lowenstein-Jensen, os casos positivos para linfadenite tuberculosa aumentaram para 30 por cento. A PCR detectou M. tuberculosis em 6 das 38 amostras de linfadenite crônica inespecífica. Três desses pacientes foram acompanhados, exibiram sintomas de tuberculose e foram curados após tratamento específico. CONCLUSÃO: Os dados obtidos neste trabalho sugerem que em todos os casos de linfadenopatia deve-se realizar exame histopatológico, cultura em Lowenstein-Jensen ou Ogawa e reação em cadeia da polimerase. A reação em cadeia da polimerase pode ser útil na detecção precoce e acurada de casos de TB extrapulmonar nos pacientes HIV-positivos com linfadenopatias, evitando-se o uso de tratamentos empíricos e o eventual desenvolvimento de cepas resistentes.

Clinical Features and Treatment of Cervical Tuberculous Lymphadenitis / 대한흉부외과학회지

BACKGROUND: Cervical tuberculous lymphadenitis is the most common form of peripheral tuberculous lymphadenitis. The American Thoracic Society recommends 6 months of isoniazid, rifampin, ethambutol and pyrazinamide for treatment of peripheral tuberculous lymphadenitis, but even with this recommended treatment, frequent relapse occurs in actual clinical situations. MATERIAL AND METHOD: The medical records of 38 patients diagnosed and treated for cervical tuberculous lymphadenitis between February 1997 and February 2007 were retrospectively reviewed. RESULT: The study included 14 males (36.8%) and 24 females (63.2%), with a mean age of 36.9+/-16.3 years. The most frequent symptom was palpable neck mass in 24 patients (63.2%); 10 patients (26.3%) complained of fever or chills. Only nine patients (23.7%) had radiologic abnormalities. All patients received anti-tuberculous medications for at least 7 months, with isoniazid, rifampin, ethambutol and pyrazinamide for the first 2 months, and then isoniazid, rifampin and ethambutol given for more than 5 months. Relapse occurred in 7 patients (21.2%). CONCLUSION: Since many patients with cervical tuberculous lymphadenitis have no symptoms and show no radiologic abnormalities, diagnosis and treatment tend to be delayed. Considering the high relapse rate, the anti-tuberculous medication period should be longer than 6 months and this is recommended by the American Thoracic Society.

Doença de Kikuchi-Fujimoto / Kikuchi-Fujimoto disease

A doença de Kikuchi-Fujimoto é caracterizada por febre e linfadenopatia, geralmente cervical. Esta doença acomete principalmente mulheres jovens. Pode ser confundida com linfoma, metástase de adenocarcinoma e tuberculose. Relatamos dois casos da doença de Kikuchi-Fujimoto. No primeiro caso, uma paciente de 28 anos havia tratado tuberculose há um ano e apresentava quadro clínico e histológico compatível com a doença de Kikuchi-Fujimoto. A segunda paciente, de 58 anos, recebeu tratamento inicialmente para granulomatose de Wegener e, posteriormente, para tuberculose. O exame histopatológico com estudo imunohistoquímico permitiu estabelecer o diagnóstico da doença de Kikuchi-Fujimoto nos dois casos. Após o diagnóstico definitivo, ambas foram tratadas sintomaticamente e melhoraram clinicamente dentro de um mês. Posteriormente, a segunda paciente desenvolveu lúpus eritematoso sistêmico.

Kikuchi-Fujimoto disease is characterized by fever and lymphadenopathy, usually localized in the cervical region. This disease principally affects young females. It can be confused with lymphoma, adenocarcinoma metastasis and tuberculosis. We report two cases of Kikuchi-Fujimoto disease. In the first case, a 28-year-old female had been treated for tuberculosis one year prior and presented with a clinical and histological profile compatible with Kikuchi-Fujimoto disease. The second patient, a 58-year-old female, initially received treatment for Wegener's granulomatosis and, subsequently, for tuberculosis. Histopathological examination followed by immunohistochemical analysis confirmed the diagnosis of Kikuchi-Fujimoto disease in both cases. After the definitive diagnosis had been made, both patients were treated symptomatically, and both presented clinical improvement within one month. Subsequently, the latter patient developed systemic lupus erythematosus.