Resposta paradoxal após o início de tratamento para tuberculose: relato de caso / Paradoxical response after initiation of tuberculosis treatment: case report

JUSTIFICATIVA E OBJETIVOS: A reação paradoxal pode ser identificada em até 30% de todos os pacientes após o início de tratamento para tuberculose, embora seu diagnóstico permaneça um desafio, já que não existem testes confiáveis que o corroborem. O objetivo deste estudo foi relatar um caso em que o diagnóstico de reação paradoxal foi realizado.RELATO DO CASO: Paciente do sexo masculino, 31 anos,um mês após o início de uso de fármacos para tratamento de tuberculose miliar, com diagnóstico realizado por lavado broncoalveolar, apresentou plegia no membro inferior direito, parestesia no membro superior direito e membro inferior esquerdo, incontinência urinária e fecal. Ressonância nuclear magnética do encéfalo evidenciou múltiplas áreas com hipersinal em T2, predominando em substância branca subcortical em ambos os hemisférios, com realce de lesões nodulares, sugestivas de infecção oportunista. Antivírus da imunodeficiência humana 1/2 foi negativo. PCR DNA para M. tuberculosis no líquor foi negativa. Iniciou-se, então, dexametasona. O paciente apresentou melhora significativa, porém permaneceu com incontinência urinária.Tomografia computadorizada de crânio realizada posteriormente não evidenciou quaisquer alterações. CONCLUSÃO: Apesar de sua elevada prevalência, continua difícilr ealizar o diagnóstico de reação paradoxal após o início de tratamento para tuberculose. Mais estudos são necessários para melhor definir os parâmetros diagnósticos e para orientar diretrizes terapêuticas mais efetivas.

BACKGROUND AND OBJECTIVES: Paradoxical response can be identified in up to 30% of all patients after initiation of tuberculosis treatment, although your diagnosis still remains a challenge, mainly because do not exist trustworthy tests to confirm it. These study aimed to describe a case were the diagnosis of a paradoxical response was made.CASE REPORT: Male patient, 31 year-old, a month after the initiation of miliary tuberculosis treatment, with the diagnosis realized by bronchoalveolar lavage, presented right lower limb plegia, right upper limb paresthesia, urge and fecal incontinence. Brain Magnetic Resonance Imaging evidenced hyper signs of T2 in multiple areas, in which predominated in white subcortical substance, beyond enhancing nodular lesions, suggesting an opportunistic infection. Anti human immunodeficiency virus 1/2 was negative. PCR DNA to M. tuberculosis in liquor was negative. After, dexamethasone treatment was started. The patient presented a significant improvement, but urge incontinence remained unchanged. Brain computed tomography realized after not evidence any alteration. CONCLUSION: Despite paradoxical response presents high occurrence, it continuous to be difficult to make the diagnosis of paradoxical response after initiation of tuberculosis treatment. Further studies are necessary in order to improve the diagnostic parameters and to orientate more effective therapeutic consensus.

Challenges in the diagnosis & treatment of miliary tuberculosis.

Miliary tuberculosis (TB) is a potentially lethal disease if not diagnosed and treated early. Diagnosing miliary TB can be a challenge that can perplex even the most experienced clinicians. Clinical manifestations are nonspecific, typical chest radiograph findings may not be evident till late in the disease, high resolution computed tomography (HRCT) shows randomly distributed miliary nodules and is relatively more sensitive. Ultrasonography, CT and magnetic resonance imaging (MRI) are useful in discerning the extent of organ involvement by lesions of miliary TB in extra-pulmonary locations. Fundus examination for choroid tubercles, histopathological examination of tissue biopsy specimens, conventional and rapid culture methods for isolation of Mycobacterium tuberculosis, drug-susceptibility testing, along with use of molecular biology tools in sputum, body fluids, other body tissues are useful in confirming the diagnosis. Although several prognostic markers have been described which predict mortality, yet untreated miliary TB has a fatal outcome within one year. A high index of clinical suspicion and early diagnosis and timely institution of anti-tuberculosis treatment can be life-saving. Response to first-line anti-tuberculosis drugs is good but drug-induced hepatotoxicity and drug-drug interactions in human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) patients pose significant problems during treatment. However, sparse data are available from randomized controlled trials to define the optimum regimen and duration of treatment in patients with drug-sensitive as well as drug-resistant miliary TB, including those with HIV/AIDS.

Tuberculosis miliar: reporte de un caso y revisión de la literatura / Miliary tuberculosis: a case report and literature review

La tuberculosis debe aún ser incluida en el diagnóstico diferencial de síndrome febril y sintomatología respiratoria en la infancia. Se presenta el caso de un adolescente con TBC miliar, patología frecuente en este grupo etario.

Miliary tuberculosis in Kuwait: clinical presentation, diagnosis and treatment outcome

To assess the demographic, clinical and laboratory features, methods of diagnosis, treatment and outcome in patients with miliary tuberculosis [TB] in Kuwait Retrospective [medical records review] Tuberculosis department, Al Rashed Allergy Center, Kuwait Thirty-four patients with miliary TB admitted from January 1996 to December 2005 Demographic features, clinical presentation, investigation results, treatment history and follow up records There were 22 male and 12 female patients; mean age 33 years. 91% were expatriates. Fever [91%], weight loss [88%], cough [82%], night sweats [61%] and hemoptysis [17%] were common presenting symptoms. Lymphadenopathy [35%], hepatomegaly [26%] and meningeal signs [12%] were seen. Anemia [65%], leucocytosis [21%], thrombocytopenia [6%], thrombocytosis [12%], raised liver enzymes [32%] and hypoalbuminemia [85%] were common laboratory findings. Sputum culture for Acid-Fast Bacilli [AFB] was positive in 64%. AFB culture was positive from cerebro-spinal fluid in three patients, lymph node in two, pus, endometrium, bronchial biopsy, liver biopsy, joint aspirate, ileal biopsy, urine, trans-bronchial biopsy and bronchial lavage in one case each. 73% were sensitive to all first line anti-TB drugs. Hepatitis [23%], hyperuricemia [9%], skin rashes [3%], nephropathy [3%] were the sideeffects of anti-tuberculosis drugs. One patient [3%] died, 56% were cured, 35% left the country or were deported, and 6% defaulted. One patient had relapse. Diagnosis of miliary TB could be confirmed by clinical features, radiological features and AFB culture, even when classical miliary patterns were not present. Anti-TB drugs were generally safe. Majority of patients were cured completely when followed up regularly

Tuberculosis congénita en el Hospital Dos de Mayo / Congenital tuberculosis at The Dos de Mayo Hospital in Lima Perú

Se presenta un caso de tuberculosis congénita con desenlace fatal. Se demostró la presencia de lesiones tuberculosas a nivel pulmonar y del tracto genital materno, por medio de biopsia de endometrio y luego por sucesivas histerosalpingografias. El niño nacido pretérino, 36 semanas de gestación, con peso de 2760 gr. luego de una evolución que incluía hiperbilirrubinemia de 15, 12 mgr por ciento, hidrocele, pie equino varo, diastasis de los rectos abdominales, piodermitis y onfalitis, presenta a los 27 días de nacido un cuadro severo de dificultad respiratoria con marcada cianosis, diagnosticándose TBC miliar y sepsis con desenlace fatal. Tomando en cuenta la propuesta de Cantwell y col. en 1994, sobre criterios diagnósticos revisados para la tuberculosis congénita, el presente caso cumple con los criterios señalados: La tuberculosis probada en el niño y la infección genital materna, corroborando por el exámen anatomopatológico de los restos obtenidos por legrado uterino, así como exclusión completa de la posibilidad de contagio postnatal por el aislamiento del niño de las madre, además de la existencia de lesiones desde las primeras semanas de vida.

Tuberculosis no pulmonar: respuesta al tratamiento en condiciones del programa: experiencia del Hospital Nacional Cayetano Heredia periodo 1980 - 1990 / Non lung tuberculosis: response to the treatment proportionate by the program experiency: Hospital Nnacional Cayetano Heredia (1980 - 1990)

De 4483 casos con tuberculosis (TBC) reportados al Programa de Control de Tuberculosis (PCTBC) del Hospital Nacional Cayetano Heredia (HNCH) y centros periféricos durante el período de 1980 - 1990. 356 casos (7,9 por ciento) correspondieron a tuberculosis no pulmonar, 4036 (90 por ciento) a tuberculosis pulmonar y 91 (2,1 por ciento) a pacientes con TBC en ambas localizaciones anatómicas. Presentando un número anual de ingresos sin mayor variación. Las localizaciones anatómicas mayormente afectadas fueron: pleural 49,4 por ciento, ganglionar 18,8 por ciento, miliar 13,2 por ciento, génito-urinario, meníngea, digestivo-perítoneal y otras localizaciones en menor proporción. Hubo diferencia (p menor 0,05) entre los grupos etarios y las localizaciones anatómicas afectadas por la tuberculosis, predominando la localización meningea en menores de 14 años, miliar en menores de 25 años y génito-urinario en mayores de 35 años, dependiendo ello de la etiopatogénia de ésta enfermedad. Los pacientes con tuberculosis no pulmonar presentaron mejoría clínica al término del tratamiento médico proporcionado por el PCTBC del HNCH durante el período 1980 -1990, obteniendo una tasa de altas o éxitos de 78.3 por ciento y una tasa de fracasos 0,2 por ciento mucho menor que el obtenido en pacientes con tuberculosis pulmonar activa (8,3 por ciento), aun recibieron el 60,8 por ciento de los pacientes con tuberculosis no pulmonar esquemas terapéuticos estándar, compuesto por una droga bacteriostática en la primera fase del tratamiento