Tuberculosis cutánea esporotricoide en la Amazonía peruana: reporte de caso / Sporotrichoid cutaneous tuberculosis in the peruvian amazon: case report

RESUMEN La tuberculosis cutánea es una presentación rara de la infección por Mycobacterium tuberculosis. Se presenta el caso de una mujer sin antecedentes médicos de importancia, con un tiempo de enfermedad de año y medio, caracterizado por lesiones tipo esporotricoide, con diseminación linfocutánea en miembro superior derecho, de evolución lentamente progresiva. Se realizó un estudio histopatológico encontrándose células gigantes tipo Langhans y escasa necrosis. El paciente recibió terapia de esquema sensible antituberculoso, con evolución favorable.

ABSTRACT Cutaneous tuberculosis is a rare presentation of Mycobacterium tuberculosis infection. We present the case of a woman without important medical history, with a disease period of one year and a half, characterized by sporotrichoid-like lesions, with lymphocutaneous dissemination in the right upper limb, and with slowly progressive evolution. The histopathological tests revealed Langhans type giant cells and scarce necrosis. The patient received therapy with a sensitive antituberculous scheme, and evolved favorably.

Primary pituitary tuberculosis

Tuberculosis is an infectious disease that involves any organ. However, the primary pituitary tuberculosis is an extremely rare disease. Intracranial tuberculomas account for 0.15-5% of intracranial space-occupying lesions, of which, pituitary as the primary site is unusual, and easily misdiagnosed as pituitary adenoma. In this setting, the late diagnosis can result in permanent endocrine dysfunction. We report the case of a 50-year-old woman who presented to the neurosurgery outpatient department with complaints of progressively increasing headache and diminished vision over the last year. On the clinical examination, the patient was conscious and oriented. The routine hematological and biochemical workup showed an increased erythrocyte sedimentation rate (ESR) and increased prolactin levels. The radiological working diagnosis was consistent with pituitary macroadenoma. No other radiological and/or clinical clue that could elicit the suspicion of pulmonary or extrapulmonary lesions of tuberculosis was found. The transsphenoidal endonasal tumor excision was done. The histopathology showed numerous epithelioid cell granulomas, Langhans giant cells along with scant necrosis. Ziehl Neelsen staining demonstrated acid-fast bacilli, and the final diagnosis of pituitary tuberculoma was made. We report this rare case of pituitary lesion that may be included in the differential diagnosis of sellar lesions to avoid unnecessary surgical interventions, especially in regions where the disease is endemic.

Tumor-like Presentation of Tubercular Brain Abscess: Case Report

A 17-year-old girl presented with complaints of headache and decreasing vision of one month's duration, without any history of fever, weight loss, or any evidence of an immuno-compromised state. Her neurological examination was normal, except for papilledema. Laboratory investigations were within normal limits, except for a slightly increased Erythrocyte Sedimentation Rate (ESR). Non-contrast computerized tomography of her head revealed complex mass in left frontal lobe with a concentric, slightly hyperdense, thickened wall, and moderate perilesional edema with mass effect. Differential diagnoses considered in this case were pilocytic astrocytoma, metastasis and abscess. Magnetic resonance imaging (MRI) obtained in 3.0 Tesla (3.0T) scanner revealed a lobulated outline cystic mass in the left frontal lobe with two concentric layers of T2 hypointense wall, with T2 hyperintensity between the concentric ring. Moderate perilesional edema and mass effect were seen. Post gadolinium study showed a markedly enhancing irregular wall with some enhancing nodular solid component. No restricted diffusion was seen in this mass in diffusion weighted imaging (DWI). Magnetic resonance spectroscopy (MRS) showed increased lactate and lipid peaks in the central part of this mass, although some areas at the wall and perilesional T2 hyperintensity showed an increased choline peak without significant decrease in N-acetylaspartate (NAA) level. Arterial spin labelling (ASL) and dynamic susceptibility contrast (DSC) enhanced perfusion study showed decrease in relative cerebral blood volume at this region. These features in MRI were suggestive of brain abscess. The patient underwent craniotomy with excision of a grayish nodular lesion. Abundant acid fast bacilli (AFB) in acid fast staining, and epithelioid cell granulomas, caseation necrosis and Langhans giant cells in histopathology, were conclusive of tubercular abscess. Tubercular brain abscess is a rare manifestation that simulates malignancy and cause diagnostic dilemma. MRI along with MRS and magnetic resonance perfusion studies, are powerful tools to differentiate lesions in such equivocal cases.

Endometrial tuberculosis causing amenorrhea and abnormal uterine bleeding in a lupus patient treated with cyclophosphamide

BACKGROUND: Amenorrhea may occur in patients with lupus treated with cyclophosphamide. This is commonly attributed to primary ovarian failure leading to infertility -- a possible complication of cyclophosphamide. Urogenital tuberculosis (TB) can be a rare cause of amenorrhea and infertility in lupus patients.OBJECTIVE: To present a case of endometrial TB causing amenorrhea and abnormal uterine bleeding in a patient with lupus nephritis treated with cyclophosphamide.CASE: A 32-year-old Filipino female, who was diagnosed with lupus nephritis, was managed with high dose steroid and intravenous (IV) cyclophosphamide. Lupus nephritis improved with treatment, but she subsequently developed amenorrhea and vaginal spotting for two months. Symptoms were initially attributed to premature ovarian failure due to cyclophosphamide.Gynecologic examination showed thickened endometrium with normal ovaries and uterus on ultrasound. Dilatation and curettage was performed. Histopathology of endometrial curetting revealed chronic granulomatous endometritis with Langhans giant cells. Endometrial TB was diagnosed, and anti-Koch's therapy was started. The patient showed a favourable response, with resumption of normal menstruation after only the first month of treatment.CONCLUSION: This paper emphasizes the importance of considering a wide range of differential diagnosis for gynecologic symptoms in patients with lupus. Tuberculosis should be considered in areas of high endemicity

[Cutaneous tuberculosis presented by chest wall fistula formation]

Tuberculosis is one of the world's most debilitating diseases and it is at the top of six most prevalent and dangerous infectious diseases recognized by World Health Organization. Although one out of every three people in the world is affected by Mycobacterium tuberculosis, cutaneous infection is a relatively uncommon event. Here, we report a rare form of cutaneous tuberculosis presented by multiple fistulas over the anterior chest wall. This is a 50 year old insulin-dependent diabetic man from Afghanistan who was presented with a history of multiple skin lesions over his anterior chest wall for 3 months duration. At first, there was a single non-painful, small popular lesion, which became fistulized and developed purulent discharge, later. The patient was suspected as a case of cutaneous tuberculosis according to his nationality and prolonged history of unresponsiveness to outpatient antimicrobial treatment. This diagnosis approved based on skin biopsy result as it revealed multiple granulomas consisted of giant Langhans cells and the detection of numerous acid fast bacilli in the Ziehl-Neelsen staining of the skin secretions. Six weeks after treatment with anti-tuberculosis drugs, the signs of improvement were appeared and 6 months later there was no active fistula any more. Cutaneous tuberculosis may present itself in uncommon forms such as fistula. It might be seen anywhere including chest wall. Therefore, this impression should be considered in patients with prolonged skin lesions and featured by fistula formation

A rare case of sarcoid-like reaction of lymph nodes associated with squamous cell carcinoma of alveolar mucosa.

Non-necrotizing granulomas are occasionally seen in patients with certain malignant disorders and are termed as "sarcoid-like reaction," which have many similarities with sarcoidosis. Sarcoidosis is a multisystem granulomatous disease of unknown etiology characterized by organ involvement and interference of organ function by granuloma or fibrosis. Sarcoidosis is occasionally found in a variety of malignant diseases with an overall incidence of 4.4% in carcinoma patients. We present here a rare case of moderately differentiated squamous cell carcinoma of alveolar mucosa with regard to mandible associated with sarcoid-like reaction of cervical lymph nodes in a female patient in the absence of clinical evidence of systemic sarcoidosis. The relevant literature including pathogenesis is also discussed.

A Case of Tuberculosis Cutis Orificialis with Perianal Involvement

Tuberculosis cutis orificialis (TCO) is a rare manifestation of cutaneous tuberculosis that is caused by auto-inoculation of mycobacteria in patients with advanced internal tuberculosis. TCO occurs in oral, perianal, or genital mucosa and adjacent skin. The tongue is the most frequently affected site, but the perianal area can also be affected. A 39-year-old male presented with a 4-month history of painful ulcers on the perianal area. The histopathologic findings revealed granulomatous infiltrates composed of epithelioid cells and Langhans-type giant cells in the dermis, and a few acid-fast bacilli noted on Ziehl-Neelsen staining. The polymerase chain reaction (PCR) was positive for Mycobacterium tuberculosis and the chest X-ray showed findings consistent with active pulmonary tuberculosis in both upper lung zones. The skin lesion showed complete resolution 2 months after the start of treatment with antituberculosis agents. We report a case of TCO with perianal involvement in a patient with underlying active pulmonary tuberculosis.

A Case of Scrofuloderma-like BCGitis Near the BCG Vaccination Sit / 대한피부과학회지

A 10-month-old male patient was seen with a nodular lesion on his left upper arm which developed several months after BCG vaccination. Physical examination revealed a bean sized, irregular surfaced, erythematous pustular nodule on the left upper arm at a place different from the vaccination site. Histopathologic examination of the nodule on the left upper arm showed tubercles composed of mononuclear cells, epithelioid cells and langhans type giant cells in the dermis. Caseation necrosis within the typical tubercles was noted. Prominent improvement of the lesion was observed 4 months after oral medication with isoniazid and rifampicin.

Linfadenitis tuberculosa en infección VIH: hallagos histológicos / Tuberculous lymphadenitis in HIV infection: histological findings

Introducción: La coinfección de virus de inmundeficiencia humana (VIH) y tuberculosis altera la presentación histológica de la tuberculosis; esto es particularmente frecuente en la linfadenitis tuberculosa. Objetivos: Identificar las diferencias histológicas más importantes entre linfadenitis tuberculosa asociada a VIH y no asociada a VIH. Diseño: Estudio descriptivo, transversal, comparativo. Lugar: Servicio de Anatomía Patológica, Hospital Dos de Mayo. Participantes: Pacientes con linfadenitis tuberculoso asociada o no a VIH. Intervenciones: Se realizó un estudio en todos los casos diagnosticados como linfadenitis tuberculosa asociados a VIH y no asociados a VIH, durante los años 2005 y primera mitad del 2006. Principales medidas de resultados: Presentación histológica de la tuberculosis. Resultados: Se identificó 22 casos de linfadenitis tuberculosa, de los cuales 27,3 porcentaje presentaba coinfección con VIH. Se identificó necrosis caseosa en 83,3 porcentaje de los casos asociados a VIH y en 100 porcentaje de los no asociados a VIH (p=0,00). La presencia de bacilos ácido alcohol resistentes se observó en 50 porcentaje de los casos asociados a VIH y en ningún caso de los VIH negativos (p=0,01). Adicionalmente, se obtuvo un riesgo atribuible de 52,3 por ciento para la presencia de células de Langhans y el desarrollo de necrosis caseosa. Conclusiones: Se ha encontrado mayor presencia de mycobacterium en los pacientes VIH positivos y mayor presencia de necrosis caseosa en los pacientes VIH negativos.

Introduction: Coinfection of human virus immunodeficiency (VIH) and tuberculosis changes the histological features of tuberculosis; this is particularly frequent in tuberculous lymphadenitis. Objective: To identify main histological diferences between tuberculous lymphadenitis associated to VIH and not associated to VIH. Design: Descriptive, transversal, comparative stufy. Setting: Pathological Anatomy Service, Dos de Mayo Hospital. Participants: Patients with tuberculous lymphadenitis associated or not to VIH. Interventions: Study of histological differences between lymphadenitis tuberculosis associated with HIV and non associated with HIV, during 2005 and first half of 2006. Main outcome measures: Histological presentation of tuberculosis. Results: Twenty-two cases of tuberculous lymphadenitis were identified, 27,3 per cent showed VIH coinfection; caseum necrosis was identified in 83,3 per cent of cases HIV-associated and in 100 per cent of non-HIV associated cases (p=0,00). Koch bacillus was identified in 50 per cent of associated HIV cases and it was not identified in any non related HIV case (p=0,01). We also found an attributable risk of 52,3 per cent for the development of caseum necrosis and presence of Langhans cells. Conclusions: We found higher presence of mycobacterium in HIV positive patients and higher presence of caseum necrosis in HIV negative patients.

Experimental study on the role of cytokines and keratinocytes in the survival mechanism of auto and allogeneic mixed skin grafting / 中华烧伤杂志

<p><b>OBJECTIVE</b>To explore the role of cytokines and keratinocytes in the survival mechanism of mixed auto and allogeneic skin grafting.</p><p><b>METHODS</b>Thirty-six SD rats were employed in the study. The rat model with mixed auto and allogeneic skin grafting and mixed human epithelial and lymphocytic culture (MELC) model were established. The change of IL-10 in the serum and the supernatant of the cultured tissue sample from the local wound was observed after the mixed skin grafting in scalded rats. And the role of epithelium in the induction of immunosuppression in vitro was monitored.</p><p><b>RESULTS</b>The serum IL-10 content in the rats with mixed skin grafting (25.89 +/- 2.82 ng/L) at 7 postoperative day (POD) was evidently higher than that in normal rats (14.20 +/- 2.43 ng/L) (P < 0.05). The IL-10 content in the culture supernatant of rat tissue samples exhibited evident different during 4-14 PODs (P < 0.05-0.01), while which was no difference to that in normal rat on 21st and 28th POD. The inhibiting effects of autologous epithelia and keratinocytes in MELC system were correlated with their dosage. After the adding of autologous keratinocytes to MELC system the cytokines secreted from Th1 could induce the secretion of cytokines from Th2 by IL-10 mediation. This effect could be corrected by the addition of monoclonal antibody of IL-10.</p><p><b>CONCLUSION</b>The keratinocytes inlayed in the autoskin during mixed grafting could increase the local IL-10 level by activating Th2 cells, which might be one of the important reasons of the survival of mixed skin grafting.</p>

Tuberculosis ganglionar. Presentación clínica / Lymphnode tuberculosis. Clinical presentation

Se evalúan dos paciente atendidos en el Servicio de Cabeza y Cuello, del Instituto Nacional de Oncología de La Habana, con diagnóstico de tuberculosis ganglionar. El caso 1, es un paciente masculino de 36 años de edad, con historia de aumento de volumen cervical izquierdo de 2 año de evolución. Al examen físico, se constató una tumoración de 60 por 40 mm de diámetro en la región parotídea izquierda, dos adenopatías de 15 mm de diámetro en el tercio superior de la cadena yugular interna del mismo lado y una adenopatía de 10 mm de diámetro en tercio superior de la cadena espinal accesoria izquierda. El caso 2, es un paciente masculino de 21 años de edad, que desde hace aproximadamente 6 meses viene notando aumento de volumen del cuello, siendo valorado por diferentes facultativos, quienes lo estudiaron, incluyendo la biopsia por aspiración con aguja fina de la región cervical, sin poder definir el diagnóstico, por lo cual es enviado al centro. Al examen físico, se constataron tumoraciones múltiples en ambas regiones cervicales, ubicadas en el tercio superior, medio e inferior de la cadena yugular interna izquierda; y en el tercio medio de la cadena espinal accesoria izquierda, en el tercio medio de la cadena yugular interna derecha, se encontró una adenopatía de 10 mm de diámetro. En ambos casos se realizó tratamiento quirúrgico, que consistió en la exéresis de una de las adenopatías, para estudio histopatológico. El estudio histopatológico informó: tuberculosis ganglionar

Histoplasmosis oral en pacientes VIH seropositivos y seronegativos / Oral Histoplasmosis in seropositive and seronegative patients VIH

La histoplasmosis es una infección granulomatosa producida por el hongo Histoplasma capsulatum que afecta principalmente a los pulmones. En los últimos años se ha reconocido que lesiones de histoplasmosis oral pueden ser la primera manifestación de la infección VIH/SIDA. En este trabajo se presentan los hallazgos clínicos e histopatológicos de histoplasmosis oral detectados en tres pacientes con SIDA y tres pacientes VIH seronegativos. En los seis casos las lesiones orales se presentaron como úlceras dolorosas de varios meses de evolución que afectaban generalmente más de una zona de la cavidad oral. En los casos el diagnóstico de SIDA se estableció a partir del diagnóstico de las lesiones orales de histopalsmosis. Histológicamente, en los pacientes VIH seronegativos, los granulomas presentaban abundante cantidad de células gigantes tipo Langhans, en contraste, las biopsias de los pacientes con SIDA no presentaron este tipo de células. También se discute la detección del Mycobacterium tuberculosis en dos de los seis casos estudiados.

Tuberculoma do cerebelo: relato de dois casos e revisäo da literatura / Cerebelar tuberculoma: report of 2 cases and literature review

Os tuberculoses cerebrais foram relatados por neurocirurgioes famosos do século passado, sendo aceita a realizaçao de ressecçao radical como única possibilidade de cura diante da gravidade da lesao. Na primeira metade deste século, com o surgimento das drogas tuberculostáticas, houve grandes modificaçoes na história natural dessa doença. Existem vários relatos na literatura asiática, pricipalmente na indiana. Em nosso país, sao raras as publicaçoes sobre os tuberculomas da fossa posterior, suas peculiaridades clínicas e cirúrgicas. A finalidade deste trabalho é apresentar dois pacientes portadores de tuberculomas do cerebelo e os aspectos clínicos, tomográficos e cirúrgicos dessa doença.

A Case of Scrofuloderma Occurring After a Percutaneous Lung Biopsy / 대한피부과학회지

Scrofuloderrna results from a direct extension of an underlying tuberculous focus such as the lymph nodes, bone or joint to he overlying skin, and is often associated with pulmonary tuberculosis. A 59-year-old male pai ient presented with an asymptomatic, flesh colored, 0.8 x 1.0 cm sized, solitary nodule on the left, middle back area. He had a CT-guided percutaneous lung biopsy 3 weeks before, for the evaluation of a round focal inhomogenous mass in the left lower lung field on radiologic study. An cxcisional biopsy specimen from the skin lesion showed granulomatous infiltration, composed of pithelioid cells, mononuclear cells and Langhans giant cells in the deep dermis and the suhcutaruous fat layer. Caseation necrosis within the tubercles was marked and numerous acid-fast bacilli were identified on AFB staining. Here we report an unusual case of scrofuloderma occurring after a percutaneous lung biopsy.

A Case of Tuberculous Gumma / 대한피부과학회지

Tuberculous gumma is the result of a hematogenous dissemination of tubercle bacilli from a primary focus during a period of lowered resistance. This unusual disease affects undernourished children of low socioeconomic status or patients who are severely immunodepressed by a disease or therapy. A 68-year-old female patient presented with tender fluctuant erythematous nodules over both upper extremities, shoulder, back and buttock. The biopsy specimen from the fluctuant plaque of right forearm revealed granulomatous infiltration composed of Langhans giant cells, epitheloid cells, plasma cells, lymphocytes and neutrophils in the deep dermis. Numerous acid fast bacilli was identified in AFB staining. Mycobacterium tuberculosis DNA was detected by polymerase chain reaction technique in the specimen from the skin lesion. We here present a very unusual case of tuberculous gumma.

A Case of Tuberculous Gumma / 대한피부과학회지

Tuberculous gumma is the result of a hematogenous dissemination of tubercle bacilli from a primary focus during a period of lowered resistance. This unusual disease affects undernourished children of low socioeconomic status or patients who are severely immunodepressed by a disease or therapy. A 68-year-old female patient presented with tender fluctuant erythematous nodules over both upper extremities, shoulder, back and buttock. The biopsy specimen from the fluctuant plaque of right forearm revealed granulomatous infiltration composed of Langhans giant cells, epitheloid cells, plasma cells, lymphocytes and neutrophils in the deep dermis. Numerous acid fast bacilli was identified in AFB staining. Mycobacterium tuberculosis DNA was detected by polymerase chain reaction technique in the specimen from the skin lesion. We here present a very unusual case of tuberculous gumma.

Sistema monocítico-macrofágico y mycobacterium leprae: su importancia en la interpretación patogénica de las distintas formas clínico-patológicas de la Lepra y de las reacciones leprosas / Monocytic-macrophagic system and mycobacterium leprae

Se realiza una revisión de la patogenia de la Lepra (Hanseniasis), en sus vinculaciones con el "sistema monocítico-macrofágico y se efectúa el estudio histopatológico, histoquimico (lipídico) y con microscopía electrónica de cuatro enfermos de Lepra, dos lepromatosos ( sin y con eritema nudoso) y otros dos dimorfos ("Borderline"). Se concluye que: 1) La Lepra presenta sus manifestaciones clínico-patológicas más ostensibles, en vinculación con lesiones del "sistema monocítico-macrofágico". 2)Existen distintos comportamientos de los macrófagos frente al mycobacterium leprae" a)en personas Mitsuda positivos se puede demostrar el predominio de "macrófagos lisadores del M.leprae" con muerte y desaparición de los bacilos; b)en individuos Mitsuda-negativos predominan los "magrófagos no lisadores del M.leprae",que también producen la muerte de los bacilos, pero con persistencia de la "envoltura lipídica bacilar", que se deposita en las vacuolas de los virchowcitos; y c)en enfermos Mitsuda-negativos, luego de formado el "Granuloma virchowiano", se desarrollan los "macrófagos lisadores de las células de Virchow" que permitirían el recambio celular de los virchowitos. 3)Los "macrófagos lisadores del M.leprae" obtienen información antigénica del "bacilo aislado" que pueden transmitir al sistema de inmunidad celular, cuyos linfocitos T activados generan los "granulomas epitelioides con células de Langhans" (granulomas tuberculoides), de la Lepra tuberculoide. 4) Los "macrófagos no lisadores del M.leprae" no obtendrían información antigénica adecuada y no tendrían capacidad para estimular ningún sistema inmunológico (celular, o humoral), originando los "granulomas virchowianos" de la Lepra lepromatosa 5)Luego del envejecimiento y muerte de los vinchowcitos, los "macrófagos lisadores de las celulas de Virchow" obtendrían información antigénica de los "bacilos degenerados asociados a lípidos y glucoproteinas citoplasmáticas", con capacidad de estimulación del sistema inmunológico humoral cuyos linfocitos B activados generarían anticuerpos complejos: a)contra bacilos ubicados en los virchowcitos en la Reacción leprosa tipo 2 (eritema nudoso leprótico); b) contra la pared de vasos en la reacción leprosa tipo 3(fenómeno de Lucio); y c)contra tejidos del huésped (enfermedad autoagresiva hanseniana-Azulay). 6)En la lepra no existiría "polaridad inmunológica" en los períodos iniciales de la instalación de la enfermedad, pero parecería secundariamente a la formación del "granulo

A Case of Retroperitoneal Tuberculoma / 대한비뇨기과학회지

Tuberculoma means a tumor-like mass resulting from enlargement of a caseous tubercle which microscopically shows infiltration of epithelioid cells, Langhans giant cells and lymphocytes. In a 57-year-old woman suffering from left renal tuberculosis, we incidentally found a large retroperitoneal tuberculoma (site: retrohepatic, above right adrenal gland, below diaphragm and outside Gerota`s fascia, size: 13X11x9cm). Generally, Mycobacteria tuberculosis invade the lung via airway, and subsequently, they can be disseminated to any organ or tissue. They are apt to establish disease in the organ or tissue of high oxygen tension level. We report a case of retroperitoneal tuberculoma with wonder that it could develop in the retroperitoneum of poor blood supply.