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Cryptococcosis caused by Cryptococcus neoformans has a wide range of clinical presentations, varying from asymptomatic colonization of the respiratory airways to the dissemination of infection into different parts of body. It is more common among immunosupressed patients such as human immunodeficiency virus (HIV) positive ones. In this report we present a case with C. neoformans meningitis and miliary pulmonary infiltrates suggesting pulmonary tuberculosis without HIV infection. A-70-years-old male was admitted to the hospital with mental confusion, 3-weeks history of headache, weight loss, dry cough and fatigue. Physical examination was normal except neck stiffness. Cerebrospinal fluid (CSF) white cell count was 120/mm3 (80% polimorphonuclear cells). Gram staining of CSF revealed poorly stained gram-positive yeast cells. Empirical therapy with lipozomal amphotericin B, ceftriaxone and ampicillin combination was started. When C. neoformans growth was detected on CSF culture, ceftriaxone and ampicillin were discontinued. Patient became conscious at 24th hour of the treatment. Peripheric blood flow-cytometric analysis revealed a significant decrease in absolute CD4+ T lymphocytes, and in CD8+28+ T lymphocytes in addition a significant increase in natural killer cell ratio. Blood immunoglobulin and complement levels were found normal. Cranial magnetic resonance imaging and computerized tomogralphy (CT) of the abdomen were normal, however, chest CT revealed multiple parenchymal millimetric nodular infiltrations on both sides and minimal fibrotic alterations. Acid-fast staining of CSF, tuberculosis culture, tuberculosis PCR results and repeated HIV serology were found negative. Despite the lack of microbiological confirmation, empirical antituberculosis treatment was also started with the suspicion of miliary tuberculosis as the patient had a symptom of long-term dry cough, miliary infiltrations on chest CT, anergic tuberculin skin test and a history of pulmonary tuberculosis in childhood. After two weeks, amphotericin B was changed to oral fluconazole which was continued for an additional eight weeks. Antituberculosis therapy was given for nine months. Control chest CT taken after four months of antituberculosis therapy revealed improvement of the lesions. This presentation emphasizes the fact that cryptococcal infections may develop in HIV negative patients, even together with tuberculosis in certain cases and radiological findings of the two infections may be confusing when both of them invade the lungs.
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PMID:[Cryptococcus neoformans meningitis in a HIV negative miliary tuberculosis-suspected patient]. 1882 99

There are many issues concerning tuberculosis during pregnancy. In our case report we discuss a 24-year-old Portuguese woman with unclear weight loss and non-specific symptoms such as fatigue and nausea during pregnancy. After diagnostic work up a pulmonary tuberculosis was diagnosed close to delivery. The treatment and outcome of tuberculosis during pregnancy and the question of breastfeeding after delivery are discussed.
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PMID:[Tuberculosis, the old fellow]. 1904 29

The aim of the present study is to define the characteristics of the clinical and histopathological features of chronic necrotizing pulmonary aspergillosis (CNPA) cases with severe hemoptysis. We conducted a histological study of three patients clinically diagnosed as having CNPA who had hemoptysis for 5 years. A tuberculosis sequelae was found as the underlying disorder in all three cases. All patients had fever, general fatigue, and hemoptysis, and their chest computed tomographic images revealed fungus balls, cavity wall thickening, consolidation surrounding the cavity, and satellite foci. All had been treated with anti-fungal drugs and corticosteroids. However, all patients died from respiratory failure due to massive hemoptysis. Histopathological examination revealed that the cavity wall consisted of three layers comprised of necrotic, granulation, and fibrous tissue layers. Aspergilli were found in both the fungus ball and necrotic tissue comprising the inner layer of the cavity. In addition, most of the vessels were incompletely occluded with thrombosis and were necrotic, as well as showing local invasion of Aspergilli. Surgical intervention should be considered as a prior procedure for CNPA patients, because vessels at the cavity wall, whether occluded completely or incompletely, are usually necrotic and/or show local invasion of Aspergilli.
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PMID:Pathophysiological study of chronic necrotizing pulmonary aspergillosis. 1905 Mar 52

A 57-year-old Somalian woman presented to the podiatry clinic in 2001, 9 years after immigrating to the United States, with a complaint of right foot pain overlying the Lisfranc joint after a twisting injury. Radiographs and CT scans showed no signs of fracture. One year later, the patient presented with painful, swollen soft tissues mass overlying the previous injury area. MRI revealed heterogeneous masses with underlying bony erosions. Soft tissue biopsy revealed a granulomatous lesion, suspect for Mycobacterium. A subsequent bone biopsy produced an acid-fast bacillus by DNA-RNA probe consistent with Mycobacterium species. The patient had a positive Mantoux test, but a negative chest X-ray, displaying no constitutive symptoms of fatigue or weight loss associated with most cases of tuberculosis. She was treated with anti-tuberculin medications for 9 months and conservative management of the bony lesions with a complete resolution of symptoms.
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PMID:Tuberculous osteomyelitis of the midfoot in the absence of a pulmonary lesion: a case report. 1908 47

Gastrocolic fistula secondary to primary gastric lymphoma is a very rare entity. On admission to outpatient clinics, it may be difficult to diagnose gastrocolic fistula, as its clinical symptoms are nonspecific. A 65-year-old man was presented with weight loss, nausea, vomiting, diarrhea, fatigue, foul-smelling eructation, and upper abdominal pain for the last 2 months. He had also been started antituberculosis drugs 2 months ago because of acid-resistant bacillus (ARB) positivity in sputum in a state hospital. Therefore, symptoms such as nausea and vomiting were attributed to the drugs used for tuberculosis. However, nausea and vomiting continued despite stopping the drugs. Upper endoscopical examination revealed a large crater on the posterior wall of gastric corpus. A large fistulous opening to the transverse colon was also identified during endoscopic examination. An upper gastrointestinal x-ray series demonstrated a fistula between the stomach and the transverse colon. Histopathological examination of the gastric biopsy was determined to be primary gastric diffuse large B-cell-type non-Hodgkin's lymphoma. In conclusion, persistent vomiting may suggest a probable gastrocolic fistula despite nonspecific clinical findings. In the literature, the present case represents the first report of a gastrocolic fistula due to gastric lymphoma in a patient with tuberculosis at its initial presentation.
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PMID:Gastrocolic fistula secondary to gastric diffuse large B-cell lymphoma in a patient with pulmonary tuberculosis. 1924 77

To improve understanding about the epidemiology and clinical features of HIV-associated tuberculosis (TB) infection we conducted a prospective, multi-center observational study of HIV-infected TB patients in Thailand. We enrolled HIV-infected patients diagnosed with TB at public health facilities from three provinces and the national infectious diseases referral hospital in Thailand. Patients underwent standardized interviews, evaluations, and laboratory testing at the beginning of TB treatment. We analyzed demographic and clinical characteristics of patients and stratified our findings by level of immune-suppression and whether antiretroviral therapy (ART) was used before TB diagnosis. Of 769 patients analyzed, pulmonary TB was diagnosed in 461 (60%). The median CD4+ T-lymphocyte (CD4) count was 63 cells/microl [interquartile range (IQR), 23-163.5] and the median HIV RNA viral load was 308,000 copies/ml (IQR, 51,900-759,000) at the time of TB diagnosis. Methamphetamine use was reported by 304 patients (40%), marijuana by 267 patients (35%), and injection drug use by 199 patients (26%). Three hundred three patients (40%) reported having been previously incarcerated. Among sexually active patients, 142 (42%) reported never using condoms at all. Patients with CD4 counts <200 cells/microl were significantly more likely than patients with CD4 counts > or =200 cells/microl to have extra-pulmonary TB, fever, fatigue, muscle weakness, no hemoptysis, tachycardia, low body mass index, jaundice, or no pleural effusion. Of the 94 patients that received ART before TB diagnosis, the median time from ART initiation to TB diagnosis was 105 days (IQR, 31-468). HIV-infected patients who developed TB after ART initiation were more likely than other HIV-infected TB patients to have extra-pulmonary TB, a normal chest radiograph, low HIV RNA viral load, or a history of previous TB treatment.
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PMID:Characteristics of HIV-infected tuberculosis patients in Thailand. 1932 40

A young Marshallese woman presented with the insidious development of fever, cough, fatigue, profound weakness, massive weight loss, cachexia, alopecia, amenorrhea, and periumbilical hyperpigmentation. Limited laboratory studies revealed anemia, leukocytosis, and hyponatremia. Imaging studies, as well as digital photographs, transmitted over the Internet, using the secure Pacific Island Health Care Project (PIHCP), store-and-forward telemedicine system, suggested the diagnosis of disseminated tuberculosis, and antimycobacterial antibiotics were begun. Sputum cultures eventually grew Mycobacterium tuberculosis. Based on the constellation of clinical signs and symptoms, the transmitted images, and limited laboratory data, adrenal tuberculosis (Addison's disease) with adrenal insufficiency was diagnosed and corticosteroids were initiated. The patient responded dramatically This case underscores the utility of telemedicine in the diagnosis and treatment of patients with unusual conditions, rarely seen today in the United States, from remote sites in the Developing World.
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PMID:Adrenal insufficiency secondary to tuberculosis: the value of telemedicine in the remote diagnosis of Addison's disease in Ebeye, Republic of the Marshall Islands. 1936 22

A 53-year-old diabetic woman with the diagnosis of myelodysplastic syndrome was admitted to our hospital with symptoms of anorexia, malaise, fatigue, night sweats, and weight loss. The radiological evaluation revealed waxing and waning pulmonary nodules. A diagnosis of pulmonary tuberculosis was reached by pathologic examination of a wedge biopsy. We did not find a similar case in the literature. Clinicians should keep tuberculosis in mind as a possible etiology of waxing and waning pulmonary nodules.
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PMID:Waxing and waning pulmonary nodules and myelodysplastic syndrome. 1948 12

An 80-year-old woman suffered from fever and loss of appetite. Her chest X-ray showed mediastinal tumors and diffuse granular shadows in the bilateral lung fields. Elevations of sIL-2r and M-protein were present. HRCT showed numerous small granules in both lungs and mediastinal lymph node enlargement. Tuberculosis DNA was detected by PCR in her sputum. Later, Mycobacterium tuberculosis was cultured from her sputum. After she started anti-tuberculosis therapy, her general fatigue and elevation of sIL-2r improved gradually. Her chest X-ray revealed a decrease in the size of mediastinal lymph nodes and small granules.
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PMID:[Case of pulmonary tuberculosis with miliary granules, mediastinal lymph node enlargement and elevation of soluble interleukin-2 receptor]. 1958 53

A 77-year-old man was admitted to our hospital complaining of general fatigue. Serum sodium was 116 mEq/l and serum antidiuretic hormone (ADH) was elevated. Radiologic examination revealed nodules in the brain as well as in both adrenal glands. Based on the findings of fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET), we had considered that the cause of the hyponatremia was syndrome of inappropriate secretion of antidiuretic hormone (SIADH) due to active extrapulmonary tuberculosis. Against our expectations, the patient's condition got worse just after he began antituberculous therapy; we finally diagnosed Addison's disease by additional hormonal tests. His condition recovered immediately with the administration of high-dose hydrocortisone, and the tuberculous lesions became smaller with antituberculous medications. Although tuberculous Addison's disease has been decreasing markedly in recent years, we have to consider the possibility of adrenal insufficiency when hyponatremia is observed in patients with active tuberculosis or those having a past history of tuberculosis.
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PMID:Addison's disease due to tuberculosis that required differentiation from SIADH. 1968 43


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