Treatment of disseminated TB with drug induced hepatitis/case study

Miliary Tuberculosis (TB) usually has an insidious clinical manifestation including fever, weight loss, night sweats, and little in the way of localizing symptoms or signs. There may be concurrent TB meningitis with associated symptoms. A 35-year old male has known case of pulmonary TB and HCV before three years ago. Presented to emergency department with Fever since 3-weeks ago, abdomen pain, headache since 10 days.

Role of HRCT in Evaluation of Lung Parenchymal Changes in Symptomatic HIV-Seropositive Individuals - Original Research Article

Background: The association between spectrum of pulmonary infection and human immunodeficiency virus (HIV) presents an immediate and grave public health and socio-economic threat, particularly in the developing world. Purpose: The purpose of this study is to demonstrate the different patterns of pulmonary abnormalities in HIV patients, to define imaging features of each disease whether infective, non-infective or HIV associated pulmonary malignancy, to differentiate different pulmonary diseases in HIV patients on the basis of pattern of involvement and localization of lesions. Materials and Methods: The cases were selected based on all patients referred to the Department of Radiology, LLRM Medical College, Meerut with proven HIV/acquired immunodeficiency syndrome (AIDS) infection which was clinically suspected of pulmonary infections. HRCT was done. Results: Total 60 cases of HIV/AIDS with suspected pulmonary disease were studied. Out of which 39 were male and 21 were female. Out of which 51.67 % of patients were diagnosed as having pulmonary TB, followed by bacterial infection in 10 % cases and fungal infection like aspergillus in 5%, pneumocystis jiroveci pneumonia in 2% & cryptococcus in 1% patients, ILD in 3% and thromboembolism in 1% patients while 23.3% of our study did not reveal any significant abnormality. Conclusion: Various findings such as pulmonary TB being the most common infection and most common HRCT finding in pulmonary TB were nodular opacity can be obtained from the present study. HRCT is a highly sensitive tool for detecting parenchymal abnormalities and allows better characterization of the lesions, with better reproducibility and less interobserver difference. Keywords: interstitial lung disease, Enzyme-linked immunosorbent assay, Miliary tuberculosis, Pulmonary tuberculosis, pneumocystis jiroveci pneumonia.

Tuberculose miliar como reação adversa grave ao uso do adalimumab na doença de Crohn: um relato de caso / Miliary tuberculosis as a severe adverse reaction to the use of adalimumab in Crohn's disease: a case report

Introdução: A doença de Crohn é uma doença inflamatória intestinal (DII) que inicia um processo inflamatório crônico idiopático intestinal, levando a um quadro clínico variávelcujo principal sintoma é a diarreia crônica. O diagnóstico é feito a partir da combinação de dados clínicos, laboratoriais e exames endoscópicos. Após confirmado o diagnóstico, otratamento pode envolver classes medicamentosas como imunobiológicos. Em relação ao uso de imunobiológicos, como o adalimumabe, deve-se ter cautela pelo seu efeitoimunossupressor, que pode, em indivíduos susceptíveis, ativar focos latentes de infecção, como os de tuberculose (TB). Objetivo: Relatar um caso de tuberculose miliar como reação adversa ao uso de adalimumabe e conscientizar a comunidade médica quanto aos riscos da administração de terapia imunobiológica. Relato de caso: Paciente do sexo masculino, 31 anos, com diagnóstico de Doença de Crohn em acompanhamento ambulatorial com terapia imunobiológica com adalimumab, é admitido na emergência com quadro agudo de sintomas respiratórios e sistêmicos. Durante a investigação hospitalar, apesar de pesquisa do bacilo álcool- -ácido resistente (BAAR) no escarro ter apresentado três amostras negativas, a tomografia computadorizada (TC) de tórax apresentava padrão sugestivo de tuberculose miliar, além de um lavado broncoalveolar com pesquisa positiva para Mycobacterium tuberculosis. Confirmado o diagnóstico de TB miliar, o tratamento foi iniciado com rifampicina, isoniazida, pirazinamida e etambutol. Conclusão: Levando em consideração a alta mortalidade e os impactos negativos da tuberculose miliar, é imprescindível que todos os pacientes com DII em uso de imunobiológicos sejam rastreados para infecção latente, através da radiografia de tórax e teste tuberculínico (PPD). Entretanto, mesmo com o rastreio regular e registro de vacinação prévia, a possibilidade de tuberculose miliar ainda não pode ser descartada em quadros clínicos inespecíficos neste perfil de pacientes.Palavras chave: Adalimumab, Tuberculose, Efeitos colaterais e reações adversas relacionados a medicamentosABSTRACTIntroduction: Crohn’s disease is an inflammatory bowel disease (IBD) that initiates a chronic idiopathic intestinal inflammatory process, leading to a variety of clinical symptoms with chronic diarrhea as the main one. Diagnosis is built from a combination of clinical, laboratory and endoscopic data. The treatment involves immunobiological drugs, such as adalimumab and due to its immunosuppressive effect, it must be administered with caution, because it isable to activate latent foci of infection, such as tuberculosis (TB), in susceptible individuals. Objective: To report a miliary tuberculosis case originated as an adverse reaction to the use of adalimumab and to make the medical community aware of the risks of administering immunobiological therapy. Case report: A 31-year-old male, diagnosed with Crohn’s Disease, undergoing immunobiological treatment with adalimumab, is admitted in the emergency department with acute respiratory and systemic symptoms. During hospitalization, despite the investigation of alcohol-acid resistant bacillus (BAAR) in sputum showing three different samples with negative results, the computerized tomography (CT) of the chest showed a pattern suggestive of miliary tuberculosis, in addition to a bronchoalveolar lavage with a positive test for Mycobacterium tuberculosis. After the diagnosis of miliary TB was confirmed, treatment with rifampicin, isoniazid, pyrazinamide and ethambutol was started. Conclusion: Considering the high mortality and negative impacts of miliary tuberculosis, it is essentialthat all patients with IBD on immunobiological treatment are screened for latent infection through chest radiograph and PPD. However, even with regular screening and registration of previous vaccinations, the possibility of miliary tuberculosis cannot be ruled out in this profile of patients with unspecific clinical conditions.Keywords: Adalimumab, Tuberculosis, Drug-related side effects and adverse reactions

A prospective study of spectrum of pulmonary tuberculosis in HIV sero positive patients

Background: Tuberculosis is the leading cause of death in India contributing to 30% of total global burden. Approximately 0.5 million people dies of TB annually and 5% of the incident TB cases in India have HIV. So it is important to understand the effect of tuberculosis and HIV on each other. HIV epidemics have leads to increased number of tuberculosis cases with various presentations.Methods: It is an observational cross-sectional study of patients with HIV positive and pulmonary TB. Patients were investigated for HIV positivity by HIV coomb's test, if positive confirmed by capillaries and tridot method. Some patients, who are diagnosed as having pulmonary Koch, are sent for HIV testing. CD4 cells count as tested in all patients with HIV positive and severity of pulmonary TB and relation with CD count is studied in all patients.Results: In chest x-ray of patients we have observed that upper zone infiltration was found in 10 (16.67%) patients, mid and lower zone infiltration was found in 19 (31.67%) patients, bilateral infiltration and miliary tuberculosis was found in 22 (36.67%). We have found that 9 (15%) patients were presented with fibro cavitary lesion.Conclusions: From present study we can conclude that tuberculosis and HIV is common between 3rd and 5th decade of life with male predominance. It was more common in daily labourer and BMI was 18.22±3.21 kg/m2. Fever, weight loss and cough was most common presentation and present in more than 90% patients pallor and lymphadenopathy was common finding and present in more than 50% patients.

Epidemiological analysis of factors influencing the course of multidrug-resistant tuberculosis in HIV-infected patients with concomitant viral hepatitis

The epidemiological significance of combined forms of especially dangerous infections has not been studied enough, unlike mono-infections. Currently, there is a tendency towards an increase in the incidence of multidrug-resistant tuberculosis. The formation of severe forms of the disease is caused by other widespread infections, such as chronic viral hepatitis and HIV. Polymorbid conditions distort the clinical manifestations of tuberculosis, reduce the effectiveness of anti-tuberculosis therapy and worsen the prognosis of the disease. Risk factors among patients in this category need analysis to carefully monitor patients and ensure infection control. Objective is to analyze the factors affecting the course of multidrug-resistant tuberculosis in HIV-infected patients with concomitant viral hepatitis. Materials and methods. Cases of the combined pathology of multiresistant tuberculosis, HIV infection and viral hepatitis with a dominant diagnosis of tuberculosis are analyzed. Results and discussion. The influence of the immunological status on the course of combined pathology was revealed. Since all the patients under study had clinical stage 4 of HIV infection, tuberculosis developed as an opportunistic infection. Severe immunosuppression (CD4 < 200 cells/ml) contributed to the progression of the generalized tuberculosis process. Long-term immunodeficiency was an unfavorable factor; in the overwhelming majority of cases, antiretroviral therapy was prescribed only after tuberculosis was detected. The dependence of the clinical form of tuberculosis on the level of CD4-lymphocytes was noted: isolated lesion of the chest organs prevailed in patients with a level of CD4-lymphocytes more than 200 cells/ml, generalization of TB process — with CD4 less than 200 cells/ml. Patients with miliary tuberculosis had a higher mortality rate compared to patients with other clinical forms, regardless of antiretroviral therapy. It was revealed that socially disoriented young people with viral hepatitis C prevailed in the structure of patients, the prevalence of which was due to the influence of aggravating factors, such as alcohol and drug abuse, and stay in prisons. Against the background of combined treatment, there was no significant effect of viral hepatitis on the course of polymorbid conditions and the effectiveness of the therapy.

Tuberculosis infection under anti-TNF alpha treatment

Background: Anti-tumor necrosis factor-α (TNF-α) is a life-changing treatment leading to quality-of-life improvement. Nonetheless, this treatment is associated with a high risk of infection, especially tuberculosis. Objective: Our study aimed to determine the frequency of active tuberculosis in our patients with chronic rheumatic disease and treated with TNF-α. Methods: We conducted a retrospective study including patients with Rheumatoid Arthritis and Spondylarthritis diagnosed according to ACR/EULAR 2009 criteria and ASAS 2010, respectively, and treated with biological agents for at least 6 months. We collected data regarding tuberculosis screening and the occurrence of active tuberculosis during follow-up. Results: 82 patients were included (37 men and 45 women). The mean age was 42 ± 3.4 years. At inclusion, no patient had a medical history of tuberculosis. The diagnosis of latent tuberculosis infection was established in 17 patients (20.7%). Prophylactic treatment was prescribed in all these cases for three months. Two cases (2.4%) of active tuberculosis occurred under biologic (infliximab). It was two severe forms of tuberculosis. The first case had miliary tuberculosis associated with hepatic and peritoneal involvement. The second one had pleural tuberculosis. These two patients received anti-tuberculosis therapy, and the biological treatment was interrupted. Given the high disease activity, the anti-TNF-α was restarted after 3 and 4 months. There was no recurrence of tuberculosis after 7 years of follow-up. Conclusion: The use of TNF-α blockers is associated with a risk of disseminated forms of tuberculosis. Tuberculosis screening, which is recommended before the biological onset, is also necessary under this treatment. Restarting the anti-TNF-α after appropriate treatment of tuberculosis seemed to be safe.