| Abstract|| |
Tuberculosis (TB) has long been a common and major public health problem in India. Pulmonary infection is the commonest form of the disease, though the bacteria can cause systemic infection in virtually any organ. The increased global incidence of acquired immune deficiency syndrome (AIDS) has led to a resurgence of TB, with reports of unusual sites being affected by the disease. Due to a very high incidence and prevalence of pulmonary TB in India, different forms of extrapulmonary TB are also relatively high. It can present in many diverse ways at unusual sites, which can be confused with many treatable and nontreatable conditions. Here, we present a case series of primary and secondary forms of TB at unusual sites.
Keywords: Acquired immune deficiency syndrome (AIDS), extrapulmonary unusual sites, pulmonary, tuberculosis (TB)
|How to cite this article:|
Kulkarni DR, Sulegaon RV, Chulki SF. Tuberculosis at unusual sites: A case series from a tertiary care center in North Karnataka, India. Ann Trop Med Public Health 2015;8:67-70
|How to cite this URL:|
Kulkarni DR, Sulegaon RV, Chulki SF. Tuberculosis at unusual sites: A case series from a tertiary care center in North Karnataka, India. Ann Trop Med Public Health [serial online] 2015 [cited 2019 Dec 9];8:67-70. Available from: http://www.atmph.org/text.asp?2015/8/3/67/157634
| Introduction|| |
Tuberculosis (TB) remains a major global health problem and is the second leading cause of death from an infectious disease worldwide, after human immunodeficiency virus (HIV).  TB flourishes wherever there is poverty, crowding, and chronic debilitating illness. Similarly, elderly persons and patients with acquired immune deficiency syndrome (AIDS) are vulnerable. HIV infection, which prevails worldwide, has become the single most important risk factor for the development of TB. 
TB is an infectious disease caused by Mycobacterium tuberculosis (M. tuberculosis) that typically affects the lungs, but virtually any extrapulmonary organ can be involved by isolated TB.  Overall, a relatively small proportion of people infected with M. tuberculosis develop TB. However, the probability of developing TB is much higher among those infected with HIV.  Lymphohematogenous dissemination leads to secondary and miliary forms of TB in other organs,  whereas ocular involvement is due to hypersensitivity reaction. 
Though most the TB cases and deaths occur among men, the burden of the disease among women is also high. TB mortality is unacceptably high, given that most deaths are preventable if people can access health care for diagnosis and the correct treatment is provided. 
| Case Report 1|| |
A 25-year-lady was followed up for antenatal checkup regularly. She was anemic, and her hepatitis B surface antigen (HBsAg) test, HIV test, and Venereal Disease Research Laboratory (VDRL) test were negative. She underwent elective cesarian section and delivered a male baby. Regular postoperative follow-ups for 2 months did not show signs of wound healing, so the tissue from the wound site was sent for histopathological examination. The biopsy report suggested TB granulomatous wound infection. Acid-fast bacilli (AFB) were not detected by Ziehl-Neelsen (ZN) stain. Clinical examination, lab investigations, x-ray of the chest, and ultrasonography (USG) of the abdomen ruled out any evidence of primary TB.
| Case Report 2|| |
A 35-year-old female had a slow-growing, occasionally painful mass in the left breast. Then, she noticed a same-sided axillary swelling. On examination of the left breast, there was no nipple retraction or discharge. An irregular 2 cm × 2 cm nontender, firm, partly mobile lump was palpable in the upper outer quadrant. There was a single 2 cm × 1 cm mobile lymph node in the left axilla. The right breast examination and other systemic examinations were within normal limits. Laboratory investigations revealed only raised erythrocyte sedimentation rate (ESR). X-ray of the chest showed prominent bronchovascular margins. Fine-needle aspiration cytology (FNAC) was performed, which was suspicious of malignancy; a biopsy was advised. Mammography was reported as Breast Imaging-Reporting and Data System (BI-RADS) III lesion. Left-sided simple mastectomy with axillary clearance was done, and the specimens were sent for histopathological examination.
Microscopically, caseating granulomas were seen in both the breast parenchyma [Figure 1] and the lymph node. ZN stain was negative for AFB.
|Figure 1: Shows breast acini and fibrofatty stroma with well-defined granuloma consisting of caseation necrosis surrounded by epithelioid cells, Langhans giant cell, and a rim of lymphocytes [hematoxylin and eosin (H and E) 40x × 10x]|
Click here to view
| Case Report 3|| |
A 45-year-old male presented with persistent redness and itching in the left eye for the last 15 days. He was treated for allergic conjunctivitis. Subsequent follow-up showed persistent redness and the formation of a small, nodular, firm mass on the bulbar conjunctiva. Laboratory investigations showed raised ESR. The excised mass was sent for histopathological examination, which suggested TB of the granulomatous lesion. Clinical examination, lab investigations, x-ray of the chest, and USG of the abdomen ruled out any evidence of primary TB.
| Case Report 4|| |
A 46-year-old male, serving life term in jail, was admitted with complaints of fever, cough with expectoration, weight loss, and abdominal pain. There was no lymphadenopathy. His chest x-ray showed evidence of bilateral pleural effusion and USG of the abdomen revealed evidence of free fluid. Other abdominal organs appeared normal. His sputum for AFB was positive and he was immunocompromised. His general condition deteriorated and he died on the day of admission to the hospital. A medicolegal postmortem was done. The organs were sent for histopathological examination.
We received pieces of the lungs, liver [Figure 2], spleen [Figure 3], kidney [Figure 4], and the whole brain. All the organs, except the brain, showed grayish white nodules of variable sizes and on microscopy, showed nonreactive granulomas with ZN stain showing plenty of AFB [Figure 5].
|Figure 2: Shows multiple small whitish nodules on the external surface of the liver|
Click here to view
|Figure 3: Shows multiple whitish nodules on the external and internal surfaces of the spleen|
Click here to view
|Figure 4: Shows multiple whitish nodules on the external surface of the kidney|
Click here to view
|Figure 5: Section from the spleen showing plenty of AFB (ZN stain; 10x × 100x)|
Click here to view
| Case Report 5|| |
A 27-year-old male presented with sudden shooting pain on the right side of the scrotum. There was no history of fever or trauma. Scrotal examination revealed swelling and redness with tenderness on palpation. Left-sided scrotal examination was within normal limits. Clinical diagnosis revealed testicular torsion. The resected testis was enlarged by 8 cm × 4 cm × 3 cm, it was soft with the cut surface showing whitish soft areas and, at places, the normal-appearing testicular tissue. The microscopy showed areas of caseous necrosis, with caseating granulomas destroying testicular and epididymal tissues [Figure 6]. AFB was negative. So the diagnosis of TB epididymo-orchitis was offered. The x-ray of his chest showed evidence of fibrocaseous TB on the left lung upper lobe.
|Figure 6: Sections from the testis show semeniferous tubules destroyed by multiple caseating granulomas (H and E; 4x × 10x)|
Click here to view
| Discussion|| |
TB has long been a common and a major public health problem in India. Pulmonary infection is the commonest form of the disease, though the bacteria can cause systemic infection in virtually any organ, which is difficult to diagnose. The increased global incidence of AIDS has led to resurgence of TB. ,
Our first case of nonhealing cesarian wound was initially thought to be a bacterial infection. In spite of the use of broad spectrum antibiotics and surgical debridement, the wound did not heal. It was eventually diagnosed to be of TB origin only on histopathological examination. , Surgical site infection by M. tuberculosis is rare; this is the first case of its kind reported from India.
Our second case presented with a slow-growing breast lump, which on mammography was thought to be malignant. But the simple mastectomy specimen showed the presence of caseating granulomas in the breast and lymph node. The diagnosis of TB mastitis is difficult since the disease has multiple patterns of clinical presentation. The most common form is a slow-growing, solitary, painless mass that mammographically mimics carcinoma,  as was seen in our patient and histopathology was diagnostic.
Our third patient presented with a persistent nodule over bulbar conjunctiva that did not respond to local medication. The excised nodule was diagnostic of TB. In current clinical practice, the incidence of TB lesions of the conjunctiva is so rare that the physician's index of suspicion is very low.  Primary TB conjunctivitis occurs as a result of an exogenous infection. Variations in the clinical picture of TB depend on the immunoallergic state of the patient. 
Our fourth case, an immunocompromised host, had disseminated TB. Extrapulmonary TB in the lymph nodes, spleen, and liver has become common in AIDS than previously recognized, along with the involvement of the kidneys, central nervous system (CNS), and gastrointestinal tract (GIT). Lanjewar et al. reported TB (pulmonary + disseminated) as the commonest cause of death in AIDS patients,  as was seen in our patient.
In our fifth case, the patient presented with features of testicular torsion. Orchidectomy specimen showed multiple caseating granulomas with large areas of caseation. TB in the male genital system initially causes epididymitis and secondarily involves the testis. It occurs due to lymphohematogenous spread from the primary focus,  as was seen in our patient.
In a country like India, where TB is endemic, caseous necrosis with epitheloid cell granulomas even in the absence of AFB should alert one in the diagnosis of TB.  Treatment of TB is curative, regardless of the site, if it is diagnosed early and if the organism remains sensitive to all first-line anti-TB drugs.  Four of our patients responded to the standard four-drug antitubercular treatment.
| References|| |
Maitra A, Kumar V. The lung. In: Kumar V, Abbas AK, Fausto N, Mitchell R, editors. Robbins Basic Pathology. 8 th
ed. Pennsylvania: Saunders; 2007. p. 516-22.
Bramante CT, Talbot EA, Rathinam SR, Stevens R, Zegans ME. Diagnosis of ocular tuberculosis: A role for new testing modalities. Int Ophthalmol Clin 2007;47:45-62.
Salam MA, Asafudullah SM, Huda MN, Akhter N, Islam AB. Surgical site infection by mycobacterium tuberculosis following caesarian section. Pak J Med Sci 2011;27:945-7.
Begum HA. Post operative tuberculous wound infection: A report of 6 cases. J Dhaka National Med Coll Hos 2011;17:49-51.
Rosen PP. Specific infections. In: Rosen PP, editor. Rosen′s Breast Pathology. 3 rd
ed. Lippincott Wiliams & Wilkins; 2009. p. 78-9.
Sollom AW. Primary conjunctival tuberculosis. Br J Ophthalmol 1967;51:685-7.
Lanjewar DN, Rao RJ, Kulkarni SB, Hira SK. Hepatic pathology in AIDS: A pathological study from Mumbai, India. HIV Med 2004;5:253-7.
Bhosale AA, Joshi AR, Ashturkar AV, Pathak GS. Primary tuberculosis of breast: A case series. Ann Trop Med Public Health 2012;5:262-4.
Fanning A. Tuberculosis: 6. Extrapulmonary disease. CMAJ 1999;160:1597-603.
Dr. Ritesh V Sulegaon
Swetha, H. No. 19-1-218/A, Mahadev Colony, Shivnagar South, Bidar - 585 401, Karnataka
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]