Context: Disseminated tuberculosis (DTB) is quite an uncommon entity. It is usually undetected as it can present in an atypically bland manner and go unsuspected. Aims: Our study aimed to determine the frequency of DTB in autopsies in our setting. Subjects and Methods: A retrospective study was done for a period of 6 years, i.e., from January 2009 to December 2015, wherein all the cases of DTB encountered in autopsy specimens were included in the study. Results: During the study period, we encountered 19 cases of DTB. In all 19 cases, the organs examined were lung (19/19 cases), liver (18/19 cases), kidney (12/19 cases), spleen (18/19 cases), pancreas (3/19 cases), heart (8/19 cases), and brain (5/19 cases). Caseating epithelioid granulomas were seen in all cases of lungs (19/19 cases), 16 cases in liver, 12 cases in kidney, and 17 cases in spleen, 2 cases of heart, and 2 cases of pancreas. DTB accounted for 1.3% (n = 19) of all autopsy cases, with the mean age being 41.35 years. The male: female ratio was 18:1. Eleven out of 19 cases were unknown bodies. Acid-fast bacilli stain showed positivity in 10 cases. Conclusions: Despite recent technological advances in the diagnosis of tuberculosis, autopsy still remains an important complementary tool for identification of DTB.
Keywords: Acid-fast bacilli stain, autopsy, disseminated tuberculosis
|How to cite this article:
Sahu KK, Suresh PK, Khadilkar UN, Pai RR, Lobo FD, Kini H, Kini JR. Uncommon sites affected by a common disease: An autopsy study. Ann Trop Med Public Health 2018;11:130-2
|How to cite this URL:
Sahu KK, Suresh PK, Khadilkar UN, Pai RR, Lobo FD, Kini H, Kini JR. Uncommon sites affected by a common disease: An autopsy study. Ann Trop Med Public Health [serial online] 2018 [cited 2020 Aug 5];11:130-2. Available from: https://www.atmph.org/text.asp?2018/11/4/130/272554
Although autopsy rates are falling worldwide, it still remains a valuable method for diagnosing and understanding pathological processes as well as increases knowledge in the subject. Tuberculosis (TB) is one of the oldest diseases known to effect humanity as proven by finding of TB spine in Egyptian mummies. Worldwide, about 9.2 million cases of TB were reported in 2006 in which 1.9 million were new cases. Disseminated tuberculosis (DTB) is still an uncommon entity. It is usually undetected because of the fact that it can present in an atypically bland manner and go unsuspected or it is just under reported. DTB refers to an active hematogenous spread of Mycobacterium tuberculosis in two or more organs/system in the body leading to a generalized systemic illness.,,,
TB of the pancreas is extremely rare and may occur as a part of DTB. Cardiac involvement is usually seen in miliary TB secondary to lesions elsewhere in the body. The incidence of cardiovascular involvement in TB is 1%–2% of which mainly affects the pericardium but very rarely myocardium and valves are involved. The involvement of spleen is also rare in TB in immunocompetent patients. It is usually seen in association with DTB and comprises about 80% of autopsied patients with DTB.,,, In the present study, 1300 autopsies were studied retrospectively without knowing their immune status to find the frequency of DTB and involvement of rare sites by DTB which were not expected during the life commonly.
|Subjects and Methods|
We retrospectively analyzed all the autopsy cases sent to the pathology department over a period of 6 years, i.e., from January 2009 to December 2015. Most of the cases (11/19 cases) were unknown/unclaimed bodies. The immune status of the cases could be not be assessed. The gross and histopathological findings with acid-fast bacilli (AFB) stain were recorded. The cases of DTB were identified following these criteria: (1) demonstration of AFB in more than one source and (2) caseating granuloma with or without AFB in histologic sections on one and more organs.
During the study period, a total of 1300 autopsy specimens were reviewed, out of which 19 cases were DTB. The mean age of presentation of DTB was 41.35 years and median being 32 years. Most of the cases were seen in males (M: F: 18:1). The samples processed were pieces of both lungs (19/19 cases), both kidneys (12/19 cases), liver (18/19 cases), spleen (18/19 cases), entire heart (12/19 cases), pancreas (3/19 cases), and brain (5/19 cases). The gross findings in six cases showed millet-like nodules in different organs and were diagnosed as miliary TB. In one of the cases, lung showed caseous material in the apex of the lung.
Microscopically all 19 cases showed caseating epithelioid granulomas in lungs, 16 cases in liver, 12 cases in kidney and 17 cases in spleen, 2 cases of heart, and 2 cases of pancreas. AFB stain was positive in 10/19 cases. Coming to the rare sites such as heart, the caseating granulomas were observed in the myocardium of the right atrium, right ventricle, left atrium, and left ventricle. In one of the cases, aorta and pericardium showed caseating granulomas, while in the other case, only pericardium adjacent to myocardium showed granulomas [Figure 1]. In both cases of the pancreas, the caseating granulomas were evident in the lobules with AFB stain positivity. A large vessel in the pancreas showed caseating granulomas with AFB stain positivity [Figure 2].
|Figure 1: (a) Tuberculosis heart. Gross picture of the heart showing white patch on the pericardium and endocardium. (b and c) Caseous necrosis with epithelioid granulomas seen in the myocardium and pericardium (H and E, ×100) inset shows acid-fast bacilli positivity. (d) Tuberculosis aorta. Epithelioid granulomas involving the wall of the aorta (H and E, ×40)
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|Figure 2: (a) Tuberculosis pancreas. Epithelioid granulomas between the pancreatic acini (H and E, ×100) (b) tuberculosis pancreas. Caseating epithelioid granulomas lining the large blood vessel adjacent to pancreas (H and E, ×100) Inset high power showing epithelioid cells. (c) Acid-fast bacilli stain highlighting the bacilli in the pancreas. (d) Tuberculosis spleen. Caseating epithelioid granulomas in the spleen (H and E, ×40)
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The mortality due to TB has decreased tremendously in developed countries but found to exist still in the higher rates in developing countries, especially among the low-economic status population. We found 1.3% (n = 19) of DTB at autopsy in our study. A study by Alexander et al. found 8% of DTB in HIV/AIDS-positive autopsy cases. A study by Garcia-Jardon et al. found 19% of DTB in their study in autopsy of HIV/AIDS patients. Garg et al. found only one case of DTB out of 115 autopsy cases. The involvement of pancreas is extremely rare in autopsies of patients who died of DTB. The reported incidence is between 2% and 4.7% and so clinical diagnosis in exceptional. In the present study, the incidence of involvement of pancreas by DTB was 0.3%. Mostly, the involvement is secondary by hematogenous spread from small reactivated, undetectable primary and secondary focus.
Similarly, cardiovascular involvement in TB occurs in 1%–2% of cases which mostly affects the pericardium but very rarely myocardium and valves are involved. In our study, two cases showed heart involvement. In one of the cases, not only the pericardium but also the myocardium and aorta showed caseating granulomas.
The involvement of spleen in immunocompetent patients is rarer than in immunocompromised one. In the present study, most of the cases (17/19 cases) showed caseating granulomas and the immune status of the patients was unknown since many of these cases were unknown bodies.
The importance of diagnosis of tuberculosis lies in the fact that it is a curable disease but fatal if undiagnosed and causes unnecessary deaths. DTB due to its variable manifestations as well as ability to involve every organ system makes it essential that the possibility of DTB be always considered in the differentials of inconclusive data. The risk of unrecognized tuberculosis not only extends to public but also to the health professional working with samples of TB as well as treating the TB patients. Autopsies are still indispensable for providing quality control and disease statistics. The present study is unique as there are hardly any literatures on DTB on autopsy studies. This is a preliminary study which can be further extended in future.
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Conflicts of interest
There are no conflicts of interest.
Garcia-Jardon M, Bhat VG, Blanco-Blanco E, Stepian A. Postmortem findings in HIV/AIDS patients in a tertiary care hospital in rural South Africa. Trop Doct 2010;40:81-4.
Andres SC, Tan-Alora A. A case series on disseminated tuberculosis. Phil J Microb Infect Dis 2001;30:29-35.
Garg M, Aggard AD, Singh S, Kotaria SP. Tuberculous lesions at autopsy. J Indian Acad Forensic Med 2011;3:116-9.
Aggarwal P, Wali JP, Jain R, Berry M. Tubercular abscess of the pancreas. Am J Gastroenterol 1989;84:985-6.
Machado MA, Herman P, Montagnini AL, Jukemura J, Leite KR, Furlan J, et al. Pancreatic tuberculosis: A rare condition mimicking pancreatic cystadenoma. Pancreas 1998;17:315-6.
Kanchan T, Nagesh KR, Lobo FD, Menezes RG. Tubercular granuloma in the myocardium: An autopsy report. Singapore Med J 2010;51:e15-7.
Rajesh S, Sricharan KN, Jayaprakash K, Monterio FN. Cardiac involvement in patients with pulmonary tuberculosis. J Clin Diagn Res 2011;6:440-2.
De Becker AI, Vanhoenacker FM, Mortele KJ, Vanschoubroeck IJ, De Keulenaer BL, Parizel PM. MRI features of spleen: Lesions in patients with disseminated tuberculosis. AJR 2006;186:1097-102.
Soeiro AM, Hovnanian AL, Pavara ER, Canzian M, Capelozzi VL. Post mortem finding histological pulmonary analysis in patients with HIV/AIDS. Clinics 2008;63:497-502.
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]