Dyspnoea, weight loss, fever, and headache caused by extrapulmonary tuberculosis in a prison inmate
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Case Report 1400 www.thelancet.com Vol 384 October 11, 2014 Dyspnoea, weight loss, fever, and headache caused by extrapulmonary tuberculosis in a prison inmate Musharaf Tarajia, Fabio Jaramillo, Amaranta Pernett, Nelson Santamaría, Amador Goodridge A 55-year-old Panamanian man was referred from a peni- tentiary clinic to Hospital Santo Tomás in March, 2014. He presented with a 10-day history of breathing difficulty, chest pain, fever, headache, and had also lost more than 10 kg in weight over the previous 2 months. His medical and family history was unremarkable; however, he reported that he had been in contact with inmates who had had chronic cough for 2 years. The patient’s vital signs were normal, apart from a respiratory rate of 28 breaths per min. Physical examination showed wasting and diminished breath sounds at the basal area of the right lung and pleural friction rub. Neurological examination showed normal mental status and sensory findings, normal reflexes, and negative meningeal signs. Routine laboratory tests showed a leucocyte count of 12 100 per μL (normal range 4000–10 000) with a high neutrophil count and microcytic anaemia. Serum chemistry tests showed mild hyponatraemia. An HIV test was negative. Chest radiography showed a right pleural effusion. Contrasted CT of the thorax showed substantial pleural thickening in the right lower lobe (figure). Thoracocentesis yielded an exudate with 80% lymphocyte predominance, 850 mg/L glucose (serum glucose 1040 mg/L), and a pH of 7·55 (normal 7·64). Acid-fast bacilli smear, Gram stain, Xpert MTB/Rif test, and Lowenstein-Jensen media culture for Mycobacterium spp in pleural fluid were all negative. Pleural fluid adenosine deaminase activity was 112 U/L. Pleural biopsy was not done. We started the patient on cefotaxime. On the fifth day in hospital, he showed signs of acute disorientation and neck stiffness, but no papilloedema. CT of the brain showed supratentorial ventricular dilation (figure). Cerebrospinal fluid from a lumbar puncture showed 90% predominance of neutrophils, with glucose cerebrospinal fluid:serum ratio less than 0·2 (normal glucose cerebrospinal fluid:serum ratio 0·6). Acid-fast bacilli cerebrospinal fluid smear test was positive. Cerebrospinal fluid latex tests for Streptococcus pneumoniae, Neisseria meningitides, Escherichia coli, and Haemophilus influenzae were negative. An Xpert MTB/Rif test suggested the presence of Mycobacterium tuberculosis susceptible to rifampicin. We diagnosed tuberculous meningitis and pleural tuberculosis, and started rifampicin, isoniazid, pyrazinamide, ethambutol, and dexamethasone. He showed signs of clinical improvement and recovered full consciousness 2 days after treatment initiation (7 days after initial admission). He was discharged 21 days after admission under directly observed treatment at the penitentiary clinic. Additionally, pyridoxine and cortico- steroids were prescribed. Before discharge, the patient had difficulty walking and so was kept under surveillance at the penitentiary clinic. Pleural tuberculosis is difficult to diagnose, mainly because of the paucibacillary nature of this disease. It is the most common cause of extrapulmonary tuberculosis worldwide. 1 The use of several laboratory tests can increase the overall sensitivity and specificity of diagnosis. Although pleural tuberculosis rarely causes sequelae, the com- bination with tuberculous meningitis can result in a very poor outcome, but tuberculous meningitis is often missed at first. It should be diagnosed quickly once neurological symptoms and signs present. Xpert MTB/Rif has been endorsed by WHO for identification of tuberculous meningitis from cerebrospinal fluid samples despite the low sensitivity in this sample type. 2 Tuberculosis in prisons is a major challenge, especially in low-income and middle-income countries. Over- crowding, poor nutrition, stress, and poor aeration encourage its spread. 3 Health-care workers in prisons should periodically screen inmates for symptoms of tuberculosis. Inmates should also be properly isolated as soon as a case of tuberculosis is confirmed and contact investigation should be done. Contributors MT did diagnostic tests. FJ, AP, and NS managed the patient. All authors contributed to the report. Acknowledgments We thank Edmundo López, Erika Santiago, and colleagues in infectious disease and radiology. References 1 Porcel JM, Light RW. Diagnostic approach to pleural effusion in adults. Am Fam Physician 2006; 73: 1211–20. 2 Automated real-time nucleic acid amplification technology for rapid and simultaneous detection of tuberculosis and rifampicin resistance: Xpert MTB/RIF assay for the diagnosis of pulmonary and extrapulmonary TB in adults and children. World Health Organization. Geneva, Switzerland; 2014. 3 O’Grady J, Maeurer M, Atun R, et al. Tuberculosis in prisons: anatomy of global neglect. Eur Respir J 2011; 38: 752–54. Lancet 2014; 384: 1400 Tuberculosis Biomarker Research Unit, Centro de Biología Molecular y Celular de Enfermedades, Instituto de Investigaciones Científicas y Servicios de Alta Tecnología, Ciudad del Saber, Panama (M Tarajia MD, A Goodridge PhD); Department of Biotechnology, Acharya Nagarjuna University, Guntur, India (M Tarajia); and Division of Pulmonary Medicine, Hospital Santo Tomás, Panama City, Panama (F Jaramillo MD, A Pernett MD, N Santamaría MD) Correspondence to: Musharaf Tarajia, Tuberculosis Biomarker Research Unit, Centro de Biología Molecular y Celular de Enfermedades, Instituto de Investigaciones Científicas y Servicios de Alta Tecnología, PO Box 0843-01103, Ciudad del Saber, Panama [email protected] Figure: CT scans (A) Contrasted CT of the thorax, showing substantial right pleural thickening and a right pleural effusion. (B) Brain CT with supratentorial ventricular dilation. A B
Transcript of Dyspnoea, weight loss, fever, and headache caused by extrapulmonary tuberculosis in a prison inmate
Case Report
1400 www.thelancet.com Vol 384 October 11, 2014
Dyspnoea, weight loss, fever, an d headache caused by extrapulmonary tuberculosis in a prison inmateMusharaf Tarajia, Fabio Jaramillo, Amaranta Pernett, Nelson Santamaría, Amador Goodridge
A 55-year-old Panamanian man was referred from a peni-tentiary clinic to Hospital Santo Tomás in March, 2014. He presented with a 10-day history of breathing diffi culty, chest pain, fever, headache, and had also lost more than 10 kg in weight over the previous 2 months. His medical and family history was unremarkable; however, he reported that he had been in contact with inmates who had had chronic cough for 2 years. The patient’s vital signs were normal, apart from a respiratory rate of 28 breaths per min. Physical examination showed wasting and diminished breath sounds at the basal area of the right lung and pleural friction rub. Neurological examination showed normal mental status and sensory fi ndings, normal refl exes, and negative meningeal signs.
Routine laboratory tests showed a leucocyte count of 12 100 per μL (normal range 4000–10 000) with a high neutrophil count and microcytic anaemia. Serum chemistry tests showed mild hyponatraemia. An HIV test was negative. Chest radiography showed a right pleural eff usion. Contrasted CT of the thorax showed substantial pleural thickening in the right lower lobe (fi gure). Thoracocentesis yielded an exudate with 80% lymphocyte predominance, 850 mg/L glucose (serum glucose 1040 mg/L), and a pH of 7·55 (normal 7·64). Acid-fast bacilli smear, Gram stain, Xpert MTB/Rif test, and Lowenstein-Jensen media culture for Mycobacterium spp in pleural fl uid were all negative. Pleural fl uid adenosine deaminase activity was 112 U/L. Pleural biopsy was not done. We started the patient on cefotaxime.
On the fi fth day in hospital, he showed signs of acute disorientation and neck stiff ness, but no papilloedema. CT of the brain showed supratentorial ventricular dilation (fi gure). Cerebrospinal fl uid from a lumbar puncture showed 90% predominance of neutrophils, with glucose cerebrospinal fl uid:serum ratio less than 0·2 (normal glucose cerebrospinal fl uid:serum ratio 0·6). Acid-fast
bacilli cerebrospinal fl uid smear test was positive. Cerebrospinal fl uid latex tests for Streptococcus pneumoniae, Neisseria meningitides, Escherichia coli, and Haemophilus infl uenzae were negative. An Xpert MTB/Rif test suggested the presence of Mycobacterium tuberculosis susceptible to rifampicin. We diagnosed tuberculous meningitis and pleural tuberculosis, and started rifampicin, isoniazid, pyrazinamide, ethambutol, and dexamethasone.
He showed signs of clinical improvement and recovered full consciousness 2 days after treatment initiation (7 days after initial admission). He was discharged 21 days after admission under directly observed treatment at the penitentiary clinic. Additionally, pyridoxine and cortico-steroids were prescribed. Before discharge, the patient had diffi culty walking and so was kept under surveillance at the penitentiary clinic.
Pleural tuberculosis is diffi cult to diagnose, mainly because of the paucibacillary nature of this disease. It is the most common cause of extrapulmonary tuberculosis worldwide.1 The use of several laboratory tests can increase the overall sensitivity and specifi city of diagnosis. Although pleural tuberculosis rarely causes sequelae, the com-bination with tuberculous meningitis can result in a very poor outcome, but tuberculous meningitis is often missed at fi rst. It should be diagnosed quickly once neurological symptoms and signs present. Xpert MTB/Rif has been endorsed by WHO for identifi cation of tuber culous meningitis from cerebrospinal fl uid samples despite the low sensitivity in this sample type.2
Tuberculosis in prisons is a major challenge, especially in low-income and middle-income countries. Over-crowding, poor nutrition, stress, and poor aeration encourage its spread.3 Health-care workers in prisons should periodically screen inmates for symptoms of tuberculosis. Inmates should also be properly isolated as soon as a case of tuberculosis is confi rmed and contact investigation should be done.ContributorsMT did diagnostic tests. FJ, AP, and NS managed the patient. All authors contributed to the report.
AcknowledgmentsWe thank Edmundo López, Erika Santiago, and colleagues in infectious disease and radiology.
References1 Porcel JM, Light RW. Diagnostic approach to pleural eff usion in
adults. Am Fam Physician 2006; 73: 1211–20.2 Automated real-time nucleic acid amplifi cation technology for rapid
and simultaneous detection of tuberculosis and rifampicin resistance: Xpert MTB/RIF assay for the diagnosis of pulmonary and extrapulmonary TB in adults and children. World Health Organization. Geneva, Switzerland; 2014.
3 O’Grady J, Maeurer M, Atun R, et al. Tuberculosis in prisons: anatomy of global neglect. Eur Respir J 2011; 38: 752–54.
Lancet 2014; 384: 1400
Tuberculosis Biomarker Research Unit, Centro de
Biología Molecular y Celular de Enfermedades, Instituto de
Investigaciones Científi cas y Servicios de Alta Tecnología,
Ciudad del Saber, Panama (M Tarajia MD,
A Goodridge PhD); Department of Biotechnology, Acharya
Nagarjuna University, Guntur, India (M Tarajia); and Division
of Pulmonary Medicine, Hospital Santo Tomás, Panama
City, Panama (F Jaramillo MD, A Pernett MD, N Santamaría MD)
Correspondence to:Musharaf Tarajia, Tuberculosis
Biomarker Research Unit, Centro de Biología Molecular y Celular de Enfermedades, Instituto de
Investigaciones Científi cas y Servicios de Alta Tecnología,
PO Box 0843-01103, Ciudad del Saber, Panama
Figure: CT scans(A) Contrasted CT of the thorax, showing substantial right pleural thickening and a right pleural eff usion. (B) Brain CT with supratentorial ventricular dilation.
A B
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