Case Series
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Study of Extrapulmonary Tuberculosis in a Tertiary Care Hospital |
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Ankita Pranab Mandal, Rama Saha, Sudipan Mitra, Jaydip Deb 1. Postgraduate Trainee, Department of Pathology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India. 2. Associate Professor, Department of Pathology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India. 3. Assistant Professor, Department of Medicine, North Bengal Medical College, Darjeeling, West Bengal, India. 4. Professor and Head, Department of Chest Medicine, Nil Ratan Sircar Medical College, Kolkata, West Bengal, India. |
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Correspondence
Address : Rama Saha, FD- 112, Salt Lake City, Sector-III, Kolkata-700106, West Bengal, India. E-mail: ankitapmandal@gmail.com |
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ABSTRACT | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
: India ranks fourth among the global Tuberculosis (TB) burden. Mycobacterium Tuberculosis (MTB) is the causative organism. The extrapulmonary involvement accounts for 10-42% of cases. Among them are the pleura, lymph node and kidney which are the most common organs affected. Other organs affected are quite rare. Aim: To study clinical features, anatomical site and histological findings of the cases with extrapulmonary TB. Materials and Methods: A prospective case series study was conducted in a tertiary care hospital for a duration of one year consisting of six cases of TB. Detailed history taking and clinical examination was done followed by blood investigations and radiological evaluation. Gross examination of the specimens followed by histopathological reporting was done. Ziehl-Neelsen (ZN) stain was also performed for the confirmation of the diagnosis. Results: The present study describes six cases of TB each involving kidney, breast, endometrium, testis and two cases involving spleen. Affected patients mostly belonged to the third and fourth decades of life with equal male and female distribution. All the patients who underwent treatment were started on Anti-Tubercular Drugs (ATD) and were followed-up as well. Conclusion: Tuberculosis presents with a varied spectrum of symptoms. In countries like India, where TB is widely prevalent, it is always suggested to keep the rare possibility of extrapulmonary TB in mind when patients report. A detailed history, combined with thorough physical examination and vital investigations are necessary, particularly in identifying atypical forms of extrapulmonary TB. Histopathological examination is essential for confirmation. Management with ATD is effective. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Keywords : Breast, Endometrium, Kidney, Spleen, Testis | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
INTRODUCTION | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
India accounts for one fourth of the global TB burden. Mycobacterium TB is the causative organism. Tuberculosis affects various organs and consists of a wide range of clinical symptoms. A 10-42% cases include extrapulmonary involvement and the commonest organs involved are pleura, lymph node and kidney (1),(2),(3),(4). Other organs affected are relatively rare. The present study describes six cases of TB, highlighting the diagnostic dilemmas faced during the work-up with an aim to expand on available literature and to emphasise on the need for careful scrutiny in the evaluation of these cases, both from a clinical and a pathological point of view. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
MATERIAL AND METHODS | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
A prospective case series study was conducted in a tertiary care hospital for duration of one year from April 2019 to April 2020 consisting of six cases of TB. Approval of the study was taken from Institutional Ethics Committee. Informed consent was taken. The patients presented with varied clinical features according to their site of infection. Proper history taking and clinical examination was done followed by blood investigations and radiological evaluation. Biopsy specimens was sent for further processing. Gross examinations were done, sections were taken from the representative areas. Different sections were embedded in paraffin, were cut and stained by haematoxylin and eosin. The sections were reported using a light microscope. ZN staining was also performed for the confirmation of the diagnosis. STATISTICAL ANALYSIS Demographic, clinical and laboratory data for each patient was recorded in statistical forms. Results were analysed using Microsoft Excel 2016 and GraphPad InStat 3. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
RESULTS | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Distribution of the cases are shown in (Table/Fig 1). Tuberculosis of Spleen Case 1 A 28-year-old female reported with complaints of fever, pain in abdomen and weight loss for six months. Her medical history was not so significant. An abdominal ultrasound showed multiple anechoic, crescentic cystic lesions (up to 23 mm) in the spleen (Table/Fig 2)a. A Mantoux test was also performed and showed an induration of 12×12 mm without any erythema, which was considered as a positive test. Chest x-ray did not reveal any lung parenchymal lesions. The patient underwent a splenectomy. The spleen showed multiple, small, greyish white nodular structures (Table/Fig 2)b which on histopathological examination showed extensive caseous necrosis with epithelioid granuloma formation and presence of langhans giant cells suggestive of a tubercular granulomatous lesion (Table/Fig 2)c. The ZN staining revealed presence of Acid Fast Bacilli (AFB), confirming the diagnosis. Following this, ATD therapy was initiated. The symptoms reduced in the post-splenectomy period. Case 2 A 62-year-old male presented with complaints of fever and pain in abdomen since three months. On ultrasonic imaging, abdomen revealed an enlarged spleen showing a large, thick-walled hypoechoic Space Occupying Lesion (SOL) measuring 6.2×5.5 cm at the mid-pole showing predominantly peripheral vascularity, suspicious of a splenic abscess. The patient underwent splenectomy for the splenic abscess. The specimen measured 8×8×3 cm with a large whitish nodular area measuring 5×4 cm was noted on cut-sections (Table/Fig 2)d. Microscopic examination revealed multiple granulomas comprising of epithelioid cells and multinucleate langhans giant cells, these features were suggestive of Koch’s lesion (Table/Fig 2)e. ZN stain showed presence of AFB which confirmed the diagnosis (Table/Fig 2)f. ATD therapy was started and complete recovery was reported on follow-up. Case 3: TB of Breast A 38-year-old female presented with a tender breast lump for last four months. The patient was febrile and had no family history of breast carcinoma. On clinical examination, tender mass measuring 5x6 cm was noted in the lower outer quadrant of left breast. No nipple discharge or skin retraction was seen. Absence of axillary or cervical lymphadenopathy was noted. Examination of other systems was within normal limit. She had no past history of pulmonary TB. Breast Ultrasound Sonography Test (USG) showed a heterogenous thick walled cystic mass. Fine Needle Aspiration Cytology (FNAC) was performed, pus was aspirated and the smear showed granuloma formation. This was followed by tru-cut biopsy. Histological examination showed multiple granulomas comprising of epithelioid cells with caseous necrosis, features were suggestive of tubercular infection (Table/Fig 3)a. ZN staining revealed presence of AFB (Table/Fig 3)b, confirming the diagnosis. Pus culture was also positive for AFB. Following this, the patient was started on ATD. The symptoms reduced on follow-up. Case 4: TB of Kidney A 35-year-old male presented with intermittent pain in the area between upper abdomen and back and fever since last two months. Three months earlier, the patient had an episode of gross haematuria. The patient had no past history of pulmonary TB. Clinical examination revealed bimanually palpable ballotable swelling in the left hypochondrium. Blood investigations revealed a raised Erythrocyte Sedimentation Rate (ESR). Contrast-Enhanced Computed Tomography (CECT) scan showed a heterogenous mass of lesion with areas of necrosis involving the left kidney. Aortocaval and para-aortic lymph nodes were enlarged. The patient underwent left radical nephrectomy. Grossly specimen measured 8×7 cm. On cut open, caseous material and areas of necrosis were noted (Table/Fig 3)c. Histology showed extensive caseous necrosis with epithelioid granuloma formation and langhans giant cells suggestive of a tubercular granulomatous lesion (Table/Fig 3)d. ZN staining revealed presence of AFB, confirming the diagnosis. The patient was then started on ATD and reported complete recovery on follow-up. Case 5: TB of Endometrium A 45-year-old nulliparous female presented with menorrhagia for one year. This was also associated with history of intermenstrual bleeding. Clinically pelvis and perineum showed no abnormality, uterus was not tender and enlarged. Cervix appeared normal on speculum examination, with no discharge from the external os. Examination of other systems showed no abnormality. Transvaginal pelvic ultrasound showed endometrial hyperplasia. Endometrial biopsy was performed by dilatation and curettage. Histology showed endometritis with presence of granuloma with caseous necrosis and langhans giant cells suggestive of TB (Table/Fig 4)a,b. The ZN stain showed presence of AFB which confirmed the diagnosis. The patient was then started on ATD. On follow-up, normal menses was resumed. Case 6: TB of Testis A 50-year-old male presented with right-sided testicular swelling for last three months. Clinical examination showed testicular swelling of 3x2 cm which was gradually increasing without any discharging sinus or scrotal ulceration. Systemic examination was unremarkable. USG revealed heterogenous mass lesion of 4×3 cm arising from right testis. Left testis was normal. Then the patient underwent Magnetic Resonance Imaging (MRI) examination of the right testicle which revealed 4×3 cm space occupying formation on the right scrotum. The case was mistaken as testicular tumour and orchidectomy was performed. Histopathological examination showed extensive caseous necrosis with epithelioid granuloma formation and langhans giant cells suggestive of a tubercular granulomatous lesion (Table/Fig 4)c,d. The ZN staining revealed presence of AFB, confirming the diagnosis. The patient was commenced on ATD and was under follow-up. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
DISCUSSION | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
The global TB report published by the World Health Organisation (WHO) in the year 2017 has enlisted India, in the top 20 in terms of, incidence of TB and Multidrug Resistant TB (5). The annual TB report published by the Government of India estimated the incidence of TB at 28,00,000 cases (6). The rampant nature of this disease makes it essential to discuss the spectrum of clinical presentations observed in this infection. Apart from the lungs, TB can affect lymph nodes, the genitourinary tract, bones, meninges, gastrointestinal tract, skin as well as serosal surfaces (7). About 11% of cases of extrapulmonary TB affect abdominal organs, usually the GIT or liver (8). Immunosuppression, preceding pyogenic infections, trauma, sickle cell disease or other haemoglobinopathies and primary infection by TB in a different organ are all considered to be risk factors associated with acquiring TB in the spleen (4). The common form of infection is when it occurs as part of miliary TB, observed in immunocompromised individuals and usually affecting the liver and lungs. Primary infection of the spleen is considered less common (8). A differential diagnoses of cysts (tubercular or hydatid), haematoma, fungal infection, abscesses, infarcts, vascular tumours, lymphomas or metastatic tumours should be considered. Two patients presented with complaints of fever and abdominal pain with radiological findings of a splenic pathology without prior history of TB. Neither FNAC nor Core Needle Biopsy (CNB) was performed in the either cases, due to the suspicion of hydatid cysts and splenic abscess. Both cases were clinically deceptive and were diagnosed by histopathology. Ultimately, both patients underwent splenectomy and were started on anti-tubercular therapy based on the histopathological report. On follow-up, both patients showed recovery to normal health. In 1829, Sir Astley Cooper first described mammary TB (9). It is an exceptionally rare condition with an incidence of 0.1% of all breast lesions in Western countries and 4% of all breast lesions in TB endemic countries (10). It is categorised as primary and secondary, of which primary is rather infrequent (11). In the present case of breast TB, as there were neither foci of additional TB on physical or radiological inspection nor any prior history of TB, breast was the primary focus. On the basis of clinical, radiological, pathological breast TB is classified into three forms: nodular, disseminated and sclerosing (12),(13). Nodular form is most common and diagnostically mimics fibroadenoma or carcinoma (14). Histological study of the tissue sample, aspirate culture and Polymerase Chain Reaction (PCR) for mycobacterium are the most dependable and definitive investigations. Of all TB cases, urogenital TB is diagnosed in 1.1-1.5% cases and 5-6% among extrapulmonary TB (15). It mostly affects male aged between 30-50 years old. Miliary TB generally affects the renal cortex because of its high oxygen tension. Clinically and radiologically, it mimics renal cell carcinoma, lymphoma, metastasis and abscess. Accordingly, the patient undergoes surgery for the affected kidney, whose histopathological study surprisingly establishes the diagnosis of TB (16),(17). In gynaecology, female pelvic TB is one of the most under-diagnosed conditions. In young women, an increase in extrapulmonary TB is being reported worldwide. In India, of all gynaecological admissions, incidence of genital TB is 0.75 to 1% (18). Majority of female genitourinary TB are asymptomatic, so they are difficult to diagnose (11%) (19). When TB affects endometrium, it causes either acute or chronic endometritis so as in this case. Histopathological examination is the basis for final diagnosis. Testicular TB is extremely rare, comprising of only 3% of genital TB (20). Testicular TB occurs commonly in a disseminated form, isolated testicular TB is extremely rare. The commonest site of genital TB in men is epididymis followed by seminal vesicles, prostate, testis and the vas deferens (21). Testicular involvement is caused by local spread or retrograde seeding from the epididymis (22),(23). So, testicular TB without epididymal involvement is exceptionally rare, so as seen in one of the cases. In elderly age group, testicular TB mimics testicular malignancy. All the patients were considered immunocompetent, in view of the negative HIV serology and also a negative history of recurrent infections or ulceration. The presence of granulomas points towards a competent immune system. These cases appear to have affected the organs in isolation, as noted by radiological investigations. This misled the search for TB in these patients. Microbiological investigations are essential in establishing the diagnosis and range from simple tests like culture to higher end techniques as the Cartridge Based Nuclear Acid Amplification Test (CBNAAT) PCR. High costs and requirement of sophisticated laboratory infrastructure makes it of limited use in developing countries. Regarding management, combined pharmacotherapy with rifampicin, isoniazid, pyrazinamide and ethambutol is the suggested protocol for both pulmonary and extrapulmonary TB (24). Evidence suggests that anti-tubercular therapy can prove beneficial in eradicating the infection in most cases. Details of few cases of extrapulmonary TB reported earlier in literature from world along with comparison with present case series is shown in (Table/Fig 5) (8),(13),(24),(25),(26),(27),(28),(29),(30),(31). | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
CONCLUSION | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Tuberculosis presents with a varied spectrum of symptoms. In countries like India where TB is widely prevalent, it is always suggested to keep the rare possibility of extrapulmonary TB in mind when patients present. A detailed history, combined with thorough physical examination and vital investigations are necessary, particularly in identifying atypical forms of extrapulmonary TB. Culture is also an essential step in diagnosis. Sophisticated techniques like PCR may not be available in a setup with limited resources. Histopathological examination is essential for confirmation. Management with ATD is effective. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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TABLES AND FIGURES | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||