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Isolated hepatic tuberculosis is an uncommon manifestation of one of the most common infections worldwide, caused by Mycobacterium tuberculosis. Extremely high serum ferritin, which is regarded as a marker of adult onset Still's disease, has not been observed in patients with tuberculosis of the liver. We report a case of hepatic tuberculosis who p...
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... finger clubbing, cyanosis and lymphadenopathy were absent. He had a generalized erythematous maculo- papular skin rash involving the palms and soles (Figure 1), a non-scaring alopecia and multiple shallow ulcers in the oral mucosa. On admission, his pulse rate was 100/mi- nute, his blood pressure was 100/70 mmHg and his respiratory rate was 46/minute. ...
Citations
... Stress has been suggested as a common risk factor for cases of all ages [9,10]. AOSD is diagnosed using predefined Yamaguchi's criteria or the more recent Fautrel's criteria [11,12]. 1 2 3 4 5 Since tuberculosis (TB) is an endemic disease in our population, most patients are misdiagnosed as TB and are initiated on antituberculous treatment [13]. Multiple antibiotics are also frequently prescribed before establishing the diagnosis of AOSD. ...
Background
Adult-onset Still's disease (AOSD) is characterized by a classical triad of spiking fever, arthritis, and evanescent rash. It is one of the main causes of hospital admissions for fever of unknown origin and has an extended mean time to diagnosis. Therefore, it remains underdiagnosed relative to its aforementioned time frame. In this study, we attempt to highlight clinical and lab findings associated with AOSD. We then compare our diagnostic results with similar previous studies. Our results should help physicians not to miss this rare entity and make the diagnosis in a reduced time frame.
Materials and methods
This a retrospective, single-center study conducted at Dow University Hospital in Karachi, Pakistan. Thirty patients were enrolled in this study for six months (July 2019-December 2019). All patients were identified and recruited in the medical outpatient department using Yamaguchi's criteria. Written consent was obtained from all patients to access all their clinical charts. Demographics and prior results of laboratory investigations were retrieved from the chart files.
Results
In our study, the mean age of patients was 26.6 years. More specifically, males accounted for 53.3% (n=16) of cases, and females accounted for 46.6% (n=14) of total cases. The most common presenting clinical features included arthralgia (100%, n=30), fever (100%, n=30), myalgia (96.6%, n=29), large joint arthritis (66.6%, n=20), sore throat (50%, n=15), hepatomegaly (40%, n=12), splenomegaly (23.3%, n=7), skin rash (36.6%, n=11) and pericarditis (20%, n=6). Furthermore, none of our patients had cervical lymphadenopathy. The most commonly reported laboratory findings include leukocytosis (100%, n=30), hyperferritinemia (90%, n=27), elevated erythrocyte sedimentation rate (100%, n=30) and abnormal liver function tests (76.6%, n=23). Chest x-rays performed in all patients revealed no abnormalities in 83% of patients (n=25). All patients in our study sample (n=30) tested negative for antinuclear antibodies and rheumatoid factor. It was also noted that the mean duration of diagnosis in our patients was 5.98 weeks. The mean hospitalization period in our patients was 12.5 days. Furthermore, 16.7% of patients (n=5) suffered from disease relapse.
Conclusion
Our study ascertains that the presence of certain clinical and laboratory findings strongly indicate a diagnosis of adult-onset Still's disease.
... Stress has been suggested as a common risk factor for cases of all ages [9,10]. AOSD is diagnosed using predefined Yamaguchi's criteria or the more recent Fautrel's criteria [11,12]. 1 2 3 4 5 Since tuberculosis (TB) is an endemic disease in our population, most patients are misdiagnosed as TB and are initiated on antituberculous treatment [13]. Multiple antibiotics are also frequently prescribed before establishing the diagnosis of AOSD. ...
Background
Adult-onset Still's disease (AOSD) is characterized by a classical triad of spiking fever, arthritis, and evanescent rash. It is one of the main causes of hospital admissions for fever of unknown origin and has an extended mean time to diagnosis. Therefore, it remains underdiagnosed relative to its aforementioned time frame. In this study, we attempt to highlight clinical and lab findings associated with AOSD. We then compare our diagnostic results with similar previous studies. Our results should help physicians not to miss this rare entity and make the diagnosis in a reduced time frame.
Materials and methods
This a retrospective, single-center study conducted at Dow University Hospital in Karachi, Pakistan. Thirty patients were enrolled in this study for six months (July 2019-December 2019). All patients were identified and recruited in the medical outpatient department using Yamaguchi's criteria. Written consent was obtained from all patients to access all their clinical charts. Demographics and prior results of laboratory investigations were retrieved from the chart files.
Results
In our study, the mean age of patients was 26.6 years. More specifically, males accounted for 53.3% (n=16) of cases, and females accounted for 46.6% (n=14) of total cases. The most common presenting clinical features included arthralgia (100%, n=30), fever (100%, n=30), myalgia (96.6%, n=29), large joint arthritis (66.6%, n=20), sore throat (50%, n=15), hepatomegaly (40%, n=12), splenomegaly (23.3%, n=7), skin rash (36.6%, n=11) and pericarditis (20%, n=6). Furthermore, none of our patients had cervical lymphadenopathy. The most commonly reported laboratory findings include leukocytosis (100%, n=30), hyperferritinemia (90%, n=27), elevated erythrocyte sedimentation rate (100%, n=30) and abnormal liver function tests (76.6%, n=23). Chest x-rays performed in all patients revealed no abnormalities in 83% of patients (n=25). All patients in our study sample (n=30) tested negative for antinuclear antibodies and rheumatoid factor. It was also noted that the mean duration of diagnosis in our patients was 5.98 weeks. The mean hospitalization period in our patients was 12.5 days. Furthermore, 16.7% of patients (n=5) suffered from disease relapse.
Conclusion
Our study ascertains that the presence of certain clinical and laboratory findings strongly indicate a diagnosis of adult-onset Still's disease.
... AOSD has been reported rarely as a cause of PUO [3]. AOSD may present with atypical and protean manifestations or may mimic other inflammatory disorders or chronic infections such as tuberculosis [4]. It may be complicated with HLH which carries a poor prognosis and high mortality, often because of delay in diagnosis and treatment [5]. ...
It is often a challenge and a dilemma for clinicians encountering patients with pyrexia of unknown origin. Numerous tests performed to determine the underlying cause often give inconclusive results. We present a 52-year-old man with undulating fever for more than 10 months with persistent hyperferritinaemia, and negative immunological and serological markers. Despite corticosteroids, disease modifying anti-rheumatic agents and immune-modulator therapy, he succumbed to the illness. A diagnosis of refractory Adult onset Still’s disease complicated by haemophagocytic lymphohistiocytosis was made.
... Primary HPS is a genetic disorder, occurs in younger age group. Secondary HPS may be triggered by viral infections like Epstein-Barr virus [1], but bacterial infections like tuberculosis (TB) is not uncommon [2][3][4][5][6]. Mortality ranges from 41 to 50% and in secondary HPS, delay in diagnosis increases mortality [7,8]. ...
Background
Tuberculosis is common, can involve various organs of the body and may have diverse presentations. Haemophagocytic syndrome is one of the rare presentations of tuberculosis carrying a very high mortality. Early detection and institution of anti-tuberculosis medications can be life-saving. Case presentationA 23-year-old Bengali man presented with prolonged fever, weight loss, hepatosplenomegaly, pancytopenia and altered liver function. He had high erythrocyte sedimentation rate, positive tuberculin test, granuloma in liver biopsy, and haemophagocytosis was evidenced by histopathological examination of bone marrow. He recovered with anti-tuberculosis therapy. Conclusion
This case demonstrates that consideration of tuberculosis as an underlying cause of haemophagocytic syndrome could be rewarding and life-saving in this rapidly fatal condition.
... In the presence of these cavitary lung lesions infection was highly suspected. A Right arm PICC line was placed and the patient received a full body Indium scan and MRI of the brain looking for a source of possible infection and further classification of his disease; both of which were negative [14]. The blood and sputum fungal and bacterial cultures were negative. ...
Acute Onset Still’s Disease (AOSD) is a disease of immunologic and hematologic dysfunction, whereby a percentage of cases develop further into Macrophage Activating Syndrome (MAS). This patient is a 35 year old Caucasian male with Acute Onset Still’s Disease without MAS was hospitalized for multiple cavitary lung lesions. Lesions included a larger estimated 2.5 cm x 2.5 cm cavitary lesion in the Right Middle Lobe and smaller estimated 1.3 x 1.4 cm and 1.8 x 1.2 cm lesions in the Left Lower Lobe of the lungs. The larger lesion was seen on chest X-ray a further detailed on a chest CT scan, which revealed the remaining two smaller pulmonary lesions. The patient experienced undulating fevers as high as 101°F. The patient was put on isolation and received serial blood cultures, sputum cultures, acid fast stains of sputum, urine cultures, viral film array serology all resulting in negative results. Over seven acid fast bacilli stains of sputum were negative in the setting of multiple cavitary lung lesions with high suspicion of active Tuberculosis. The patient received immediate broad spectrum antibiotic and antifungal intravenous antibiotics without relief in fever or symptoms. The patient received a full body Indium scan and MRI of the brain looking for a source of possible infection and further classification of his disease; both of which were negative. The blood and sputum fungal and bacterial cultures were negative. Serial chest CT and chest X-ray demonstrated slightly smaller cavitary lung lesions with thinner walls. The suspicion of Tuberculosis remained high and a lung biopsy was obtained of the large cavitary lesion in the Left Middle Lobe, which did not demonstrate acid fast staining on three separate samples. This patient was concluded to have noninfectious cavitary lung lesions and discharged home with close follow up. He is the first patient reported with AOSD Disease without MAS hospitalized for undulating fevers and multiple cavitary lung lesions without evidence of Tuberculosis of active infection.
... [9] As per our literature search, there has been only one case report of tuberculosis with extreme hyperferritinemia mimicking AOSD in which the patient had hepatic tuberculosis. [10] Such atypical manifestation of not so easily diagnosed abdominal tuberculosis in endemic areas can pose a major diagnostic challenge and delay the necessary treatment. ...
A 50-year-old female presented with fever, symmetrical arthralgias, rash, painful oral ulcerations and alopecia since 8 weeks. Examination showed mild hepatospleenomegaly. Investigations revealed leucocytosis, neutrophilia, elevated sedimentation rate and raised ferritin levels (3850 ng/ml). Computerized tomography (CT) abdomen showed hepatospleenomegaly, mild ascitis and mild bilateral pleural-effusion. After ruling out occult infections, tuberculosis, malignancies and autoimmune diseases by appropriate investigations, and due to raised ferritin levels, adult onset stills disease (AOSD) was diagnosed. Patient responded to oral steroids initially, but after 7 days developed severe abdominal pain. Repeat CT showed multiple enlarged, necrotic and matted retroperitoneal lymph nodes with caseating granuloma on histopathology suggesting tuberculosis. Patient was given four-drug anti-tubercular treatment and she improved. Thus our patient of occult abdominal tuberculosis with reactive arthritis (Poncet's disease) presented with hyperferritinemia mimicking AOSD. We postulate that extreme hyperferritinemia can be seen in tuberculosis and tuberculosis must be conclusively ruled out before diagnosing AOSD in tropics.
... Hepatic TB lack typical clinical manifestations and imaging diagnosis, it may follow common clinical complaints with mild fever, right upper quadrant pain, hepatomegaly, weakness, night sweats, and so on. Hepatomegaly is usually found with an increase in alkaline phosphatase and normal transaminase levels [4,5,7,8,[10][11][12]. Jaundice caused by tuberculosis invasion and oppression bile duct, is easy to be confused with hilar tumors, and some liver tuberculoma patients may associated with portal hypertension or biliary tract bleeding [13,14]. ...
Hepatic tuberculosis is uncommon, lack of specific clinical manifestations and imaging features, so it can easily be misdiagnosed in clinical. Herein, we discuss variety of its forms and summarize the diagnosis and treatment of hepatic tuberculosis in this paper. Five cases of hepatic tuberculosis are described. The diagnosis, treatment and outcome of the patients are discussed. Image examination associated with image-guided fine needle aspiration biopsy is the best diagnostic method. In our center, three patients underwent needle biopsy and confirmed hepatic tuberculosis. In addition, two patients preoperative misdiagnosed as cholangiocarcinoma were confirmed hepatic tuberculosis by postoperative pathology. Three patients underwent surgical procedures along with anti-tubercular drug therapy, two patients received only anti-tubercular drug therapy. The renal post-transplantation patient with hepatic tuberculosis eventually died of multiple organ failure (MODS). The other four patients were followed for 48~120 months, yielding no recurrence of hepatic tuberculosis. In conclusion, hepatic tuberculosis usually associated with atypical clinical manifestations. Image examination associated with image-guided fine needle aspiration biopsy is the best diagnostic method. Anti-TB treatment is effective in most of cases. However, if there are indications for surgery or difficult to diagnose, surgical procedures along with anti-tubercular drug therapy could be adopted.
Liver disease is one of the most common non-AIDS-related causes of death in HIV-infected patients, but the incidence may be declining with advances in antiretroviral therapy (Jennifer and Thio, Clin Gastroenterol Hepatol 8:1002–1012, 2010; Pettit et al. J Int AIDS Soc 21, 2018; Sherman et al. Hepatology 62:1871–1882, 2015). Recognizing and treating opportunistic infections of the liver is essential in the care of HIV-infected patients. This chapter will review the epidemiology, pathophysiology, and clinical presentation along with diagnostic testing and treatment of the most common hepatic presentations of HIV opportunistic fungal, bacterial, viral, and mycobacterial diseases. This chapter will emphasize the less common and often non-hepatotropic viral infections. The more common viral hepatitides, hepatitis A, B, C, D, and E, will be discussed in greater detail in another chapter. In addition to infectious processes that can cause hepatic injury, treatment of HIV with HAART and other medications used for the treatment and prevention of opportunistic infections can lead to drug-induced liver injury (DILI). Since liver injury has a broad differential and can mimic vascular and neoplastic diseases, it takes an astute physician to recognize opportunistic infections and DILI that occur in HIV-infected persons. Clinicians must be aware of these potentially serious hepatic effects when managing HIV-positive patients.
