Title : Unravelling the challenges in disseminsted tuberculosis- A complex case presentation
Abstract:
Introduction: Disseminated tuberculosis is a severe form of the disease involving two or more non-contiguous body sites or blood or bone marrow concurrently.The diagnosis and management often pose a challenge due to varied clinical presentations.
Case Report: We report a case of a 32 years old male who presented with a 2 months history of loss of weight and appetite, cough with expectoration for one week ,slurring of speech for one week and pain and swelling in the right knee joint and left great toe for one week.His general physical examination revealed pallor ,swelling and tenderness over right knee joint and left great toe. His systemic examination was normal except for slurred speech.
A complete blood count revealed neutrophilic leukocytosis, anaemia,and elevated erythrocyte sedimentation rate .His renal and liver function tests were normal. His Hepatitis B, Hepatitis C and Human immunodeficiency virus status were negative. Sputum smear and nucleic acid amplification tests were negative for mycobacterium tuberculosis .An immunological profile testing of the patient revealed reduced CD4 counts, low CD4/CD8 ratio,reduced NK cells (CD16+56). Computed Tomography of chest revealed fibro-bronchiectatic changes and enlarged mediastinal lymph nodes.MRI brain showed multiple ring enhancing lesions.A high frequency ultrasound scan showed synovial thickening and effusion in right infrapatellar region and first metatarsophalangeal joint. A fibreoptic bronchoscopy was done and samples sent for Catridge based nucleic acid amplification test and mycobacterial growth indicator tube culture.Ultrasound guided aspiration of synovial fluid was done from first metatarsophalangeal joint and sent for MGIT culture. Due to high index of clinical suspicion patient was diagnosed as a case of disseminated tuberculosis with pulmonary, brain and skeletal involvement and started on antitubercular treatment as per national tuberculosis elimination programme guidelines. Later MGIT culture from synovial fluid aspirate showed growth of mycobacterium tuberculosis. Eventually patient condition deteriorated and succumbed to death.
Discussion: Our case report reiterates the importance of awareness of atypical presentationof TB in an apparent immunocompetent individual and perhaps lower threshold for early testing for TB depending upon the clinical presentation to prevent delay in diagnosis and treatment.
Disseminated tuberculosis generally spreads via lympho-haemotogenous route .Predisposing factors contributing to dissemination and recurrence of tuberculosis like immunodeficiency ,malnutrition, alcoholism, diabetes mellitus, drugs etc should be evaluated and managed accordingly.There is a need for multidisciplinary team approach for management of disseminated tuberculosis.
Conclusion: Early diagnosis and management are essential for reducing the morbidity and mortality associated with disseminated form of tuberculosis. Multi centered, large studies are required to throw light on various clinical presentations and effective diagnostic modalities and management of disseminated tuberculosis.
