Title : A case of disseminated tuberculosis along with recurrent tuberculosis at multiple sites.
Disseminated tuberculosis is a severe form of the disease involving two or more non-contiguous body sites or blood or bone marrow concurrently. Recurrent tuberculosis is occurrence of tuberculosis in a previously treated individual.The diagnosis and management often pose a challenge due to varied clinical presentations.
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.He had history of previous pulmonary tubercular infection 8 years ago, for which he completed 6 months of treatment as per Revised national tuberculosis control programme guidelines .Three years later he developed abdominal tuberculosis and completed treatment as per guidelines . His general physical examination revealed pallor ,swelling and tenderness over right knee joint and left great toe. A scar mark was noted over the posterior aspect of left shoulder. 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 tuberculomas.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 .Patient was diagnosed as a case of disseminated tuberculosis with pulmonary, brain and skeletal involvement.
Disseminated tuberculosis generally spreads via lympho-haemotogenous route. Recurrent tuberculosis can be due to relapse with a previous strain or re-infection with a new strain.
This case report highlights the need for high index of clinical suspicion to diagnose disseminated tuberculosis in endemic areas.
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.
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
Keywords: Disseminated tuberculosis, Recurrent tuberculosis tuberculoma, pulmonary tuberculosis