Sowjanya Dasari

Brucellosis and tuberculosis: Clinical overlap and pitfalls

OBJECTIVE To identify characteristic features of tuberculosis in patients with culture proven brucellosis. METHODS A retrospective analysis was performed on patients diagnosed with culture proven brucellosis between January and December 2011, based on review of their medical records. Patients with demonstrable co-infection with tuberculosis were excluded. Clinical features, laboratory parameters and tissue histopathology reports where available were noted. RESULTS Thirty-two patients with brucellosis were included in the study. Twenty-one (65.63%) patients had chronic fever, thirteen (40.63%) had a productive cough, while significant weight loss, evening rise of temperature and night sweats were reported by eight (25.00%), eleven (34.38%) and five (15.63%) patients respectively. Nine (28.13%) patients had at least three of these symptoms. Lymphadenopathy, hepatomegaly and splenomegaly were noted on examination in seven (21.88%), fifteen (46.88%) and twelve (37.50%) patients respectively. Eight (25.00%) patients had hepato-splenomegaly, of these only two had associated significant lymphadenopathy. Respiratory examination was normal in all patients. Elevated ESR greater than 50 mm/hr was seen in eight (25.00%), it was greater than 100 mm/hr in five (15.63%) patients. Hypergammaglobulinemia was seen in eight (25.00%) cases. Bone marrow biopsy showed non-caseating granulomas in three (9.38%) cases, lymph node biopsy showed granulomas in one case. Overall, three (9.38%) patients had known risk factors for tuberculosis, while six (18.75%) had risk factors for brucellosis. CONCLUSIONS There is a clear overlap between brucellosis and tuberculosis both in terms of clinical presentation and laboratory parameters. It is essential to carefully rule out tuberculosis in all cases of suspected or proven brucellosis before initiating antimicrobial therapy, in order to forestall development of drug-resistant tuberculosis.

A rare case of seronegative culture-­proven infection with Brucella suis

Brucellosis is a chronic infection produced by members of the Brucella family. Diagnosis of this condition requires either isolation of the organism in culture or positive serological tests.We describe a 27-year-old male admitted as a case of pyrexia of unknown origin (PUO), who tested negative for Brucella IgM ELISA test on preliminary evaluation but was subsequently diagnosed on the strength of positive blood and bone marrow cultures to be a case of brucellosis secondary to Brucella suis infection. In addition to highlighting the pathogenic potential of an unusual organism, this case demonstrates the unreliability of standard serological tests based on the Brucella melitensis antigen for infection with other species of Brucella.

A rare case of strychnine poisoning by consumption of Strychnos nux-vomica leaves

A 22-year-old male presented with severe myalgias and backache of acute onset, as well as one episode of opisthotonus. On repeated questioning, he admitted to having consumed leaves of Strychnos nux-vomica with suicidal intent. He was treated conservatively with intravenous diazepam and analgesia and made a complete recovery. Strychnine poisoning is rarely encountered and poisoning by consumption of leaves is even rarer. This case demonstrates the potent toxicity of strychnine as well as the effectiveness of therapy when initiated early.

An unusual cause for hyponatremia with seizures

A 50-year-old Asian Indian female with known hypertension presented with persistent vomiting but no other symptoms of meningism. Clinical examination and basic laboratory parameters were entirely normal except for significant hyponatremia. Further investigation was suggestive of the syndrome of inappropriate antidiuretic hormone (SIADH) secretion. Subsequently, despite steady correction of hyponatremia, the patient developed generalised seizures. Cerebrospinal fluid (CSF) analysis performed was inconclusive. Screening for a chronic meningitis underlying SIADH, yielded positive blood and CSF titres for venereal disease research laboratory (VDRL), which were confirmed by Treponema pallidum haemagglutination (TPHA). The patient was treated for neurosyphilis and made a complete recovery. Hyponatremia resolved and she had no further episodes of seizures. She was tested for HIV infection which was negative. On follow-up, she remained TPHA positive but VDRL titres became negative.

An unusual cause for recurrent jaundice in an otherwise healthy male.

A 41-year-old Asian-Indian male presented with recurrent episodes of jaundice over the past six months. Physical examination was normal, barring mild icterus. Laboratory parameters revealed indirect hyperbilirubinemia. Further evaluation yielded a diagnosis of severe nutritional vitamin B12 deficiency. Indirect hyperbilirubinemia was ascribed to ineffective erythropoiesis. Underlying Gilberts syndrome was ruled out by provocative testing with lipid-restricted diet. Presentation of severe vitamin B12 deficiency with isolated hyperbilirubinemia without concomitant major haematologic or neurologic dysfunction is unusual and potentially underdiagnosed. Awareness of this possibility can permit early diagnosis of vitamin B12 deficiency and forestall development of severe haematologic and neurologic sequelae.

Cranial melioidosis with extradural extension after a fall in the bathroom

A 32-year-old diabetic male, with a past history of head injury and seizures, presented with a painful swelling over his forehead present for the past three months. Cranial MRI demonstrated the presence of a scalp collection with extradural extension through a bony defect. Biopsy from the area showed caseating necrosis suggestive of tuberculosis. Although the patient failed to return for initiation of anti-tubercular therapy for the next 11 months, the swelling did not progress, and there were no constitutional symptoms. The indolent nature of the swelling prompted re-evaluation and delayed cultures of pus from the collection grew Burkholderia pseudomallei.

Polymyositis-like syndrome with rhabdomyolysis in association with brucellosis.

Diffuse myositis with progression to rhabdomyolysis has been reported in association with wide range of viral infections. We report a case of polymyositis-like syndrome complicated by rhabdomyolysis secondary to brucellosis. This case report thus contributes yet another atypical presentation to a disease already infamous for its protean manifestations.

Tuberculous mediastinal abscess as a paradoxical reaction in an immunocompetent individual

A 22-year-old man, diagnosed 7 weeks before with pulmonary tuberculosis and started on antitubercular therapy, presented with non-exertional retrosternal chest pain since the past week. He was diagnosed on the strength of thoracic radiograms and CT imaging to have a mediastinal abscess, which was percutaneously drained. He was continued on the same regimen of drugs. Analysis of the fluid obtained was suggestive of tuberculous aetiology. Steroids were not required.

HIV–tuberculosis co–infection in an Indian scenario: The role of associated evidence of immunosuppression

OBJECTIVE To determine the relationship between tuberculosis and the degree of immunosuppression as determined by CD4 count. The impact of immunosuppression on the severity of tuberculosis was also studied. METHODS A retrospective analysis was performed in patients newly diagnosed with HIV infection and antiretroviral therapy (ART)-naive patients with known HIV seropositivity. All patients were diagnosed with active tuberculosis between January 2008 and December 2010, based on review of their medical records. Patients on chemoprophylaxis for opportunistic infection were excluded. Pattern and severity of tuberculosis, associated stigmata of immunosuppression, and CD4 counts were noted. RESULTS Of 140 patients satisfying the inclusion criteria, 52 had mild tuberculosis with no other evidence of immunosuppression, 52 had tuberculosis of variable severity with associated evidence of immunosuppression, and 36 had severe tuberculosis with no other evidence of immunosuppression. The CD4 count was highest in the first group [(109.2±99.9) cells/μL] and least in the second group [(58.4±39.8) cells/μL], and the difference was statistically significant (P=0.004). No statistical difference was observed in the CD4 count between those with mild tuberculosis and those with severe tuberculosis. CONCLUSIONS In developing countries with a high prevalence of tuberculosis in the general population, the possibility of incidental tuberculosis in patients with HIV should always be considered. CD4 count does not appear to influence the severity of tuberculosis. The presence of concomitant evidence of immunosuppression in the form of category B and C conditions is indicative of underlying immunosuppression and associated with a significantly lower CD4 count.

Ketosis-prone type 2 diabetes mellitus in a patient with Sheehan’s syndrome: a rare convergence of two distinct endocrine entities

A 36-year-old housewife, previously diagnosed with Sheehan’s syndrome on glucocorticoid and thyroxine replacement therapy, presented with unprovoked diabetic ketoacidosis. Ketoacidosis was corrected with intravenous fluids and insulin therapy. Further evaluation was suggestive of type 2 diabetes mellitus. On follow-up, she experienced repeated episodes of hypoglycaemia and insulin was tapered and stopped. Adequate glycaemic control was maintained with metformin monotherapy.