Loss of Left Ventricular Torsion as the Predominant Mechanism of Left Ventricular Systolic Dysfunction in a Patient with Tubercular Cardiomyopathy

Pericarditis is the commonest form of cardiac involvement in tuberculosis whereas myocardial involvement is exceedingly rare. We hereby report a patient who presented with cardiac tuberculosis manifesting as predominantly right‐sided cardiomyopathy. In addition to being a very rare clinical presentation, this case provided an interesting insight into the left ventricular (LV) myocardial mechanics. The patient had nearly preserved contractile function of the LV myocardium (except for segmental abnormalities in circumferential strain) but had marked impairment of torsion resulting in LV systolic dysfunction. Such disproportionate loss of LV torsion leading to LV systolic dysfunction has not been previously described on echocardiography. These myocardial mechanical abnormalities almost completely recovered with adequate antitubercular treatment. Thus, this case proved to be a unique demonstration of the significant, independent role played by torsion in maintenance of normal LV systolic function.     

Tuberculous involvement of the oesophagus with oesophagobroncheal fistula

Tuberculous involvement of the oesophagus is a rare disease. Even if it is suspected, diagnosis is often difficult though dysphagia and chest pain are the most common symptoms without any other specific signs of tuberculosis. The diagnosis is based on oesophagography, oesophagoscopy, bronchoscopy, and computed tomographic scan. Suspected tuberculosis can be confirmed with histology, smear, and culture. The two most common differential diagnoses are Crohn's disease and carcinoma. The case is reported of a female patient with tuberculous involvement of the oesophagus, who developed an oesophagobroncheal fistula during steroid treatment started for suspicion of Crohn's disease. The patient was immunocompromised due to treatment with azathioprine that she was receiving for multiple sclerosis. The fistula was successfully treated by antituberculous chemotherapy alone.     

早期肠结核的病理变化

目的探讨早期肠结核的病理变化。方法对结肠镜诊断的３例早期肠结核进行分析。结果早期肠结核的病理特征是：回盲部粘膜充血、水肿或（和）糜烂；纤维素样渗出及霜样白苔，回盲瓣红肿变形；无溃疡和息肉样增生；光镜下见粘膜层内结核结节，无溃疡和肉芽、纤维组织增生。结论认识早期肠结核的病理变化，对促进早期肠结核的诊断和完善肠结核的病理分型具有重要意义     

Tuberculous retropharyngeal abscess without cervical spine TB

Tuberculous retropharyngeal abscess is a rare presentation. It is present in adults usually due to involvement of cervical spine by tuberculosis. Retropharyngeal space usually gets involved in children due to pyogenic organisms or secondary to trauma. Here is a case of tuberculous retropharyngeal abscess in an adult female, with pulmonary tuberculosis. The patient was not having tuberculous involvement of cervical spine and was managed surgically by aspirating the retropharyngeal abscess transorally and AKT Category I.     

Noncompaction of the ventricular myocardium: report of two cases with bicuspid aortic valve demonstrating poor prognosis and with prominent right ventricular involvement

Noncompaction of the ventricular myocardium is a rare, unclassified cardiomyopathy due to an arrest of myocardial morphogenesis. The characteristic echocardiographic findings consist of multiple, prominent myocardial trabeculations and deep intertrabecular spaces communicating with the left ventricular (LV) cavity. The disease typically involves the LV myocardium, but right ventricular (RV) involvement is not uncommon. The clinical manifestations include heart failure (HF) signs, ventricular arrhythmias and cardioembolic events. Noncompacted myocardium may occur as an isolated cardiac lesion, as well as it can be in association with congenital anomalies. We describe two illustrative cases of noncompaction of the ventricular myocardium, a 19-year-old male with bicuspid aortic valve and progressive worsening of HF, and a 61-year-old male with marked RV involvement in addition to LV apical involvement, both with the typical clinical and echocardiographic features of the disease.     

Clinical role of bronchoscopy in adults with intrathoracic tuberculous lymphadenopathy

Twenty-five adult tuberculosis patients with intrathoracic lymphadenopathy were studied. Intrathoracic tuberculous lymphadenopathy seems rare in Chinese and affects more older and female subjects. The most common symptoms were cough, followed by chills, fever and the most common physical finding was peripheral lymph node enlargement. The roentgenographic appearance of mediastinal lesions varied but often included right paratracheal involvement. Nine patients had clear lungs. Tuberculous involvement was limited to the lower lung field in seven out of 16 patients with concomitant parenchymal lesions. The remaining nine patients had pulmonary tuberculosis involving the upper lobes. Consolidation was the most common form of pulmonary lesion. A diagnosis was made on the basis of sputum examination in nine patients; however, peripheral lymph node examination yielded a higher diagnostic rate (90 percent). Endobronchial involvement was proved by bronchoscopy in 12 of 16 patients. In three instances, the final diagnosis could be documented after mediastinoscopy or exploratory thoracotomy.     

Hepatobiliary tuberculosis

Tuberculous involvement of the liver as part of generalized military tuberculosis is well known. It is said to be found in 50-80% of all cases dying from pulmonary tuberculosis (1). However, localized tuberculosis of the liver as a clinical entity and producing large nodules or abscesses have been considered exceedingly rare, even in areas where tuberculosis is relatively common. Leader (2), in an extensive review of the world literature in 1952, documented only 80 cases of hepatic tuberculosis with large abscesses or nodules. Other publications deal with localized tuberculous involvement of the hepatobiliary tract in isolated case reports (1-8). In order to learn more about the clinical manifestation and course of this disease, we therefore prospectively evaluated our total experience on hepatobiliary tuberculosis during the last two decades of our practice.     

Male genital tuberculosis: a review of the literature with instructive case reports

The prevalence of extrapulmonary tuberculosis, including cases at male genital sites, has remained relatively constant during the past two decades in the United States. The most common genital sites of tuberculous infection are the epididymis and prostate; the testicle is infected in a lower proportion of cases. The usual modes of genital involvement include descending infection from the kidneys, intracanalicular or direct extension from neighboring foci in the genital tract, and hematogenous seeding. Local symptoms are usually insidious and progressive. Systemic manifestations such as fever, chills, and sweats are infrequently present in isolated genital tuberculosis. Tuberculous genital infection can be confused with other bacterial (including nontuberculous mycobacterial) infections, fungal disease, tumors, and cysts as well as with a number of less common illnesses. Although some diagnostic and therapeutic indications for surgical excision still exist, the preferred approach to treatment is primarily multiple-drug antituberculous chemotherapy.     

Clinical features of tuberculous septic arthritis in Khon Kaen, Thailand: a 10-year retrospective study

Tuberculous septic arthritis is difficult to diagnose. A retrospective analysis was done on patients over 15 years of age who attended Srinagarind Hospital, Khon Kaen, Thailand, between January 1, 1997 and December 31, 2006, whose synovial fluid culture was positive for Mycobacterium tuberculosis. The medical records of 77 patients were reviewed; one-third were in their sixth decade. Comorbid disease was found in 33 cases (42.9%), with systemic sclerosis being the most common (9 cases) followed by diabetes mellitus (5 cases) and chronic kidney disease (5 cases). Chronic monoarthritis was the most common presentation (34 cases) followed by acute monoarthritis (20 cases). More than half of the polyarticular involvements were disseminated tuberculosis. The knee was the most commonly affected joint (36.4%). Sixty percent had delayed diagnosis due to an incorrect diagnosis. Abnormal chest radiography and blood eosinophilia were found in 40 and 57.3% of cases, respectively. Synovial fluid and synovial tissue staining for acid-fast bacteria were positive in 30 and 40% of cases, respectively. A caseous granuloma was present in 57.5% of cases and non-specific synovitis in 12%. Sixty-three percent had bone erosions. Tuberculous septic arthritis should be considered in patients who present with acute or chronic monoarthritis, and who have an abnormal chest radiograph or eosinophilia. Polyarticular involvement was commonly related to having disseminated tuberculosis and may indicate systemic involvement of tuberculous infection.     

Anal Tuberculosis: Report of Two Cases and Literature Review

Tuberculous involvement of the anus is an extreme rarity. We report two cases of anal tuberculosis and discuss the clinical features, the difficulty in differentiating from Crohn's disease, and the diagnostic aspects in the context of the pertinent medical literature.     

The endocrinology of adrenal tuberculosis: the effects of tuberculosis on the hypothalamo-pituitary-adrenal axis and adrenocortical function

Tuberculosis may affect many of the endocrine glands including the hypothalamus, pituitary, thyroid and adrenals. The most commonly involved endocrine organ in tuberculosis is the adrenal gland. Adrenal glands may be directly or indirectly affected by tuberculosis. Tuberculous Addison's disease is still an important cause of primary adrenocortical insufficiency particularly in the developing countries. Recent improvements in imaging techniques and modern endocrinological tests for the investigation of adrenal function have given us greater insight into the endocrinology of adrenal tuberculosis. Hypothalamo-pituitary-adrenal (HPA) axis is also involved in tuberculosis and recent findings revealed that HPA axis is activated rather than underactivated in active pulmonary tuberculosis. Activated HPA axis in tuberculosis causes increased cortisol secretion which results in a shift in the Th1/Th2 balance towards Th2. T cell dysfunction due to high cortisol and low DHEAS levels may be responsible for immunologically-mediated tissue damage in tuberculosis. In this review, recent findings concerning the adrenocortical function, radiological changes in adrenal glands and HPA axis involvement in tuberculosis are discussed.     

Embolic thrombosis of the abdominal aorta with tuberculous (histologic) lesions of the heart containing giant cells with radial inclusions

Tuberculous myocarditis with endocardial thrombosis is not infrequent, but embolism from these thrombi seem to occur rarely. Tuberculous lesions of the myocardium and endocardium, associated with mural thrombosis and obturator thrombosis (embolism) of the abdominal aorta and other vessels, is reported.Some of the giant cells in the lesions of the myocardium, lymph nodes, and lungs contained radial inclusions.     

Abdominal tuberculosis in children: CT findings

Tuberculous peritonitis is a rare manifestation of childhood tuberculosis. The computed tomographic (CT) scans of three patients with abdominal tuberculosis were reviewed to determine the range of abdominal involvement. This report describes the following CT features of abdominal tuberculosis: (1) diffuse lymphadenopathy involving mesenteric and retroperitoneal lymph nodes; (2) low-density lymph nodes with multilocular appearance following intravenous contrast; (3) high-density ascites; (4) mottled low-density masses in the omentum; (5) thickening of the bowel wall adjacent to the mesentery; and (6) hepatic pseudotumors. These CT features of abdominal tuberculosis, in the appropriate clinical setting, should help optimize the correct diagnosis and management of tuberculosis in children.     

Focal tuberculosis of the liver with local hemorrhage in a patient with acquired immunodeficiency syndrome

Abstract: Tuberculosis of the liver is common in patients with acquired immunodeficiency syndrome (AIDS). Tuberculous liver granulomas in such patients are usually atypical. The liver granulomas may be even totally absent, but liver tissue usually reveals numerous acid-fast bacilli. Focal tuberculosis of the liver is a less common form of liver tuberculous infection. We present a 33-year old white homosexual man infected with the human immunodeficiency virus. He had three tumour-like lesions in the left liver lobe, which were subsequently diagnosed as focal hepatic tuberculosis with local hemorrhage. This unusual presentation of liver tuberculosis indicates the necessity of an aggressive diagnostic approach for the evaluation of focal liver lesions in patients with AIDS.     

Tuberculous tenosynovitis: an uncommon manifestation

INTRODUCTION: Synovial sheath involvement of the foot is a rare location of tuberculosis. Its diagnosis is often delayed because of the indolent and chronicity of the clinical features. OBSERVATION: We report a case of bilateral tuberculous tenosynovitis of the anterior tibial and the common extensor of the toes, with uneventful outcome with antituberculous therapy. CONCLUSION: Tuberculous tenosynovitis is uncommon but should be kept in mind in chronic tenosynovitis.     

Tuberculosis of oral cavity

Tuberculous involvement of oral cavity is very rare. A 34-year-old male presented with non-healing ulcer at upper lip mucosa. Biopsy from ulcer revealed tuberculous lesion. He also had asymptomatic pulmonary tuberculosis diagnosed during work up for primary site of the disease.     

Hibernating Myocardium: A Review

Within a few seconds after a sudden reduction of coronary blood flow regional contractile dysfunction ensues. The mechanisms responsible for the rapid reduction in contractile function during acute myocardial ischemia remain unclear, but may involve a rise in inorganic phosphate. When severe ischemia, such as resulting from a sudden and complete coronary artery occlusion, is prolonged for more than 20–40 min, myocardial infarction develops, and there is irreversible loss of contractile function. When myocardial ischemia is less severe but nevertheless prolonged, the myocardium is dysfunctional but can remain viable. In such ischemic and dysfunctional myocardium, contractile function is reduced in proportion to the reduction in regional myocardial blood flow; i.e. a state of “perfusion-contraction matching” exists. The metabolic status of such myocardium improves over the first few hours, as myocardial lactate production is attenuated and creatine phosphate, after an initial reduction, returns towards control values. Ischemic myocardium, characterized by perfusion-contraction matching, metabolic recovery and lack of necrosis, has been termed “short-term hibernating myocardium”. Short-term hibernating myocardium can respond to an inotropic stimulation with increased contractile function, however, at the expense of a renewed worsening of the metabolic status. This situation of an increased regional contractile function at the expense of metabolic recovery during inotropic stimulation can be used to identify short-term hibernating myocardium. When inotropic stimulation is prolonged, the development of short-term hibernation is impaired and myocardial infarction develops. The mechanisms responsible for the development of short-term myocardial hibernation remain unclear at present; a significant involvement of adenosine and of activation of ATP-dependent potassium channels has been excluded. Whereas short-term hibernation is well characterized in animal experiments, the existence of hibernation over weeks or months (long-term hibernation) can only be inferred from clinical studies. Hibernation, as defined by Rahimtoola, is a state of chronic contractile dysfunction which is fully reversible upon reperfusion. Clinical syndromes consistent with the existence of myocardial hibernation include unstable and stable angina, acute myocardial infarction and left ventricular dysfunction and/or congestive heart failure. In long-term hibernating myocardium morphological alterations occur; the myofibrils are reduced in number and disorganized and myocardial glycogen content as well as the extracellular collagen network are increased. Thus, despite the fact that the myocardium remains viable during persistent ischemia and contractile dysfunction is reversible upon reperfusion, there are severe morphological alterations. Understandably, full functional recovery following reperfusion might therefore require weeks or even months.     

A tuberculous abscess of the chest wall in a renal allograft recipient

Tuberculous abscess of the chest wall is a rare localization of tuberculosis. We herein report a case of tuberculosis of the chest wall on a renal allograft recipient and provide discussion on optimal therapeutic management.KEY WORDS : Tuberculous abscess, chest wall, renal allograft     

Noninfiltrating Adenocarcinoma of the Lung Causing ST-Segment Elevation

ST-segment-elevation myocardial infarction is a leading cause of cardiovascular morbidity and death. We describe the case of a 51-year-old woman with advanced adenocarcinoma of the lung who presented with ST-segment elevation in the presence of an extracardiac lung mass but no objective evidence of myocardial ischemia or pericardial involvement. After the patient died of hypoxic respiratory failure, autopsy findings confirmed normal-appearing pericardium and myocardium, and mild-to-moderate atherosclerosis in the coronary arteries. A 4.5 × 4-cm extracardiac left hilar lung mass was confirmed to be poorly differentiated adenocarcinoma of the lung adjacent to the myocardium. The persistent current of injury that had been detected electrocardiographically was thought to occur from direct myocardial compression. ST-segment elevations secondary to direct mass contact on the myocardium should be considered in patients who have a malignancy and ST-segment elevation.     

结核性脑膜炎129例的临床与病理

目的 探讨结核性脑膜炎（结脑）的诊断。方法 对１９５２￣１９９４年经尸检证实的１２９例结脑进行回顾性分析。结果 生前误诊６４例，误诊率为４９．６％，其中３４例误诊为其他脑病疾病，余３０例误诊为重症肺结核、重症肺炎、胃癌、风湿性心脏病、肺心病及白血病。临床上以脑膜炎和脑外结核表现为主，脑脊液改变压力升高，细胞计数与蛋白含量增高，糖与氯化物降低。脑ＣＴ显示脑实质粟粒性结节影，颅底面、脑脚间池和大脑裂呈