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Generalised tuberculosis in a patient with Acquired Immunodeficiency Syndrome
Journal of Infection (x985) xo, 57-59
CASE REPORT
G e n e r a l i s e d t u b e r c u l o s i s in a p a t i e n t w i t h A c q u i r e d Immunodeficiency Syndrome A. de la Loma,* A. Manrique,* R. R u b i o , t M. S. Jim6nez,* J. Alvar,* E. P a l e n c i a t and R. N~jera*
* Centro Nacional de Microbiologia, Virologia e Inmunologia Sanitarias, Majadahonda, Madrid, Spain af Unidad de Cuidados Intensivos, Hospital Provincial de Madrid, Spain Accepted for publication 8 August I984 Summary We describe a heroin addict who presented with cellular immunodeficiency,generalised tuberculosis, and pneumonia caused by Pneumocystis carinii, and discuss the risk of these associations. Introduction In Spain, as in many other parts of the world, generalised tuberculosis is now a rare disease. Despite the severe cellular immunodepression of the acquired immunodeficiency syndrome (AIDS) 1, 2 this type of infection is usually found only in that part of the high-risk group constituted by Haitians. 3 T h e description of generalised tuberculosis in a Spanish drug addict diagnosed as having A I D S may therefore be of interest.
Case report A previously healthy 25-year-old unmarried man with a history of intravenous drug abuse and without a history of blood transfusion had been imprisoned from September I982 until October I983. He presented in November I983 with desquamation of the scalp and face, and over the sacrum. This was diagnosed as seborrhoeic dermatitis. T h e r e was also enlargement of cervical, inguinal and retroauricular lymph nodes which regressed when treated with an anti-inflammatory drug. During the last week of December I983 the patient complained of malaise, anorexia, extreme fatigue, diarrhoea, high fever and progressive dyspnoea, all of which forced him to remain in bed. On admission to hospital in January I984 interstitial pneumonia was diagnosed. After samples had been taken for microbiological tests he was treated with erythromycin, tobramycin and mezlocillin. His clinical and radiological condition continued to deteriorate and 6 days after admission he was transferred to the intensive care unit with X-ray appearances consistent with diffuse interstitial and alveolar pneumonia. Oropharyngeal candidiasis developed and the liver enlarged as far as 3 cm below the costal margin. Small bilateral inguinal lymph nodes were palpable. oi63-4453/85/oioo57 + 03 $02.00/o
© ~985 The British Society for the Study of Infection
58
A. D E L A L O M A
ETAL.
Cultures of blood and urine, Gram and Zhiel-Neelsen stains of sputum and bronchial washings were all repeatedly negative. Complement-fixation tests for antibodies to respiratory viruses (influenza A, influenza B, parainfluenza I, parainfluenza 2, parainfluenza 3, adenovirus, respiratory syncitial virus), Herpes simplex virus, cytomegalovirus and Mycoplasma pneumoniae, as well as indirect immunofluorescence tests for antibodies to Legionella pneumophila, Toxoplasma gondii and Epstein-Barr virus, were all negative. A I D S was suspected and immunological investigations were performed. These showed severe cellular immunodeficiency(cutaneous anergy, diminished P H A and Con A proliferative responses of lymphocytes), with normal humoral immunity and phagocytic function. Concentrations of IgG and IgA were elevated. T r e a t m e n t with ketoconozole was begun, and lung and lymph node biopsies taken. U p o n identification of Pneumocystis carinii by Giemsa staining in the lung biopsy, treatment was initiated with cotrimoxazole. Later, when fever persisted and a severe haematological reaction took place, pentamidine was substituted. Acid-fast bacilli were first observed in sputum on I7 February I984 when treatment was begun with isoniazid, rifampicin and ethambutol. Four days later, M. tuberculosis was isolated on L6wenstein-Jensen medium from both biopsy specimens. Despite treatment the patient died of respiratory failure on 22 February r984. M. tuberculosis was subsequently isolated from necropsy specimens of small intestine, liver, spleen, lung, bone marrow and an inguinal lymph node. All biopsy and necropsy samples were negative for viruses in cell culture. Discussion
Although tuberculosis is still prevalent in Spain, 4 the generalised form is unusual and extremely rare in young persons with a normal immune system. In A I D S there is severe immunodeficiency and generalised tuberculosis has been reported in patients from Haitifl where the prevalence of tuberculosis is extremely h i g h ) Delay in the diagnosis and treatment of tuberculosis in conditions of severe immunodepression will lead to dissemination of the disease and early death of the patient. We would therefore like to suggest the following measures: (I) Complete microbiological investigation of specimens, including biopsy samples, in all cases of pneumonia of unknown origin, especially if A I D S is suspected. (2) In countries where tuberculosis is endemic, initiation of prophylactic anti-tuberculosis therapy in all immunodepressed patients until such diagnosis can be reliably excluded. (3) Investigation for A I D S in patients with generalised tuberculosis without any known underlying cause. References
I. JandaWM. Update on the Acquired Immune DeficiencySyndrome.Clin MicrobiolNewslet 1984; 6:9-13 . 2. AIDS in Europe, Status Quo 1983. EurJ Cancer Clin Oncol 1984; 2o: 155-173.
Generalised tuberculosis in A I D S
59
3. Center for Disease Control. Opportunistic Infections and Kaposi's sarcoma among Haitians in the United States - Florida. M M W R 1982; 3x: 353-354~ 36o-361. 4. Carifiena J, Chac6n E, Candiel Me Carifiena ML. Consideraciones sobre la situaci6n actual de la endemia tuberculosa en Espafia. Rev San Hig Pub 1982; 56: 1153-1164. 5. Pitchewik AE, Fischl MA. Disseminated tuberculosis and the Acquired Immunodeficiency Syndrome. Ann Intern Med I983; 3: II2.
CASE REPORT
G e n e r a l i s e d t u b e r c u l o s i s in a p a t i e n t w i t h A c q u i r e d Immunodeficiency Syndrome A. de la Loma,* A. Manrique,* R. R u b i o , t M. S. Jim6nez,* J. Alvar,* E. P a l e n c i a t and R. N~jera*
* Centro Nacional de Microbiologia, Virologia e Inmunologia Sanitarias, Majadahonda, Madrid, Spain af Unidad de Cuidados Intensivos, Hospital Provincial de Madrid, Spain Accepted for publication 8 August I984 Summary We describe a heroin addict who presented with cellular immunodeficiency,generalised tuberculosis, and pneumonia caused by Pneumocystis carinii, and discuss the risk of these associations. Introduction In Spain, as in many other parts of the world, generalised tuberculosis is now a rare disease. Despite the severe cellular immunodepression of the acquired immunodeficiency syndrome (AIDS) 1, 2 this type of infection is usually found only in that part of the high-risk group constituted by Haitians. 3 T h e description of generalised tuberculosis in a Spanish drug addict diagnosed as having A I D S may therefore be of interest.
Case report A previously healthy 25-year-old unmarried man with a history of intravenous drug abuse and without a history of blood transfusion had been imprisoned from September I982 until October I983. He presented in November I983 with desquamation of the scalp and face, and over the sacrum. This was diagnosed as seborrhoeic dermatitis. T h e r e was also enlargement of cervical, inguinal and retroauricular lymph nodes which regressed when treated with an anti-inflammatory drug. During the last week of December I983 the patient complained of malaise, anorexia, extreme fatigue, diarrhoea, high fever and progressive dyspnoea, all of which forced him to remain in bed. On admission to hospital in January I984 interstitial pneumonia was diagnosed. After samples had been taken for microbiological tests he was treated with erythromycin, tobramycin and mezlocillin. His clinical and radiological condition continued to deteriorate and 6 days after admission he was transferred to the intensive care unit with X-ray appearances consistent with diffuse interstitial and alveolar pneumonia. Oropharyngeal candidiasis developed and the liver enlarged as far as 3 cm below the costal margin. Small bilateral inguinal lymph nodes were palpable. oi63-4453/85/oioo57 + 03 $02.00/o
© ~985 The British Society for the Study of Infection
58
A. D E L A L O M A
ETAL.
Cultures of blood and urine, Gram and Zhiel-Neelsen stains of sputum and bronchial washings were all repeatedly negative. Complement-fixation tests for antibodies to respiratory viruses (influenza A, influenza B, parainfluenza I, parainfluenza 2, parainfluenza 3, adenovirus, respiratory syncitial virus), Herpes simplex virus, cytomegalovirus and Mycoplasma pneumoniae, as well as indirect immunofluorescence tests for antibodies to Legionella pneumophila, Toxoplasma gondii and Epstein-Barr virus, were all negative. A I D S was suspected and immunological investigations were performed. These showed severe cellular immunodeficiency(cutaneous anergy, diminished P H A and Con A proliferative responses of lymphocytes), with normal humoral immunity and phagocytic function. Concentrations of IgG and IgA were elevated. T r e a t m e n t with ketoconozole was begun, and lung and lymph node biopsies taken. U p o n identification of Pneumocystis carinii by Giemsa staining in the lung biopsy, treatment was initiated with cotrimoxazole. Later, when fever persisted and a severe haematological reaction took place, pentamidine was substituted. Acid-fast bacilli were first observed in sputum on I7 February I984 when treatment was begun with isoniazid, rifampicin and ethambutol. Four days later, M. tuberculosis was isolated on L6wenstein-Jensen medium from both biopsy specimens. Despite treatment the patient died of respiratory failure on 22 February r984. M. tuberculosis was subsequently isolated from necropsy specimens of small intestine, liver, spleen, lung, bone marrow and an inguinal lymph node. All biopsy and necropsy samples were negative for viruses in cell culture. Discussion
Although tuberculosis is still prevalent in Spain, 4 the generalised form is unusual and extremely rare in young persons with a normal immune system. In A I D S there is severe immunodeficiency and generalised tuberculosis has been reported in patients from Haitifl where the prevalence of tuberculosis is extremely h i g h ) Delay in the diagnosis and treatment of tuberculosis in conditions of severe immunodepression will lead to dissemination of the disease and early death of the patient. We would therefore like to suggest the following measures: (I) Complete microbiological investigation of specimens, including biopsy samples, in all cases of pneumonia of unknown origin, especially if A I D S is suspected. (2) In countries where tuberculosis is endemic, initiation of prophylactic anti-tuberculosis therapy in all immunodepressed patients until such diagnosis can be reliably excluded. (3) Investigation for A I D S in patients with generalised tuberculosis without any known underlying cause. References
I. JandaWM. Update on the Acquired Immune DeficiencySyndrome.Clin MicrobiolNewslet 1984; 6:9-13 . 2. AIDS in Europe, Status Quo 1983. EurJ Cancer Clin Oncol 1984; 2o: 155-173.
Generalised tuberculosis in A I D S
59
3. Center for Disease Control. Opportunistic Infections and Kaposi's sarcoma among Haitians in the United States - Florida. M M W R 1982; 3x: 353-354~ 36o-361. 4. Carifiena J, Chac6n E, Candiel Me Carifiena ML. Consideraciones sobre la situaci6n actual de la endemia tuberculosa en Espafia. Rev San Hig Pub 1982; 56: 1153-1164. 5. Pitchewik AE, Fischl MA. Disseminated tuberculosis and the Acquired Immunodeficiency Syndrome. Ann Intern Med I983; 3: II2.