A 74-year-old Finnish-born woman with a history of nummular eczema presented to the emergency department with fever and abdominal pain. Computed tomography revealed ascites and cholecystitis. The inflamed gallbladder was removed laparoscopically. During the operation, the peritoneal surface was observed to be covered with nodules, and a biopsy was taken. Histopathological analysis showed necrotizing granulomas; however, polymerase chain reaction (PCR), Ziehl-Neelsen staining, and cultures were negative for tuberculosis. Subsequently, new biopsies and fluid samples were collected from ascites, pleural fluid, an axillary lymph node, and via endobronchial ultrasound; all were culture- and PCR-negative for tuberculosis and histologically negative for malignancy. Only the histological sample taken from the axilla showed granulomas and a structure that could represent a single tuberculosis bacillus (Fig. 1, 2). Positron emission tomography (PET) revealed extensive peritoneal inflammation and some active lymph nodes (Fig. 3C1-3C4). Empiric four-drug tuberculosis therapy was initiated. Finally, both PCR and culture from a cervical lymph node confirmed tuberculosis, which was sensitive to first-line drugs. After six months of treatment, the inflammation had almost resolved (Fig. 3C5-3C8) except for a small focus of persistent inflammatory metabolic activity on the caudal surface of the liver and in the liver parenchyma. Some studies suggest that persistent inflammation on follow-up PET scans is associated with a higher risk of tuberculosis relapse [1, 2]. Due to this and especially the widespread nature of the disease, treatment was extended to 9 months. This case also illustrates the challenges of diagnosing tuberculosis, as five separate samples were required before the diagnosis was confirmed.
Fig. 1.
Histologically, the lymph node biopsy revealed sarcoid-like granulomas (red arrow) composed of epithelioid histiocytes and multinucleated Langhans-type giant cells
Fig. 2.
A single acid-fast, mycobacteria-like organism (black arrow) was identified in the granulomas using Ziehl –Neelsen staining
Fig. 3.
FDG-PET / contrast-enhanced CT Images at baseline (upper row) and after treatment (lower row). Maximum Intensity Projection (MIP) at baseline showing diffuse metabolic activity in lymph nodes of the neck, mediastinum, and epigastrium. Diffuse hypermetabolism is seen in the intra-abdominal cavity along the mesentery and peritoneum (C1). After treatment, complete resolution of supradiaphragmatic lymph nodes is observed. A new active focus in the liver parenchyma and low-grade persistent metabolic activity on the caudal surface of the liver are noted, while other peritoneal and mesenteric foci have disappeared (C5). Diffuse mesenteric and peritoneal wall hypermetabolic changes and a good treatment response are visualized in coronal and sagittal fusion images (C2, C3, C6, C7). Contrast-enhanced CT shows nodulation, diffuse mesenteric edema, and ascites, as well as their resolution after treatment (C4, C8)
Author contributions
L.T.: conceptualization, clinical management, writing and editing; A.M.: pathological investigation, editing; H.T.: imagining, editing, JR: conceptualization, clinical management, writing-original draft, and editing. All authors have read and approved the final draft.
Funding
Open access funding provided by Tampere University (including Tampere University Hospital). No external funding.
Data availability
No datasets were generated or analysed during the current study.
Declarations
Informed consent
The patient has given written consent for the presentation and publication of the case.
Competing interests
The authors declare no competing interests.
References
- 1.Lang D, Huber H, Kaiser B, Virgolini I, Lamprecht B, Gabriel M. SUV as a possible predictor of disease extent and therapy duration in complex tuberculosis. Clin Nucl Med. 2018;43(2):94–100. [DOI] [PubMed]
- 2.Malherbe ST, Shenai S, Ronacher K, Loxton AG, Dolganov G, Kriel M. et al. Persisting positron emission tomography lesion activity and Mycobacterium tuberculosis mRNA after tuberculosis cure. Nat Med. 2016;22(10):1094–1100. doi: 10.1038/nm.4177. [DOI] [PMC free article] [PubMed]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
No datasets were generated or analysed during the current study.