LYMPHADENITIS

A total of 48 patients were admitted with tuberculous lymphadenitis. Lymph node enlargement was the only sign of infection in 47 of them, preceding their admission by a median of 35 days (range: two days to one year). The remaining patient was admitted with high grade fever; he developed lymph node enlargement three days post-admission. The submandibular and anterior cervical lymph nodes were the most frequently involved nodes.

Twenty four of the 48 patients had a concurrent site of infection, including hilar lymphadenitis (23 patients) and adenoid tonsils and nasal tubercle (one patient). Chest radiographs disclosed a primary focus of infection and enlarged hilar lymph nodes in 21 patients, and calcified nodules in two others; the remaining 25 patients had normal chest radiographs. Tuberculin skin test in 47 patients had a median induration of 15 mm (range 10–30 mm). One patient noted a 5 mm induration.

Treatment consisted of a nine month course of isoniazid and rifampicin (35 patients) or a six month course of isoniazid and rifampicin in association with pyrazinamide during the first two months (13 patients). Thirty three of the 48 patients underwent surgery for diagnostic and/or therapeutic reasons at a median of 60 days (range: two days to one year) following the onset of lymphadenitis, including total excision (27 patients), incision and drainage (five patients), and wide debridement (one patient). Lymph node examination in 29 patients revealed histopathological features compatible with tuberculosis in all and M tuberculosisdetection in 11. In addition, histopathology and cultures revealed tuberculosis in the excised nasal granuloma and adenoid tonsils. Two patients had a second operation; one because of the development of axillary tuberculous lymphadenitis 75 days following total removal of collateral epitrochlear lymphadenitis, and another for aesthetic reasons. Gastric fluid cultures were performed in 15 patients and were positive in eight. Overall, 19 cases of tuberculous lymphadenitis were culture confirmed. In the remaining 29 cases, distinction from non-tuberculous mycobacterial lymphadenitis was based on a positive tuberculin skin test reaction, in association with chest radiographic findings compatible with tuberculosis and/or a history of exposure to tuberculosis.

PLEURAL EFFUSION

Of the 27 patients with tuberculous pleural effusion, 24 had symptoms including fever (22 patients), cough (10 patients), chest pain (seven patients), weakness (five patients), weight loss (four patients), and respiratory distress (two patients). Fever persisted for a median of 10 days (range 1–30 days). In the remaining three asymptomatic patients, pleural effusion was detected through contact investigation of a family member recently diagnosed with tuberculosis. The median tuberculin skin test induration for 26 patients was 20 mm (range 10–30 mm); one patient had no reaction. In addition to pleural effusion, chest radiographs showed enlarged hilar lymph nodes and nodular infiltrates in nine patients, interstitial markings in two, and atelectases in another. Seventeen patients had gastric fluid cultures, nine of which were positive. Fifteen patients received isoniazid plus rifampicin for nine months, and 12 received isoniazid and rifampicin for six months in association with pyrazinamide during the first two months. Adjunctive steroid treatment was administered for six weeks in 13 patients. All 27 patients noted clinical and radiographic response; however, three of them had recurrence of pleural effusion within one month of steroid discontinuation. Residual lesions (parenchymal or lymph node calcifications, or small pleural adhesions) were present at treatment completion in six patients; all others noted complete radiographic resolution.

MENINGITIS

Of the 16 patients with tuberculous meningitis, six were completely unvaccinated, very low income immigrants. Overall, patients with meningitis accounted for 46% of very low income patients, 42% of immigrants, and 25% of completely unvaccinated patients with extra-pulmonary tuberculosis.

All patients with meningitis presented with high grade fever preceding their admission by a median of seven days (range 0–17 days). Fever persisted for a median of 19 days (range 5–50 days). Additional signs and symptoms included nuchal rigidity (12 patients), vomiting (11 patients), headache (nine patients), drowsiness (seven patients), refusal to feed (four patients), weakness (three patients), status epilepticus (one patient), and irritability (one patient). Overall, tuberculous meningitis cases were classified as grades I and II with eight patients in each group.

The median tuberculin skin test induration in 14 patients was 15 mm (range 10–22 mm); two patients had no reaction. Chest radiographs showed nodular infiltrates and enlarged hilar lymph nodes in seven patients and calcified nodules in two. Seven patients had normal radiographs. Computed tomography and/or magnetic resonance examinations were performed in 11 patients and were abnormal in six. Findings included hydrocephalus in all six patients in association with basal ganglia vascular infarcts in one patient, tubercle located at hypophysis in another, and spinal leptomeninges involvement in a third. Microbiological confirmation was established in eight patients. Overall, cerebrospinal fluid (CSF) cultures were performed in 16 patients and were positive in six; gastric fluid cultures were attempted in 11 patients and were positive in four.

Patients with meningitis remained hospitalised for a median of 33 days (range 16–125 days). Antituberculous treatment was instituted in all patients at a median of two days (range 0–8 days) following admission. From 1982 to 1988, treatment for tuberculous meningitis consisted of isoniazid and rifampicin for 12 months in association with streptomycin during the first two months. Beginning in 1989, pyrazinamide for two months was added to the aforementioned regimen. Adjunctive steroid treatment was administered to all patients for a four week period followed by gradual dosage tapering. Five patients developed generalised seizures followed by apnoea, including two who required mechanical ventilation; two underwent shunt surgery for CSF flow relief; two had 7th cranial nerve palsy; and one developed transient diabetes insipidus. None of the patients died. However, two patients noted recurrence of meningitis as a result of non-compliance with treatment. Close supervision of treatment administration ensured their compliance. Regarding long term complications, six of the 16 patients developed permanent neurological deficits including balance impairment and urinary incontinence (two patients), blindness (one patient), quadriplegia, severe mental retardation, and seizures (one patient), fine movements impairment (one patient), and learning disabilities (one patient). Both patients with meningitis recurrence had neurological deficits. The median interval from admission to treatment introduction was six days (range 3–8 days) for patients with long term complications, and one day (range 0–3 days) for patients with no long term complications (p = 0.21). A further comparison between patients with and without long term complications showed that the former patients were younger (median age 3 v 5 years; p = 0.97), had smaller skin test reactions (median induration 7 v 15 mm; p = 0.45) and more pronounced CSF abnormalities (table 4). In particular, increased white blood and neutrophil counts were associated with the development of complications (p ⩽ 0.10). No difference was observed regarding the median interval from the onset of symptoms to time of admission and the addition of pyrazinamide to treatment.

SKELETAL TUBERCULOSIS

Five patients developed skeletal tuberculosis. The following sites were affected: hip–femoral joint (two patients), knee joint (two), and thoracic spine (one). Findings included localised inflammation (four patients), fever (three patients), limping as a result of pain (three patients), and restricted movements (two patients). Isotope scanning showed increased radionuclide uptake from the involved sites. Patients had a median tuberculin skin test induration of 20 mm (range 14–20 mm). Enlarged hilar lymph nodes were shown in three patients; the other two had normal chest radiographs. Surgery was performed in both patients with hip–femoral joint tuberculosis and revealed granulomatous tissue; however, bone cultures were negative. Synovial fluid cultures were performed in one patient with knee tuberculosis and were negative. Treatment consisted of isoniazid, rifampicin, pyrazinamide, and streptomycin for two months, followed by isoniazid and rifampicin for a total of 12 months. Complete clinical and imaging restoration was achieved in all patients within five months of treatment introduction. However, one patient developed chronic painless otorrhoea three months following treatment introduction. Computed tomography showed mastoiditis, and otomicroscopy disclosed white caseous material and granulomatous tissue in the inner ear. Cultures grew a multiple drug resistant M tuberculosis strain. Moderate unilateral high frequency sensorineural hearing loss was manifested. Ethambutol and cycloserin were added to treatment for a total of six months with complete clinical response.

MILIARY TUBERCULOSIS

Three patients developed miliary tuberculosis. The following symptoms were present: fever (three patients), cough (two patients), failure to thrive (two patients), tachypnoea, expiratory wheezing, and prolonged expiration (one patient), and night sweats (one patient). Chest radiographs showed bilateral, diffuse micronodules and lobular consodilation (three patients), atelectases (two patient), and enlarged hilar lymph nodes (one patient). The median tuberculin skin test induration was 10 mm (range 10–15 mm). All patients had positive gastric fluid cultures. Bronchiolitis was initially diagnosed in one infant; steroids were administered followed by clinical deterioration. At that time, the patient's positive tuberculin skin test reaction and its family history of tuberculosis became known and the diagnosis was established. All three patients were successfully treated with a nine month course of isoniazid plus rifampicin, in association with pyrazinamide and streptomycin during the first two months. Steroids were also administered for six weeks. No complications or relapse occurred among the three infants with miliary tuberculosis.

ABDOMINAL TUBERCULOSIS

Two patients developed abdominal tuberculosis; both presented with abdominal distension and fever for two weeks. One patient reported anorexia, fatigue, and low grade fever during the past three months, whereas constipation and dilated superficial abdominal veins were encountered in the other. Both patients had anaemia, positive skin test reactions (16 and 11 mm), and normal chest radiographs. Abdominal imaging revealed enlarged mesenteric lymph nodes and a large amount of peritoneal fluid in both patients, and an enteric–peritoneal fistula in one. No signs of intestinal obstruction were present. Patients received a 12 month course of isoniazid plus rifampicin in association with pyrazinamid for two months. Excellent response was noted. Both patients are free of active infection approximately 10 years following diagnosis.

PERICARDITIS

One child was admitted with fever, chest pain, and respiratory distress of three days duration. Weight loss was noted during the last month. Tuberculin skin test reaction was 20 mm. Chest imaging findings included miliary tuberculosis, accumulation of pericardial fluid, and adhesions within the pericardial space. Paracentesis yielded 300 ml of fluid. Pericardial and gastric fluid cultures grewM tuberculosis. The patient was successfully treated with isoniazid and rifampicin for 12 months in association with streptomycin, pyrazinamide, and steroids during the first two months. No complications or relapse of tuberculosis occurred.