Hemodialysis International 2015; 19:611–618
Disseminated tuberculosis mimicking metastatic colon cancer in a hemodialysis patient
To the Editor: We have read the interesting tuberculosis-related articles.1–3 We agree that disseminated tuberculosis (DT) is quite a neglected entity, notably in hemodialysis patients. To further complicate things, DT has become even more frequent (due to the increase in hemodialysis, immunosuppressant use, and human immunodeficiency virus [HIV] infection); but DT diagnosis is often delayed, potentially compromising patients’ prognosis.4–6 Additionally, we consider that an important way of fighting DT might be to publish more articles that will alert physicians about the disease. Thus, we describe here a very rare presentation of DT mimicking metastatic colon cancer in a hypertensive nephrosclerosis hemodialysis patient. A 44-year-old man presented with a 30-day history of fever, weight loss, low back pain, and hematochezia. Important laboratory findings were anemia, normal leukocytes, hypercalcemia, negative blood/urine cultures, and negative HIV testing. Consequently, the main hypothesis was metastatic colon cancer. During investigation at the ward, the patient had acute abdominal pain and rebound tenderness and surgical abdomen was diagnosed. Surgery showed yellow ascitic fluid, whitish peritoneal nodules, 8-cm cecal mass, and intra-abdominal lymphadenomegaly, with right hemicolectomy being performed. Histopathological sections showed confluent, caseating granulomas, compatible with tuberculosis.
Additionally, to investigate low back pain, a lumbosacral spine computed tomography (CT) was performed, revealing tuberculosis-compatible lesions (Figure 1). Finally, patient underwent a chest radiography, which was suggestive of tuberculosis (supported by a chest CT), although he denied respiratory symptoms (Figure 1). Thus, sputum was collected after being induced by aerosolized hypertonic saline, which was positive for Mycobacterium tuberculosis by GeneXpertMTB/RIF® (Cepheid, Sunnyvale, CA, USA) (confirmed by culture and sensitive to rifampicin-isoniazid). Thereafter, patient initiated rifampicin, isoniazid, pyrazinamide, and ethambutol. He showed good clinical outcome and is currently on his 6th month of tuberculosis treatment, with no complaints. This report’s main objective is to describe a very rare presentation of DT in a hemodialysis patient (mimicking metastatic colon cancer). A search in PubMed (February 28, 2015) using the terms disseminated tuberculosis AND (colon OR colorectal) AND cancer yielded only 6 articles.7,8 Additionally, we found only 2 cases of hemodialysis patients with tuberculosis presenting as hematochezia (1 had good clinical outcome, but the other died).9,10 So the few articles describing tuberculosis manifesting as hematochezia or metastatic colon cancer in hemodialysis reinforce the possibility of underdiagnosis of this infectious disease. Consequently, it is evident of the need to alert physicians to consider DT in different clinical scenarios
Figure 1 (a) A lumbosacral spine computed tomography (CT) revealing anterolateral vertebral body lesion (L3 level) with paraspinal abscess, compatible with tuberculosis. (b) High-resolution CT showing pulmonary infiltrates (with tree-in-bud pattern) in right upper lobe and right lower lobe, compatible with tuberculosis.
© 2015 International Society for Hemodialysis DOI:10.1111/hdi.12324
617
Letters to the Editor
(especially in hemodialysis patients with hematochezia, abdominal pain, low back pain, or weight loss), allowing early diagnosis, adequate treatment, and possibly improving prognosis.
3
4
DISCLOSURES None related to this article. Juliana BENTO-DA-CUNHA, Sergio R. CAVECHIA, Alfredo N.C. SANTANA HRAN Medical School, Escola Superior de Ciencias da Saude (ESCS), Brasilia, Distrito Federal, Brazil E-mail: [email protected]
5
6
7
Manuscript received March 2015; revised May 2015. 8
REFERENCES 1 Gavriilaki E, Sabanis N, Paschou E, Kalaitzoglou A, Michalaki K, Zarampoukas T. Disseminated tuberculosis: A neglected entity in immunocompromised hemodialysis patients. Hemodial Int. 2014; doi: 10.1111/hdi.12228. 2 Koulmane Laxminarayana SL, Nagaraju SP, Prabhu Attur R, Manohar C, Parthasarathy R, Chari B. Hemophagocytic lymphohistiocytosis: An unusual presentation of
618
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10
tuberculosis in hemodialysis patients. Hemodial Int. 2014; doi: 10.1111/hdi.12232. Hung YM, Huang NC, Wang JS, Wann SR. Isolated hepatic tuberculosis mimicking liver tumors in a dialysis patient. Hemodial Int. 2015; 19:344–346. Ayaslioglu E, Basar H, Duruyurek N, et al. Disseminated tuberculosis with lymphatic, splenic and scrotal abscesses: A case report. Cases J. 2009; 2:6995. Higuita LM, Nieto-Ríos JF, Daguer-Gonzalez S, et al. Tuberculosis in renal transplant patients: The experience of a single center in Medellín-Colombia, 2005–2013. J Bras Nefrol. 2014; 36:512–518. Sengoz G, Sengoz A, Pehlivanoglu F. AIDS and disseminated tuberculosis after Immune Reconstitution Inflammatory Syndrome. Braz J Infect Dis. 2014; 18:462– 463. García-Castro JM, Javier-Martínez R, López-Gómez M, Hidalgo-Tenorio C, López-Ruz MÁ, Jiménez-Alonso J. [Intestinal tuberculosis mimicking disseminated colorectal carcinoma]. Gastroenterol Hepatol. 2013; 36:461–463. Li YJ, Zhang Y, Gao S, Bai RJ. Systemic disseminated tuberculosis mimicking malignancy on F-18 FDG PETCT. Clin Nucl Med. 2008; 33:49–51. Siu YP, Tong MK, Kwok YL, et al. An unusual case of both upper and lower gastrointestinal bleeding in a kidney transplant recipient. Transpl Infect Dis. 2008; 10:276–279. García Marcos S, Borrego FJ, Martínez de la Victoria JM, et al. [Ileocecal tuberculosis during hemodialysis simulating carcinoma of the colon]. Nefrologia. 2001; 21:314– 318.
Hemodialysis International 2015; 19:611–618
Disseminated tuberculosis mimicking metastatic colon cancer in a hemodialysis patient
To the Editor: We have read the interesting tuberculosis-related articles.1–3 We agree that disseminated tuberculosis (DT) is quite a neglected entity, notably in hemodialysis patients. To further complicate things, DT has become even more frequent (due to the increase in hemodialysis, immunosuppressant use, and human immunodeficiency virus [HIV] infection); but DT diagnosis is often delayed, potentially compromising patients’ prognosis.4–6 Additionally, we consider that an important way of fighting DT might be to publish more articles that will alert physicians about the disease. Thus, we describe here a very rare presentation of DT mimicking metastatic colon cancer in a hypertensive nephrosclerosis hemodialysis patient. A 44-year-old man presented with a 30-day history of fever, weight loss, low back pain, and hematochezia. Important laboratory findings were anemia, normal leukocytes, hypercalcemia, negative blood/urine cultures, and negative HIV testing. Consequently, the main hypothesis was metastatic colon cancer. During investigation at the ward, the patient had acute abdominal pain and rebound tenderness and surgical abdomen was diagnosed. Surgery showed yellow ascitic fluid, whitish peritoneal nodules, 8-cm cecal mass, and intra-abdominal lymphadenomegaly, with right hemicolectomy being performed. Histopathological sections showed confluent, caseating granulomas, compatible with tuberculosis.
Additionally, to investigate low back pain, a lumbosacral spine computed tomography (CT) was performed, revealing tuberculosis-compatible lesions (Figure 1). Finally, patient underwent a chest radiography, which was suggestive of tuberculosis (supported by a chest CT), although he denied respiratory symptoms (Figure 1). Thus, sputum was collected after being induced by aerosolized hypertonic saline, which was positive for Mycobacterium tuberculosis by GeneXpertMTB/RIF® (Cepheid, Sunnyvale, CA, USA) (confirmed by culture and sensitive to rifampicin-isoniazid). Thereafter, patient initiated rifampicin, isoniazid, pyrazinamide, and ethambutol. He showed good clinical outcome and is currently on his 6th month of tuberculosis treatment, with no complaints. This report’s main objective is to describe a very rare presentation of DT in a hemodialysis patient (mimicking metastatic colon cancer). A search in PubMed (February 28, 2015) using the terms disseminated tuberculosis AND (colon OR colorectal) AND cancer yielded only 6 articles.7,8 Additionally, we found only 2 cases of hemodialysis patients with tuberculosis presenting as hematochezia (1 had good clinical outcome, but the other died).9,10 So the few articles describing tuberculosis manifesting as hematochezia or metastatic colon cancer in hemodialysis reinforce the possibility of underdiagnosis of this infectious disease. Consequently, it is evident of the need to alert physicians to consider DT in different clinical scenarios
Figure 1 (a) A lumbosacral spine computed tomography (CT) revealing anterolateral vertebral body lesion (L3 level) with paraspinal abscess, compatible with tuberculosis. (b) High-resolution CT showing pulmonary infiltrates (with tree-in-bud pattern) in right upper lobe and right lower lobe, compatible with tuberculosis.
© 2015 International Society for Hemodialysis DOI:10.1111/hdi.12324
617
Letters to the Editor
(especially in hemodialysis patients with hematochezia, abdominal pain, low back pain, or weight loss), allowing early diagnosis, adequate treatment, and possibly improving prognosis.
3
4
DISCLOSURES None related to this article. Juliana BENTO-DA-CUNHA, Sergio R. CAVECHIA, Alfredo N.C. SANTANA HRAN Medical School, Escola Superior de Ciencias da Saude (ESCS), Brasilia, Distrito Federal, Brazil E-mail: [email protected]
5
6
7
Manuscript received March 2015; revised May 2015. 8
REFERENCES 1 Gavriilaki E, Sabanis N, Paschou E, Kalaitzoglou A, Michalaki K, Zarampoukas T. Disseminated tuberculosis: A neglected entity in immunocompromised hemodialysis patients. Hemodial Int. 2014; doi: 10.1111/hdi.12228. 2 Koulmane Laxminarayana SL, Nagaraju SP, Prabhu Attur R, Manohar C, Parthasarathy R, Chari B. Hemophagocytic lymphohistiocytosis: An unusual presentation of
618
9
10
tuberculosis in hemodialysis patients. Hemodial Int. 2014; doi: 10.1111/hdi.12232. Hung YM, Huang NC, Wang JS, Wann SR. Isolated hepatic tuberculosis mimicking liver tumors in a dialysis patient. Hemodial Int. 2015; 19:344–346. Ayaslioglu E, Basar H, Duruyurek N, et al. Disseminated tuberculosis with lymphatic, splenic and scrotal abscesses: A case report. Cases J. 2009; 2:6995. Higuita LM, Nieto-Ríos JF, Daguer-Gonzalez S, et al. Tuberculosis in renal transplant patients: The experience of a single center in Medellín-Colombia, 2005–2013. J Bras Nefrol. 2014; 36:512–518. Sengoz G, Sengoz A, Pehlivanoglu F. AIDS and disseminated tuberculosis after Immune Reconstitution Inflammatory Syndrome. Braz J Infect Dis. 2014; 18:462– 463. García-Castro JM, Javier-Martínez R, López-Gómez M, Hidalgo-Tenorio C, López-Ruz MÁ, Jiménez-Alonso J. [Intestinal tuberculosis mimicking disseminated colorectal carcinoma]. Gastroenterol Hepatol. 2013; 36:461–463. Li YJ, Zhang Y, Gao S, Bai RJ. Systemic disseminated tuberculosis mimicking malignancy on F-18 FDG PETCT. Clin Nucl Med. 2008; 33:49–51. Siu YP, Tong MK, Kwok YL, et al. An unusual case of both upper and lower gastrointestinal bleeding in a kidney transplant recipient. Transpl Infect Dis. 2008; 10:276–279. García Marcos S, Borrego FJ, Martínez de la Victoria JM, et al. [Ileocecal tuberculosis during hemodialysis simulating carcinoma of the colon]. Nefrologia. 2001; 21:314– 318.
Hemodialysis International 2015; 19:611–618
