1040
Tuberculous Abscesses in Patients with AIDS Helene Lupatkin,* Norbert Bran, Phyllis Flomenberg,t and Michael S. Simberkoff
From the Medical Service, Infectious Diseases Section, New York Veterans Affairs Medical Center, New York, New York
Infection with the human immunodeficiency virus (HIV) is associated with a host of immunologic defects, including depression of cell-mediated immunity [ 1 ]. Cell-mediated immunity is the principle host defense against infection with Mycobacterium tuberculosis [2]. Therefore, one might expect an increased frequency of symptomatic tuberculosis (TB) in persons infected with HIV and an increase in the severity of these infections. Before 1984 the number of cases of TB in the United States was steadily declining [3]. However, in 1986, 5 years after cases of AIDS were first reported, an increase of 2.6% in the annual number of cases of TB indicated a reversal of this trend [4]. Since then the number of cases of TB has increased dramatically; a 5% increase was observed in 1989, and a 6% increase was observed in 1990 (preliminary data) [5]. It appears that this resurgence of TB, especially in Florida, New York City, and California, is because of concomitant infection with HIV [6-12]. In patients with AIDS, the presentation of infection with M. tuberculosis can be atypical. For instance, for patients with pulmonary TB, a chest roentgenogram may appear normal or show interstitial infiltrates that can be confused with those observed in cases of Pneumocystis carinii pneumonia. (PCP). One particular feature of TB in HIV-infected individuals is that extrapulmonary manifestations occur more frequently. In 1979, during the pre-AIDS era, extrapulmonary
Received 26 August 1991; revised 9 December 1991. * Present address: Bronx Veterans Affairs Medical Center, Bronx, New York. t Present address: Milwaukee County Medical Center, Milwaukee, Wisconsin. Correspondence: Dr. Norbert Brat', Medical Service, Infectious Diseases Section, New York Veterans Affairs Medical Center, 423 East 23rd Street, New York, New York 10010. Reprints: Dr. Michael S. Simberkoff, Medical Service, Infectious Diseases Section, New York Veterans Affairs Medical Center, 423 East 23rd Street, New York, New York 10010.
Clinical Infectious Diseases 1992;14:1040-4 This article is in the public domain.
TB occurred in 14.9% of all cases of tuberculous infection in the United States [13]. In contrast, 50%-72% of HIV-infected patients with TB have involvement of extrapulmonary sites [9-12]. Over a 2-year period, several cases of large tuberculous abscesses in patients with AIDS have been observed at the New York Veterans Affairs Medical Center. These cases are described and analyzed herein.
Patients and Methods Patients. Forty-three patients with AIDS (as defined by the Centers for Disease Control [14]) for whom a diagnosis of TB was made between 1 January 1988 and 31 December 1989 were identified. Five of these patients were found to have one or more tuberculous abscesses. All five patients were hospitalized at the time of diagnosis. The abscesses were identified on the basis of appearance on computed tomography (CT), and a smear that was positive for acid-fast bacilli (AFB) or a culture of aspirated material that was positive for M. tuberculosis confirmed the diagnosis. These five cases were reviewed with respect to the following parameters: location of abscess on the CT scan, clinical presentation, prior diagnosis of AIDS, prior diagnosis of TB, treatment, and outcome. In addition, the chest roentgenographic findings, results of mycobacterial cultures and susceptibility tests, as well as CD4 + cell counts were reviewed. Mycobacteriologic methods. Clinical specimens were evaluated for the presence of AFB by auramine-rhodamine staining of smears. Cultures were performed on standard media (Lowenstein-Jensen and Middlebrook 7H11 agar) with an incubation period of 8 weeks. Blood specimens were collected in lysis-centrifugation tubes (Isolator, DuPont, Wilmington, DE). All the M. tuberculosis strains were identified with use of the DNA probe test (Gen-Probe, San Diego). Susceptibility of isolates to the following drugs was routinely tested: isoniazid, rifampin, streptomycin, ethambutol, kana-
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Five cases of large tuberculous abscesses in patients with AIDS were observed over a 2-year period at the New York Veterans Affairs Medical Center. These cases represent 11.6% of the 43 cases of tuberculosis diagnosed in patients with AIDS during that period. The abscesses were located in the liver, abdominal wall, psoas muscle, mediastinum, and peripancreatic area. All patients presented with localized pain or swelling, and four of five patients had fever. The diagnosis was made on the basis of detection of abscesses on computed tomography (CT) and the results of culture of abscess material obtained by CT-guided aspiration. CT-guided therapeutic drainage was performed in two cases. Despite administration of therapy, two of five patients died of tuberculous infection. Formation of tuberculous abscesses appears to be a common complication of tuberculosis in patients with AIDS. This diagnosis should be considered for patients with AIDS who have fever and localized pain or swelling.
Tuberculous Abscesses in Patients with AIDS
CID 1992;14 (May)
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Table 1. Characteristics and presentation of patients with tuberculous abscesses and AIDS.
Patient no.
Prior AIDSdefining illness
Prior diagnosis of TB
HIV risk factor
CD4 + cells per mm 3
Clinical presentation
Location of abscess
Fever, left flank mass
Liver, abdominal wall
Swelling and discharge at the right groin Fever, vomiting, abdominal pain Fever, swollen and Painful neck Fever, headache, swollen neck
Left psoas muscle, abdominal wall Peripancreatic
Increased markings in both bases Fibrotic changes in left upper lobe Normal
Neck, mediastinum
Left hilar prominence
Neck, mediastinum
Left upper and lower lobe infiltrates
PCP
None
IVDU
21
2
Miliary TB
Miliary
IVDU
456
3
None
None
IVDU
71
4
None
None
Homosexuality
15
5
PCP
Pulmonary
IVDU
n.d.
NOTE. TB = tuberculosis; PCP = Pneumocystis carinii pneumonia; IVDU = intravenous drug use; n.d. = not determined.
mycin, ethionamide, and p-aminosalicylic acid. Additional susceptibility testing with pyrazinamide, capreomycin, cycloserine, and ciprofloxacin was performed at the West Haven (CT) Veterans Affairs Medical Center.
Case Reports A summary of the patients' clinical presentation and characteristics is provided in table 1. Table 2 shows mycobacteriologic data, treatment modalities, and outcome for the patients. Patient 1. A 38-year-old man with a history of intravenous drug use (IVDU), AIDS, PCP, and esophageal candidiasis presented with fever, diarrhea, and a left flank mass of 2 weeks' duration. An abdominal CT scan showed two large
fluid collections in the liver and one in the adjacent abdominal wall (figure 1). Aspiration of the fluid in the abdominal wall yielded 60 mL of pus, and CT-guided drainage of one of the fluid collections in the liver yielded 120 mL of pus. Staining of both aspirates for AFB revealed many organisms, and M. tuberculosis was isolated from cultures of the aspirates. The patient received a regimen of isoniazid, rifampin, and pyrazinamide. Ethambutol was added to the regimen later when the M. tuberculosis isolate was found to be resistant to isoniazid. M. tuberculosis was isolated from sputum, urine, and blood as well as from the abscess aspirate. Despite appropriate antituberculous therapy, the patient developed progressive bilateral tuberculous pneumonia and empyema with bilateral pneumothoraces. He died 65 days after the initial treatment was begun.
Table 2. Summary of mycobacteriologic data, treatment, and outcome for patients with tuberculous abscesses and AIDS. Patient no.
Results of blood culture for M. tuberculosis
+
Other specimens + for M. tuberculosis
Drug resistance of M. tuberculosis isolate
None
3
Peripancreatic abscess fluid, stool Mediastinal abscess fluid, sputum, stool Mediastinal abscess fluid, sputum, urine
5
+
Improved
44
Improved
INH, Rif, PZA
48
Improved
Rif, Emb, PZA, Amik, Cpfx
94
Died
INH, Rif, Stm, Ethionamide
Sputum, CSF, urine
4
27
None
2
Outcome Died
Stm
INH
LOS (d) 65
INH, Rif, PZA, Emb, drainage of 60 mL of pus from abdominal wall abscess and 120 mL of pus from liver abscess INH, Rif, PZA, drainage of 1,200 mL of pus from psoas muscle abscess INH, Rif, PZA
Liver and abdominal wall abscess fluids, sputum, urine
1
Treatment
NOTE. + = positive; LOS = length of hospital stay; INH = isoniazid; Rif = rifampin; PZA = pyrazinamide; Emb = ethambutol; — = negative after 8 weeks; Stm = streptomycin; Amik = amikacin; Cpfx = ciprofloxacin.
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Appearance of chest roentgenogram
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Patient 2. A 32-year-old man with a history of IVDU was initially admitted for evaluation of fever and weight loss; the appearance of his chest roentgenogram was consistent with that of miliary TB. Treatment with isoniazid, rifampin, and pyrazinamide was begun; after the patient's condition improved clinically, he was discharged and continued to take these medications. M. tuberculosis that was sensitive to all drugs was isolated from sputum, urine, and CSF. The patient tested positive for HIV, and AIDS was diagnosed on the basis of this episode of extrapulmonary TB. After receiving a 5month course of antituberculous treatment, the patient returned to the hospital with swelling and purulent discharge at the right groin. Abdominal CT revealed a fluid collection in the right psoas muscle (without vertebral involvement) and in the adjacent abdominal wall (figure 2). Erosion of the right acetabulum was also noted. CT-guided drainage of the psoas muscle abscess yielded 1,200 mL of pus that showed many organisms on AFB stain. Mycobacterial cultures of the abscess fluid were negative. Treatment with three antituberculous drugs was continued, and the patient's condition improved clinically after the abscess was drained. He was discharged after 27 days. Patient 3. A 45-year-old man who reported former IVDU was admitted with fever, vomiting, and severe abdominal pain. Amylase levels were normal, and abdominal CT showed a poorly defined fluid collection surrounding the head of the pancreas. A chest roentgenogram was normal. CT-guided aspiration yielded purulent fluid with many AFB on staining, and M. tuberculosis grew in cultures of the fluid. A test for antibodies to HIV was positive, and AIDS was diagnosed. The patient's absolute CD4 + cell count was 71/ mm 3 . After treatment with isoniazid, rifampin, and pyrazinamide, the fever and abdominal symptoms resolved. After 44 days of hospitalization, the patient's condition was good, and he was discharged.
Patient 4. A 52-year-old homosexual man presented with fever and a swollen and painful neck. A chest roentgenogram showed prominence of the left hilum, and a CT scan of the chest and neck showed two fluid collections beneath the right sternocleidomastoid and tracheal displacement. Aspiration yielded purulent fluid; a smear of the fluid revealed AFB, and a culture of the fluid yielded M. tuberculosis. When treatment with isoniazid, rifampin, and pyrazinamide was instituted, the neck swelling and fever subsided gradually. The patient tested positive for antibodies to HIV, and AIDS was diagnosed. Despite continuous administration of antituberculous treatment, the neck swelling recurred 9 months later, thus necessitating multiple aspirations of fluid. All aspirates were negative for AFB on smear and cultures. Subsequently, the neck swelling resolved over 2 months without further intervention, and the patient has not experienced relapse for 2 years. Patient 5. A 33-year-old man with a history of IVDU, AIDS, and PCP initially presented with fever and dyspnea, and pulmonary infiltrates were noted on his chest roentgenogram. Sputum smears were positive for AFB, and treatment with isoniazid, rifampin, and pyrazinamide was begun. The patient was readmitted to the hospital 3 months later with fever, headache, and right-sided neck swelling. Aspiration of the neck swelling yielded pus, and a smear of the pus was positive for AFB. He refused to undergo lumbar puncture. The M. tuberculosis isolate from the original sputum culture performed 3 months earlier was resistant to multiple drugs, including isoniazid, rifampin (low level), ethionamide, and streptomycin; it was susceptible to ethambutol, pyrazinamide, kanamycin, capreomycin, cycloserine, ciprofloxacin, and p-aminosalicylic acid. The regimen was changed to a combination of rifampin, ethambutol, pyrazinamide, ciprofloxacin, and amikacin. The patient's condition improved
Figure 2. Pelvic CT image of patient 2 that shows (c) an abscess in the right psoas muscle and (d) an abscess in the adjacent abdominal wall.
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Figure 1. Abdominal CT image of patient 1 that demonstrates (a) an abscess beneath the right lateral thoracic wall and (b) a multiloculated abscess in the hepatic portal.
CID 1992;14 (May)
CID 1992;14 (May)
Tuberculous Abscesses in Patients with AIDS
Discussion Formation of tuberculous abscesses was a rare event in the pre-AIDS era. A review of 71 cases of extrapulmonary TB that were observed between 1968 and 1977 in two Boston hospitals revealed only six cases of tuberculous abscesses (three, paraspinal in association with osseous TB; one, dental; one, mediastinal; and one, psoas muscle) [15]. Since the beginning of the AIDS epidemic, 10 cases of tuberculous abscess formation in patients with AIDS have been reported; these included three pancreatic abscesses [16-18], two liver abscesses [19, 20], one testicular abscess [21], one prostatic abscess [17], one psoas muscle abscess [22], and two splenic abscesses [23]. Of these 10 patients, four required surgical drainage, four underwent percutaneous catheter drainage of the abscess, one underwent splenectomy, and one patient was treated solely with antituberculous medication. All 10 patients were discharged from the hospital. The five patients with AIDS described here had tuberculous abscesses in atypical locations. Tuberculous abscesses in HIV-negative individuals are typically found in association with tuberculous spondylitis (Pott's disease), and they present as paraspinal or psoas muscle abscesses [15, 24]. The abscesses described here were found in the neck and mediastinum, liver, abdominal wall, pancreas, and psoas muscle (without vertebral involvement but with possible pelvic bone involvement), sites rarely described before the AIDS epidemic. All patients presented with localized swelling or pain, and four of five presented with fever. The abscess was the initial presentation of tuberculous disease in three of the five cases. For two patients, the abscess, an extrapulmonary manifestation of TB, was the first AIDS-defining illness. No patient required surgical intervention. All cases were diagnosed by means of CT-guided aspiration of the abscess, and CT-guided therapeutic drainage was performed for two patients. Formation of tuberculous abscesses was a poor prognostic sign for two of the five patients; they died of overwhelming tuberculous infection despite therapy. Both deaths were associated with mycobacteremia, and in both cases M.
tuberculosis isolates were resistant to isoniazid (one strain was resistant to multiple drugs). The prevalence of TB, especially extrapulmonary TB, is high among patients with AIDS. However, the frequency of tuberculous abscesses in these patients is unknown. In this limited series, tuberculous abscesses were identified in five (11.6%) of 43 patients who had AIDS and TB. This percentage is probably an underestimate, since other patients for whom TB was diagnosed may have had abscesses without localized symptoms that would have led to a diagnostic work-up. A high index of suspicion with regard to tuberculous abscess formation should therefore be maintained for patients who have AIDS and TB, especially patients with persistent fevers despite administration of antituberculous treatment. CT imaging appears to be useful in both early diagnosis and percutaneous drainage of tuberculous abscesses.
References Hamburg MA, Koenig S, Fauci AS. Immunology of AIDS and HIV infection. In: Mandell GL, Douglas RG Jr, Bennett JE, eds. Principles and practice of infectious diseases. 3rd ed. New York: Churchill Livingstone, 1990:1046-59. 2. Collins FM. The immunology of tuberculosis. Am Rev Respir Dis 1982;125:42-9. 3. Centers for Disease Control. Tuberculosis-United States, 1985. MMWR 1986;35:699-703 4. Centers for Disease Control. Tuberculosis, final data-United States, 1986. MMWR 1988;36:817-20. 5. Centers for Disease Control. Cases of specified notifiable diseases, United States (52nd week). MMWR 1990;39:941-4. 6. Centers for Disease Control. Tuberculosis and acquired immunodeficiency syndrome-New York City. MMWR 1987;36:785-95. 7. Pitchenik AE, Burr J, Suarez M, Fertel D, Gonzalez G, Moas C. Human T-cell lymphotropic virus-III (HTLV-III) seropositivity and related disease among 71 consecutive patients in whom tuberculosis was diagnosed. Am Rev Respir Dis 1987;135:875-9. 8. Handwerger S, Mildvan D, Senie R, McKinley FW. Tuberculosis and the acquired immunodeficiency syndrome at a New York City hospital: 1978-1985. Chest 1987;91:176-80. 9. Sunderam G, McDonald RJ, Maniatis T, Oleske J, Kapila R, Reichman LB. Tuberculosis as a manifestation of the acquired immunodeficiency syndrome (AIDS). JAMA 1986;256:362-6. 10. Chaisson RE, Schecter GF, Theuer CP, Rutherford GW, Echenberg DF, Hopewell PC. Tuberculosis in patients with the acquired immunodeficiency syndrome: clinical features, response to therapy, and survival. Am Rev Respir Dis 1987;136:570-4. Pitchenik AE, Cole C, Russell BW, Fischl MA, Spira TJ, Snider DE Jr. Tuberculosis, atypical mycobacteriosis, and the acquired immunodeficiency syndrome among Haitian and non-Haitian patients in South Florida. Ann Intern Med 1984;101:641-5. 12. Louie E, Rice LB, Holzman RS. Tuberculosis in non-Haitian patients with acquired immunodeficiency syndrome. Chest 1986;90:542-5. 13. Centers for Disease Control. Tuberculosis Control Division. Tuberculosis in the United States, 1979. Atlanta: Centers for Disease Control, 1981:4-31. 14. Centers for Disease Control. Revision of the CDC surveillance case definition for acquired immunodeficiency syndrome. MMWR 1987;36(suppl 1):1S-15S. .
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clinically, but he left the hospital against medical advice after 3 weeks. He was readmitted 10 days later with recurrent fever and right-sided neck swelling. CT of the chest at that time showed a right posterior triangular abscess that extended into the upper mediastinum. The abscess was aspirated, and cultures of the fluid yielded M. tuberculosis. The patient continued to receive his antituberculous regimen but became progressively obtunded. Results of CT of the head with contrast were normal, and the family refused further evaluation. He died 6 weeks later. Sites from which M. tuberculosis was isolated included sputum, blood, the neck abscess, and urine.
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1 5. Alvarez S, McCabe WR. Extrapulmonary tuberculosis revisited: a re-
16. 17. 18.
19.
20. Weinberg JJ, Cohen P, Malhotra R. Primary tuberculous liver abscess associated with the human immunodeficiency virus. Tubercle 1988;69:145-7. 21. Goodman P, Maklad NF, Verani RR, Gottlieb HE. Tuberculous abscess of the testicle in AIDS: sonographic demonstration. Urol Radiol 1990;12:53-5. 22. Johnson SC, Stamm CP, Hicks CB. Tuberculous psoas muscle abscess following chemoprophylaxis with isoniazid in a patient with human immunodeficiency virus infection. Rev Infect Dis 1990;12:754-6. 23. Wolff MJ, Bitran J, Northland RG, Levy IL. Splenic abscesses due to Mycobacterium tuberculosis in patients with AIDS. Rev Infect Dis 1991;13:373-5. 24. Griffiths DL. Tuberculosis of the spine: a review. Adv Tuberc Res 1980;20:92-110.
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view of experience at Boston City and other hospitals. Medicine (Baltimore) 1984;63:25-55. Tetzeli JP, Pisegna JR, Barkin JS. Tuberculous pancreatic abscess as a manifestation of AIDS [letter]. Am J Gastroenterol 1989;84:581-2. Meinke AK. Pancreatic tuberculous abscess. Conn Med 1989;53:13941 Cho KC, Lucak SL, Delany HM, Morehouse HT, Jennings TA. CT appearance in tuberculous pancreatic abscess. J Comput Assist Tomogr 1990;14:152-4. Moreno S, Pacho E, LOpez-Herce JA, Rodriguez-Creixems M, MartinScapa C, Bouza E. Mycobacterium tuberculosis visceral abscesses in the acquired immunodeficiency syndrome (AIDS) [letter]. Ann Intern Med 1988;109:437.
CID 1992;14 (May)
Tuberculous Abscesses in Patients with AIDS Helene Lupatkin,* Norbert Bran, Phyllis Flomenberg,t and Michael S. Simberkoff
From the Medical Service, Infectious Diseases Section, New York Veterans Affairs Medical Center, New York, New York
Infection with the human immunodeficiency virus (HIV) is associated with a host of immunologic defects, including depression of cell-mediated immunity [ 1 ]. Cell-mediated immunity is the principle host defense against infection with Mycobacterium tuberculosis [2]. Therefore, one might expect an increased frequency of symptomatic tuberculosis (TB) in persons infected with HIV and an increase in the severity of these infections. Before 1984 the number of cases of TB in the United States was steadily declining [3]. However, in 1986, 5 years after cases of AIDS were first reported, an increase of 2.6% in the annual number of cases of TB indicated a reversal of this trend [4]. Since then the number of cases of TB has increased dramatically; a 5% increase was observed in 1989, and a 6% increase was observed in 1990 (preliminary data) [5]. It appears that this resurgence of TB, especially in Florida, New York City, and California, is because of concomitant infection with HIV [6-12]. In patients with AIDS, the presentation of infection with M. tuberculosis can be atypical. For instance, for patients with pulmonary TB, a chest roentgenogram may appear normal or show interstitial infiltrates that can be confused with those observed in cases of Pneumocystis carinii pneumonia. (PCP). One particular feature of TB in HIV-infected individuals is that extrapulmonary manifestations occur more frequently. In 1979, during the pre-AIDS era, extrapulmonary
Received 26 August 1991; revised 9 December 1991. * Present address: Bronx Veterans Affairs Medical Center, Bronx, New York. t Present address: Milwaukee County Medical Center, Milwaukee, Wisconsin. Correspondence: Dr. Norbert Brat', Medical Service, Infectious Diseases Section, New York Veterans Affairs Medical Center, 423 East 23rd Street, New York, New York 10010. Reprints: Dr. Michael S. Simberkoff, Medical Service, Infectious Diseases Section, New York Veterans Affairs Medical Center, 423 East 23rd Street, New York, New York 10010.
Clinical Infectious Diseases 1992;14:1040-4 This article is in the public domain.
TB occurred in 14.9% of all cases of tuberculous infection in the United States [13]. In contrast, 50%-72% of HIV-infected patients with TB have involvement of extrapulmonary sites [9-12]. Over a 2-year period, several cases of large tuberculous abscesses in patients with AIDS have been observed at the New York Veterans Affairs Medical Center. These cases are described and analyzed herein.
Patients and Methods Patients. Forty-three patients with AIDS (as defined by the Centers for Disease Control [14]) for whom a diagnosis of TB was made between 1 January 1988 and 31 December 1989 were identified. Five of these patients were found to have one or more tuberculous abscesses. All five patients were hospitalized at the time of diagnosis. The abscesses were identified on the basis of appearance on computed tomography (CT), and a smear that was positive for acid-fast bacilli (AFB) or a culture of aspirated material that was positive for M. tuberculosis confirmed the diagnosis. These five cases were reviewed with respect to the following parameters: location of abscess on the CT scan, clinical presentation, prior diagnosis of AIDS, prior diagnosis of TB, treatment, and outcome. In addition, the chest roentgenographic findings, results of mycobacterial cultures and susceptibility tests, as well as CD4 + cell counts were reviewed. Mycobacteriologic methods. Clinical specimens were evaluated for the presence of AFB by auramine-rhodamine staining of smears. Cultures were performed on standard media (Lowenstein-Jensen and Middlebrook 7H11 agar) with an incubation period of 8 weeks. Blood specimens were collected in lysis-centrifugation tubes (Isolator, DuPont, Wilmington, DE). All the M. tuberculosis strains were identified with use of the DNA probe test (Gen-Probe, San Diego). Susceptibility of isolates to the following drugs was routinely tested: isoniazid, rifampin, streptomycin, ethambutol, kana-
Downloaded from http://cid.oxfordjournals.org/ at Flinders University of South Australia on February 7, 2015
Five cases of large tuberculous abscesses in patients with AIDS were observed over a 2-year period at the New York Veterans Affairs Medical Center. These cases represent 11.6% of the 43 cases of tuberculosis diagnosed in patients with AIDS during that period. The abscesses were located in the liver, abdominal wall, psoas muscle, mediastinum, and peripancreatic area. All patients presented with localized pain or swelling, and four of five patients had fever. The diagnosis was made on the basis of detection of abscesses on computed tomography (CT) and the results of culture of abscess material obtained by CT-guided aspiration. CT-guided therapeutic drainage was performed in two cases. Despite administration of therapy, two of five patients died of tuberculous infection. Formation of tuberculous abscesses appears to be a common complication of tuberculosis in patients with AIDS. This diagnosis should be considered for patients with AIDS who have fever and localized pain or swelling.
Tuberculous Abscesses in Patients with AIDS
CID 1992;14 (May)
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Table 1. Characteristics and presentation of patients with tuberculous abscesses and AIDS.
Patient no.
Prior AIDSdefining illness
Prior diagnosis of TB
HIV risk factor
CD4 + cells per mm 3
Clinical presentation
Location of abscess
Fever, left flank mass
Liver, abdominal wall
Swelling and discharge at the right groin Fever, vomiting, abdominal pain Fever, swollen and Painful neck Fever, headache, swollen neck
Left psoas muscle, abdominal wall Peripancreatic
Increased markings in both bases Fibrotic changes in left upper lobe Normal
Neck, mediastinum
Left hilar prominence
Neck, mediastinum
Left upper and lower lobe infiltrates
PCP
None
IVDU
21
2
Miliary TB
Miliary
IVDU
456
3
None
None
IVDU
71
4
None
None
Homosexuality
15
5
PCP
Pulmonary
IVDU
n.d.
NOTE. TB = tuberculosis; PCP = Pneumocystis carinii pneumonia; IVDU = intravenous drug use; n.d. = not determined.
mycin, ethionamide, and p-aminosalicylic acid. Additional susceptibility testing with pyrazinamide, capreomycin, cycloserine, and ciprofloxacin was performed at the West Haven (CT) Veterans Affairs Medical Center.
Case Reports A summary of the patients' clinical presentation and characteristics is provided in table 1. Table 2 shows mycobacteriologic data, treatment modalities, and outcome for the patients. Patient 1. A 38-year-old man with a history of intravenous drug use (IVDU), AIDS, PCP, and esophageal candidiasis presented with fever, diarrhea, and a left flank mass of 2 weeks' duration. An abdominal CT scan showed two large
fluid collections in the liver and one in the adjacent abdominal wall (figure 1). Aspiration of the fluid in the abdominal wall yielded 60 mL of pus, and CT-guided drainage of one of the fluid collections in the liver yielded 120 mL of pus. Staining of both aspirates for AFB revealed many organisms, and M. tuberculosis was isolated from cultures of the aspirates. The patient received a regimen of isoniazid, rifampin, and pyrazinamide. Ethambutol was added to the regimen later when the M. tuberculosis isolate was found to be resistant to isoniazid. M. tuberculosis was isolated from sputum, urine, and blood as well as from the abscess aspirate. Despite appropriate antituberculous therapy, the patient developed progressive bilateral tuberculous pneumonia and empyema with bilateral pneumothoraces. He died 65 days after the initial treatment was begun.
Table 2. Summary of mycobacteriologic data, treatment, and outcome for patients with tuberculous abscesses and AIDS. Patient no.
Results of blood culture for M. tuberculosis
+
Other specimens + for M. tuberculosis
Drug resistance of M. tuberculosis isolate
None
3
Peripancreatic abscess fluid, stool Mediastinal abscess fluid, sputum, stool Mediastinal abscess fluid, sputum, urine
5
+
Improved
44
Improved
INH, Rif, PZA
48
Improved
Rif, Emb, PZA, Amik, Cpfx
94
Died
INH, Rif, Stm, Ethionamide
Sputum, CSF, urine
4
27
None
2
Outcome Died
Stm
INH
LOS (d) 65
INH, Rif, PZA, Emb, drainage of 60 mL of pus from abdominal wall abscess and 120 mL of pus from liver abscess INH, Rif, PZA, drainage of 1,200 mL of pus from psoas muscle abscess INH, Rif, PZA
Liver and abdominal wall abscess fluids, sputum, urine
1
Treatment
NOTE. + = positive; LOS = length of hospital stay; INH = isoniazid; Rif = rifampin; PZA = pyrazinamide; Emb = ethambutol; — = negative after 8 weeks; Stm = streptomycin; Amik = amikacin; Cpfx = ciprofloxacin.
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Appearance of chest roentgenogram
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Patient 2. A 32-year-old man with a history of IVDU was initially admitted for evaluation of fever and weight loss; the appearance of his chest roentgenogram was consistent with that of miliary TB. Treatment with isoniazid, rifampin, and pyrazinamide was begun; after the patient's condition improved clinically, he was discharged and continued to take these medications. M. tuberculosis that was sensitive to all drugs was isolated from sputum, urine, and CSF. The patient tested positive for HIV, and AIDS was diagnosed on the basis of this episode of extrapulmonary TB. After receiving a 5month course of antituberculous treatment, the patient returned to the hospital with swelling and purulent discharge at the right groin. Abdominal CT revealed a fluid collection in the right psoas muscle (without vertebral involvement) and in the adjacent abdominal wall (figure 2). Erosion of the right acetabulum was also noted. CT-guided drainage of the psoas muscle abscess yielded 1,200 mL of pus that showed many organisms on AFB stain. Mycobacterial cultures of the abscess fluid were negative. Treatment with three antituberculous drugs was continued, and the patient's condition improved clinically after the abscess was drained. He was discharged after 27 days. Patient 3. A 45-year-old man who reported former IVDU was admitted with fever, vomiting, and severe abdominal pain. Amylase levels were normal, and abdominal CT showed a poorly defined fluid collection surrounding the head of the pancreas. A chest roentgenogram was normal. CT-guided aspiration yielded purulent fluid with many AFB on staining, and M. tuberculosis grew in cultures of the fluid. A test for antibodies to HIV was positive, and AIDS was diagnosed. The patient's absolute CD4 + cell count was 71/ mm 3 . After treatment with isoniazid, rifampin, and pyrazinamide, the fever and abdominal symptoms resolved. After 44 days of hospitalization, the patient's condition was good, and he was discharged.
Patient 4. A 52-year-old homosexual man presented with fever and a swollen and painful neck. A chest roentgenogram showed prominence of the left hilum, and a CT scan of the chest and neck showed two fluid collections beneath the right sternocleidomastoid and tracheal displacement. Aspiration yielded purulent fluid; a smear of the fluid revealed AFB, and a culture of the fluid yielded M. tuberculosis. When treatment with isoniazid, rifampin, and pyrazinamide was instituted, the neck swelling and fever subsided gradually. The patient tested positive for antibodies to HIV, and AIDS was diagnosed. Despite continuous administration of antituberculous treatment, the neck swelling recurred 9 months later, thus necessitating multiple aspirations of fluid. All aspirates were negative for AFB on smear and cultures. Subsequently, the neck swelling resolved over 2 months without further intervention, and the patient has not experienced relapse for 2 years. Patient 5. A 33-year-old man with a history of IVDU, AIDS, and PCP initially presented with fever and dyspnea, and pulmonary infiltrates were noted on his chest roentgenogram. Sputum smears were positive for AFB, and treatment with isoniazid, rifampin, and pyrazinamide was begun. The patient was readmitted to the hospital 3 months later with fever, headache, and right-sided neck swelling. Aspiration of the neck swelling yielded pus, and a smear of the pus was positive for AFB. He refused to undergo lumbar puncture. The M. tuberculosis isolate from the original sputum culture performed 3 months earlier was resistant to multiple drugs, including isoniazid, rifampin (low level), ethionamide, and streptomycin; it was susceptible to ethambutol, pyrazinamide, kanamycin, capreomycin, cycloserine, ciprofloxacin, and p-aminosalicylic acid. The regimen was changed to a combination of rifampin, ethambutol, pyrazinamide, ciprofloxacin, and amikacin. The patient's condition improved
Figure 2. Pelvic CT image of patient 2 that shows (c) an abscess in the right psoas muscle and (d) an abscess in the adjacent abdominal wall.
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Figure 1. Abdominal CT image of patient 1 that demonstrates (a) an abscess beneath the right lateral thoracic wall and (b) a multiloculated abscess in the hepatic portal.
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Tuberculous Abscesses in Patients with AIDS
Discussion Formation of tuberculous abscesses was a rare event in the pre-AIDS era. A review of 71 cases of extrapulmonary TB that were observed between 1968 and 1977 in two Boston hospitals revealed only six cases of tuberculous abscesses (three, paraspinal in association with osseous TB; one, dental; one, mediastinal; and one, psoas muscle) [15]. Since the beginning of the AIDS epidemic, 10 cases of tuberculous abscess formation in patients with AIDS have been reported; these included three pancreatic abscesses [16-18], two liver abscesses [19, 20], one testicular abscess [21], one prostatic abscess [17], one psoas muscle abscess [22], and two splenic abscesses [23]. Of these 10 patients, four required surgical drainage, four underwent percutaneous catheter drainage of the abscess, one underwent splenectomy, and one patient was treated solely with antituberculous medication. All 10 patients were discharged from the hospital. The five patients with AIDS described here had tuberculous abscesses in atypical locations. Tuberculous abscesses in HIV-negative individuals are typically found in association with tuberculous spondylitis (Pott's disease), and they present as paraspinal or psoas muscle abscesses [15, 24]. The abscesses described here were found in the neck and mediastinum, liver, abdominal wall, pancreas, and psoas muscle (without vertebral involvement but with possible pelvic bone involvement), sites rarely described before the AIDS epidemic. All patients presented with localized swelling or pain, and four of five presented with fever. The abscess was the initial presentation of tuberculous disease in three of the five cases. For two patients, the abscess, an extrapulmonary manifestation of TB, was the first AIDS-defining illness. No patient required surgical intervention. All cases were diagnosed by means of CT-guided aspiration of the abscess, and CT-guided therapeutic drainage was performed for two patients. Formation of tuberculous abscesses was a poor prognostic sign for two of the five patients; they died of overwhelming tuberculous infection despite therapy. Both deaths were associated with mycobacteremia, and in both cases M.
tuberculosis isolates were resistant to isoniazid (one strain was resistant to multiple drugs). The prevalence of TB, especially extrapulmonary TB, is high among patients with AIDS. However, the frequency of tuberculous abscesses in these patients is unknown. In this limited series, tuberculous abscesses were identified in five (11.6%) of 43 patients who had AIDS and TB. This percentage is probably an underestimate, since other patients for whom TB was diagnosed may have had abscesses without localized symptoms that would have led to a diagnostic work-up. A high index of suspicion with regard to tuberculous abscess formation should therefore be maintained for patients who have AIDS and TB, especially patients with persistent fevers despite administration of antituberculous treatment. CT imaging appears to be useful in both early diagnosis and percutaneous drainage of tuberculous abscesses.
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clinically, but he left the hospital against medical advice after 3 weeks. He was readmitted 10 days later with recurrent fever and right-sided neck swelling. CT of the chest at that time showed a right posterior triangular abscess that extended into the upper mediastinum. The abscess was aspirated, and cultures of the fluid yielded M. tuberculosis. The patient continued to receive his antituberculous regimen but became progressively obtunded. Results of CT of the head with contrast were normal, and the family refused further evaluation. He died 6 weeks later. Sites from which M. tuberculosis was isolated included sputum, blood, the neck abscess, and urine.
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