A Case of Rib Tuberculosis and Chest Wall Abscess with Multi-Drug Hypersensitivity Reactions

Extrapulmonary tuberculosis is the reactivation of the remaining latent organism which spreads during primary infection by the lymphohematogenous way. It should be considered in the differential diagnosis especially in endemic countries for tuberculosis. Tuberculosis (TB) treatment is based on the principle of the combined use of several drugs. As a result of the combination therapy there can be life threatening side effects which can lead to improper use of medications and may also cause drug resistance. In this report, we present an 85-year-old male patient desensitized due to the development of allergy against multi-drugs with rib tuberculosis and chest wall abscess to whom, culture, drug susceptibility and genotypical tests were applied. In November 2012, the patient applied to a medical center with complaints of swelling and pain under the right rib, underwent rib resection and eventually diagnosed as rib TB by histopathological examination. However, the anti-TB treatment was discontinued due to the hypersensitivity reactions in the skin and in addition to the hepatic and renal dysfunction side effects. The patient had widespread redness, rash and pruritus on the body and the laboratory findings were as follows; ALT: 114 U/L, AST: 152 U/L, ALP: 93 U/L, GGT: 26U/L, blood urea nitrogen (BUN): 26 mg/dL and creatinine: 1.7 mg/dL. After the disapperance of the complaints within 3 days of drug discontinuation, isoniazid treatment was initiated. However, the new treatment was also discontinued when the reactions reoccurred. Afterwards, the patient developed hypersensitivity reactions against the combination of streptomycin and ethambutol. The patient refused any further treatment and was discharged from the hospital. The patient was untreated for the last 5 months and admitted to our clinic with a fistulized swelling and abscess in the right chest wall. Bacteria was not detected in the acid-fast staining of the abscess material, however Mycobacterium tuberculosis was isolated from culture by MGIT (Mycobacteria Growth Incubator Tube; BBL MGIT, BD, USA) system. The spoligotyping revealed that the genotype was Haarlem 1. Major drug susceptibility testing against rifampin, streptomycin, ethambutol, isoniazid, and pyrazinamide yielded sensitivity to those drugs. Minor drug susceptibility testing against paraaminosalicylic acid, ethionamide, kanamycin, capreomycin and ofloxacin was found to be sensitive. A regimen of isoniazid 300 mg/day, ethambutol 1000 mg/day and moxifloxacin 400 mg/day was initiated. Rapid oral desensitization against isoniazid and ethambutol were repeated on two consecutive days. The patient continued antituberculosis therapy for 12 months without adverse reactions. The chest wall fistula was closed. Abscess was drained surgically. Clinical and radiological improvements were achieved. The patient remains clinically disease free and continues his regular follow ups. This case is presented to emphasize about the importance of culture and susceptibility testing in extrapulmonary tuberculosis cases and desensitization in drug hypersensitivity reactions

A Case of Rib Tuberculosis and Chest Wall Abscess with Multi-Drug Hypersensitivity Reactions

Akciğer dışı tüberküloz, primer enfeksiyon sırasında lenfohematojen yolla yayılan ve latent kalan basilin ileri bir dönemde reaktive olması ile gelişir. Özellikle tüberkülozun endemik olduğu ülkelerde ayırıcı tanıda düşünülmelidir. Tüberküloz (TB) tedavisinde ilaçların birlikte kullanımından kaynaklanan yan etkiler, hasta hayatını tehdit etmekte, ayrıca ilaçların düzensiz kullanımına yol açarak ilaç direncine neden olmaktadır. Bu raporda, çok ilaca karşı aşırı duyarlılık reaksiyonu gelişmesi nedeniyle desensitizasyon uygulanan, kültür, ilaç duyarlılık testi ve genotipik tiplendirmesi yapılan kot tüberkülozu ve göğüs duvarı apsesi saptanan 85 yaşındaki bir erkek olgu sunulmaktadır. Hastaya Kasım 2012'de sağ kaburga altında şişlik ve ağrı ile başvurduğu merkezde kot rezeksiyonu yapılmış ve biyopsinin histopatolojik incelemesi sonucunda kot TB tanısı konulmuştur. Başlanan dörtlü anti-TB tedavi deride aşırı duyarlılık reaksiyonları ile böbrek ve karaciğer fonksiyon bozukluğu yan etkileri nedeniyle kesilmiştir. Vücutta yaygın kızarıklık, döküntü ve kaşıntı şikayeti olan hastanın laboratuvar tetkiklerinde; ALT: 114 U/L, AST: 152 U/L, ALP: 93 U/L, GGT: 26 U/L, kan üre azotu (BUN): 26 mg/dL ve kreatinin: 1.7 mg/dL olarak tespit edilmiştir. İlaçlar kesildikten 3 gün sonra şikayetler geçince tedaviye kademeli olarak başlanmıştır. Tekrar reaksiyon gelişince hasta tedaviyi reddetmiş ve klinikten taburcu edilmiştir. Beş aydır ilaç kullanmayan hasta sağ göğüs duvarında fi stülize şişlik ve apse nedeniyle kliniğimize başvurmuştur. Apse materyalinde aside dirençli boyamada bakteri görülmemiştir. MGIT (Mycobacteria Growth Incubator Tube; BBL, MGIT, BD, ABD) sistemi ile yapılan kültürde Mycobacterium tuberculosis üretilmiştir. Spoligotiplendirme ile üretilen suşun Haarlem 1 genotipi olduğu saptanmıştır. Majör ilaçlara karşı yapılan duyarlılık testlerinde izolat; rifampisin, streptomisin, etambutol, izoniyazid ve pirazinamide duyarlı, minör ilaçlara karşı yapılan duyarlılık testlerinde ise paraaminosalisilik asit, etionamid, kanamisin, kapreomisin ve ofl oksasine duyarlı bulunmuştur. Alerji kliniğine sevk edilen hastaya, desensitizasyon protokolü uygulanmış ve hastanın tedavisi yeniden düzenlenmiştir. Hastaya; izoniazid 300 mg/gün, etambutol 1000 mg/gün ve moksifl oksasin 400 mg/gün şeklinde antitüberküloz tedavi başlanmıştır. Tedavi sırasında alerjik reaksiyon izlenmemiştir. Cerrahi olarak apse boşaltılmıştır. Klinik ve radyolojik iyileşme sağlanmıştır. Tedaviye toplam 12 ay devam edilmiştir. Hasta halen sağlıklı olarak kontrollerine gelmektedir. Bu hasta, akciğer dışı tüberküloz olgularında, kültür ve duyarlılık testlerinin önemini ve ilaç duyarlılığı gösteren olgularda desensitizasyonun önemini vurgulamak amacıyla sunulmuşturExtrapulmonary tuberculosis is the reactivation of the remaining latent organism which spreads during primary infection by the lymphohematogenous way. It should be considered in the differential diagnosis especially in endemic countries for tuberculosis. Tuberculosis (TB) treatment is based on the principle of the combined use of several drugs. As a result of the combination therapy there can be life threatening side effects which can lead to improper use of medications and may also cause drug resistance. In this report, we present an 85-year-old male patient desensitized due to the development of allergy against multi-drugs with rib tuberculosis and chest wall abscess to whom, culture, drug susceptibility and genotypical tests were applied. In November 2012, the patient applied to a medical center with complaints of swelling and pain under the right rib, underwent rib resection and eventually diagnosed as rib TB by histopathological examination. However, the anti-TB treatment was discontinued due to the hypersensitivity reactions in the skin and in addition to the hepatic and renal dysfunction side effects. The patient had widespread redness, rash and pruritus on the body and the laboratory fi ndings were as follows; ALT: 114 U/L, AST: 152 U/L, ALP: 93 U/L, GGT: 26U/L, blood urea nitrogen (BUN): 26 mg/dL and creatinine: 1.7 mg/dL. After the disapperance of the complaints within 3 days of drug discontinuation, isoniazid treatment was initiated. However, the new treatment was also discontinued when the reactions reoccurred. Afterwards, the patient developed hypersensitivity reactions against the combination of streptomycin and ethambutol. The patient refused any further treatment and was discharged from the hospital. The patient was untreated for the last 5 months and admitted to our clinic with a fi stulized swelling and abscess in the right chest wall. Bacteria was not detected in the acid-fast staining of the abscess material, however Mycobacterium tuberculosis was isolated from culture by MGIT (Mycobacteria Growth Incubator Tube; BBL MGIT, BD, USA) system. The spoligotyping revealed that the genotype was Haarlem 1. Major drug susceptibility testing against rifampin, streptomycin, ethambutol, isoniazid, and pyrazinamide yielded sensitivity to those drugs. Minor drug susceptibility testing against paraaminosalicylic acid, ethionamide, kanamycin, capreomycin and ofl oxacin was found to be sensitive. A regimen of isoniazid 300 mg/day, ethambutol 1000 mg/day and moxifl oxacin 400 mg/day was initiated. Rapid oral desensitization against isoniazid and ethambutol were repeated on two consecutive days. The patient continued antituberculosis therapy for 12 months without adverse reactions. The chest wall fi stula was closed. Abscess was drained surgically. Clinical and radiological improvements were achieved. The patient remains clinically disease free and continues his regular follow ups. This case is presented to emphasize about the importance of culture and susceptibility testing in extrapulmonary tuberculosis cases and desensitization in drug hypersensitivity reactions

Factors Affecting the Interval from Diagnosis to Treatment in Patients with Lung Cancer

Aims and background. We aimed to investigate the factors affecting the interval from the beginning of the symptoms until diagnosis and treatment in patients with lung cancer

Factors affecting the interval from diagnosis to treatment in patients with lung cancer

Aims and background. We aimed to investigate the factors affecting the interval from the beginning of the symptoms until diagnosis and treatment in patients with lung cancer