Trismus and voice change after starting tuberculosis treatment.
Trismus and voice change after starting tuberculosis treatment.
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DOI：
10.1016/j.idcr.2021.e01307
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发表时间：
2021
期刊：
影响因子：
1.5
通讯作者：
Sereti I
中科院分区：
文献类型：
--
作者：
Rocco JM;Hammoud DA;Allen CT;Galindo F;Laidlaw E;Sereti I
一名29岁的男性，患有围产期获得性人类免疫缺陷病毒(HIV)，新诊断为播散性结核病，在重新开始抗逆转录病毒治疗(ART)一个月后，出现发烧、鼻塞和声音改变。他出生在马拉维，10岁时移居美国，没有额外的国外旅行。他的艾滋病毒一直得到很好的控制，直到新冠肺炎大流行开始时，他失去了工作和医疗保险。随后，他患上双侧上叶肺炎，痰培养出结核分枝杆菌。在重新启动ART之前，他接受了两个月的抗分枝杆菌治疗。在提交给美国国立卫生研究院后，他获得了知情同意，并登记参加了临床试验NCT02147405。他发烧伴有双侧颈淋巴结病，并因三叉神经痛而无法完全张开嘴。实验室研究显示，自开始抗逆转录病毒治疗以来，C反应蛋白117.8毫克/L，CD+T细胞计数126个细胞/毫升，艾滋病毒病毒载量减少了4对数。正电子发射断层扫描(PET)显示多处积液，周围摄取的FDG与炎性坏死性淋巴结一致(图1、A和B)。血、痰和淋巴结抽吸物培养均为阴性。泼尼松最初用于治疗免疫重建炎症综合征(IRIS)，但随访的计算机断层扫描(CT)显示坏死性淋巴结的大小没有明显减小(图1C)。他接受了多次切开和引流手术，鼻塞和嗓音改变随后得到改善，颈部淋巴结明显缩小(图1D)。抗酸染色始终显示出沉重的生物负荷，但所有分枝杆菌培养在6周时仍为阴性。经过5个月的泼尼松和抗分枝杆菌治疗，他的炎症症状消失了。结核病-IRIS可导致全身淋巴结坏死，并可能涉及独特的部位[1]。尽管分枝杆菌对抗酸染色的负担很重，但没有分离出活的微生物，这突显了这种炎症过程是由抗原驱动的，不需要复制病原体[2]。当出现大的坏死性淋巴结时，可以安全地进行切开和引流以减少抗原负荷。其他治疗主要包括类固醇治疗，同时继续使用抗分枝杆菌药物和ART，直到炎症症状改善[1]。英夫利昔单抗也被成功地用于控制难治性病例的IRIS相关炎症[3]。
A 29-year-old man with perinatally-acquired human immunodeficiency virus (HIV) and newly diagnosed disseminated tuberculosis on treatment presented one month after restarting antiretroviral therapy (ART) with fevers, nasal obstruction, and change in voice. He was born in Malawi and moved to the United States at 10-years old with no additional travel outside the country. His HIV was well-controlled until he lost his job and health insurance at the start of the COVID-19 pandemic. Subsequently, he developed bilateral, upper lobe pneumonia with sputum culture growing Mycobacterium tuberculosis. He was treated for two-months with anti-mycobacterials prior to restarting ART. On presentation to the National Institutes of Health, informed consent was obtained, and he enrolled on clinical trial NCT02147405. He was febrile with bilateral cervical lymphadenopathy and unable to fully open his mouth due to trismus. Laboratory studies revealed a CRP 117.8 mg/L, CD4+ T cell count 126 cells/mcL and a four log HIV viral load reduction since starting ART. Positron emission tomography (PET) scan demonstrated multiple fluid collections with peripheral uptake of FDG consistent with inflamed necrotic lymph nodes (Fig. 1 A and B). Blood, sputum, and lymph node aspirate cultures were negative. Prednisone was initiated for immune reconstitution inflammatory syndrome (IRIS), but follow-up computed tomography (CT) showed no appreciable decrease in the size of the necrotic lymph nodes (Fig. 1 C). He underwent multiple incision and drainage procedures and his nasal obstruction and voice changes subsequently improved with markedly decreased size of the cervical lymph nodes (Fig. 1 D). Acid fast staining consistently showed heavy organism burden, but all mycobacterial cultures remained negative at six-weeks. After five-months of prednisone with anti-mycobacterial therapy, his inflammatory symptoms resolved. Tuberculosis-IRIS can cause lymph node necrosis throughout the body and may involve unique locations [1]. Despite heavy burden of mycobacteria on acid-fast staining, no viable organisms were isolated, highlighting this inflammatory process is antigen driven and does not require replicating pathogens [2]. When large necrotic lymph nodes are present, incision and drainage can be safely performed to decrease antigen burden. Treatment otherwise consists primarily of steroids while continuing anti-mycobacterials and ART until inflammatory symptoms improve [1]. Infliximab has also been used successfully to control IRIS-related inflammation in refractory cases [3].
DOI：
10.1016/j.jctube.2016.03.002
发表时间：
2016-05-01
影响因子：
2
作者：
Lanzafame, Massimiliano;Vento, Sandro
通讯作者：
Vento, Sandro
影响因子：
4.1
作者：
Sereti, Irini;Rodger, Alison J.;French, Martyn A.
通讯作者：
French, Martyn A.