Disseminierte Tuberkulose imitiert metastasiertes Magenkarzinom – ein Fallbericht

Zusammenfassung

Bei zuletzt stabiler nach in den Jahren davor steigender Inzidenz der aktiven Tuberkuloseerkrankung in Deutschland sind zunehmend auch extrapulmonale Manifestationen von differenzialdiagnostischer Bedeutung. Insbesondere bei Verdacht auf eine metastasierte Tumorerkrankung kommt die Tuberkulose differenzialdiagnostisch in Betracht. Wir berichten über einen 77-jährigen Patienten, der sich mit einseitigen Beinschmerzen und B-Symptomatik vorstellte. Neben einer osteolytischen Sakralwirbelkörper(SWK)-1-Läsion ergab sich bildgebend der Verdacht auf ein metastasiertes Magenkarzinom. In den gewonnenen Biopsien zeigten sich nekrotisierende Granulome mit Riesenzellen, im Verlauf gelang der kulturelle und molekularbiologische Nachweis von Mycobacterium tuberculosis anstelle neoplastischen Gewebes. Nach Sicherung einer disseminierten Tuberkulose mit ossärer Beteiligung erfolgte eine antibiotische Therapie nach nationalen Leitlinien über insgesamt neun Monate. Klinisch und radiologisch zeigte sich in der Abschlussuntersuchung nach Therapieende eine Regredienz der Befunde im Sinne einer definitiven Heilung.

Abstract

Increasing numbers of active tuberculosis in Germany were recorded in the last years. Thus, also extrapulmonary manifestations of tuberculosis gain clinical significance as differential diagnoses, especially when a metastatic tumor disease is suspected. We report the case of a 77-year-old male patient who presented with unilateral leg pain and B symptoms. Further investigations revealed an osteolytic mass in the sacrum as well as CT-morphological findings consistent with metastatic gastric cancer. However, transgastric biopsies showed necrotising granuloma with giant cells leading to molecular and cultural detection of Mycobacterium tuberculosis instead of suspected neoplastic tissue. A nine-month treatment regimen for suspected disseminated tuberculosis with bone involvement was initiated according to national guidelines. Clinical and radiological follow up examinations after treatment completion showed complete remission.

Schlüsselwörter

disseminierte Tuberkulose - abdominelle Tuberkulose - Knochentuberkulose - Karzinom

Key words

disseminated tuberculosis - abdominal tuberculosis - bone tuberculosis - carcinoma

• Literatur

• 1 World Health Organization. Global tuberculosis report 2018. 2018 Im Internet: http://www.who.int/iris/handle/10665/274453
• 2 Houben RMGJ, Dodd PJ. The Global Burden of Latent Tuberculosis Infection: A Re-estimation Using Mathematical Modelling. PLOS Medicine 2016; 5: 1-13 Im Internet: http://dx.doi.org/10.1371/journal.pmed.1002152
• 3 Leitlinie E, Tuberkulose B Der, Dgp S. S2k-Leitlinie: Tuberkulose im Erwachsenenalter. Tuberculosis Guideline for Adults Guideline for Diagnosis and Treatment of Tuberculosis including LTBI Testing and Treatment of the German Central Committee (DZK) and the German Respiratory. 2017: 325-397
• 4 Hinks TS, Varsani N, Godsiff DT. et al. High background rates of positive tuberculosis-specific interferon-γ release assays in a low prevalence region of UK: a surveillance study. BMC Infect Dis 2012; 12: 339 Im Internet: https://bmcinfectdis.biomedcentral.com/articles/10.1186/1471-2334-12-339
• 5 Comstock GW, Livesay VT, Woolpert SF. The prognosis of a positive tuberculin reaction in childhood and adolescence. Am J Epidemiol 1974; 99: 131-138 Im Internet: http://www.ncbi.nlm.nih.gov/pubmed/4810628
• 6 Getahun H, Matteelli A, Chaisson RE. et al. Latent Mycobacterium tuberculosis Infection. N Engl J Med 2015; 372: 2127-2135 Im Internet: http://www.nejm.org/doi/10.1056/NEJMra1405427
• 7 Shea KM, Kammerer JS, Winston CA. et al. Re: Estimated rate of reactivation of latent tuberculosis infection in the United States, overall and by Population Subgroup. Am J Epidemiol 2014; 180: 450-451 Im Internet: http://aje.oxfordjournals.org/%0Ahttp://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=emed15&NEWS=N&AN=373840273
• 8 Keane J, Bresnihan B. Tuberculosis reactivation during immunosuppressive therapy in rheumatic diseases: diagnostic and therapeutic strategies. Curr Opin Rheumatol 2008; 20: 443-449 Im Internet: http://www.ncbi.nlm.nih.gov/pubmed/18525359
• 9 Christopoulos AI, Diamantopoulos AA, Dimopoulos PA. et al. Risk factors for tuberculosis in dialysis patients: a prospective multi-center clinical trial. BMC Nephrol 2009; 10: 36 Im Internet: http://www.ncbi.nlm.nih.gov/pubmed/19895701
• 10 Katsenos S, Nikolopoulou M, Gartzonika C. et al. Use of Interferon-Gamma Release Assay for Latent Tuberculosis Infection Screening in Older Adults Exposed to Tuberculosis in a Nursing Home. J Am Geriatr Soc 2011; 59: 858-862 Im Internet: http://www.ncbi.nlm.nih.gov/pubmed/21517785
• 11 Jeon CY, Murray MB. Diabetes Mellitus Increases the Risk of Active Tuberculosis: A Systematic Review of 13 Observational Studies. PLoS Med 2008; 5: e152 Im Internet: http://www.ncbi.nlm.nih.gov/pubmed/18630984
• 12 Ramirez-Lapausa M, Menendez-Saldana A, Noguerado-Asensio A. Extrapulmonary tuberculosis: An overview. Rev Esp Sanid Penit 2015; 17: 3-11
• 13 García-Rodríguez JF, Álvarez-Díaz H, Lorenzo-García MV. et al. Extrapulmonary tuberculosis: epidemiology and risk factors. Enferm Infecc Microbiol Clin 2011; 29: 502-509 Im Internet: https://www.sciencedirect.com/science/article/pii/S0213005X1100125X?via%3Dihub
• 14 Health P. Canadian Tuberculosis Standards. 7th . Edition.
• 15 Robert Koch-Institut R. Bericht zur Epidemiologie der Tuberkulose in Deutschland für 2017. 2018: 1-2 Im Internet: papers3://publication/uuid/887FA663-B0E4-4086-8563-DEC01DF69865
• 16 European Centre for Disease Prevention and Control/WHO Regional Office for Europe. Tuberculosis surveillance and monitoring in Europe 2018–2016 data. 2018
• 17 Association AM. Association Between Use of Non–Vitamin K Oral Anticoagulants With and Without Concurrent Medications and Risk of Major Bleeding in Nonvalvular Atrial Fibrillation. JAMA 2018; 318: 1250-1259
• 18 Vakkalagadda B, Frost C, Byon W. et al. Effect of Rifampin on the Pharmacokinetics of Apixaban, an Oral Direct Inhibitor of Factor Xa. Am J Cardiovasc Drugs 2016; 16: 119-127 Im Internet: http://link.springer.com/10.1007/s40256-015-0157-9
• 19 Wang JY, Hsueh PR, Wang SK. et al. Disseminated tuberculosis: A 10-year experience in a medical center. Medicine (Baltimore) 2007; 86: 39-46
• 20 Slavin RE, Walsh TJ, Pollack AD. Late generalized tuberculosis: a clinical pathologic analysis and comparison of 100 cases in the preantibiotic and antibiotic eras. Medicine (Baltimore) 1980; 59: 352-366 Im Internet: http://www.ncbi.nlm.nih.gov/pubmed/7432152
• 21 Sievers ML. The Second „Great Imitator“ – Tuberculosis. JAMA 1961; 176: 809 Im Internet: http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.1961.63040220009017a
• 22 Jetley S, Jairajpuri ZS, Pujani M. et al. Tuberculosis “The Great Imitator”: A usual disease with unusual presentations. Indian J Tuberc 2017; 64: 54-59 Im Internet: http://www.ncbi.nlm.nih.gov/pubmed/28166920
• 23 Prapruttam D, Hedgire SS, Mani SE. et al. Tuberculosis – The Great Mimicker. Semin Ultrasound, CT MRI 2014; 35: 195-214 Im Internet: http://www.ncbi.nlm.nih.gov/pubmed/24929261
• 24 Chamberlin K, Orfanos S, Mukherjee A. et al. A case of disseminated tuberculosis mimicking metastatic cancer. Respir Med Case Reports 2018; 25: 239-241 Im Internet: https://doi.org/10.1016/j.rmcr.2018.10.001
• 25 Li YJ, Zhang Y, Gao S. et al. Systemic Disseminated Tuberculosis Mimicking Malignancy on F-18 FDG PET-CT. Clin Nucl Med 2008; 33: 49-51 Im Internet: https://insights.ovid.com/crossref?an=00003072-200801000-00016
• 26 Fahlbusch T, Künzli B, Schlottmann R. et al. Tuberculosis Mimicking Disseminated Peritoneal Carcinomatosis of a Sigmoid Carcinoma. J Gastrointest Surg 2019; 23: 877-878 Im Internet: http://www.ncbi.nlm.nih.gov/pubmed/29736664
• 27 Sharma SK, Mohan A, Sharma A. et al. Miliary tuberculosis: new insights into an old disease. Lancet Infect Dis 2005; 5: 415-430 Im Internet: http://www.ncbi.nlm.nih.gov/pubmed/15978528
• 28 Gurzu S, Molnar C, Contac AO. et al. Tuberculosis terminal ileitis: A forgotten entity mimicking Crohn’s disease. World J Clin Cases 2016; 4: 273 Im Internet: http://www.ncbi.nlm.nih.gov/pubmed/27672643
• 29 Elzein F, Elzein A, Mohammed N. et al. Miliary tuberculosis mimicking systemic lupus erythematosus flare. Respir Med Case Reports 2018; 25: 216-219 Im Internet: http://www.ncbi.nlm.nih.gov/pubmed/30237973
• 30 Storla DG, Yimer S, Bjune GA. A systematic review of delay in the diagnosis and treatment of tuberculosis. BMC Public Health 2008; 8: 15 Im Internet: https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-8-15
• 31 Getnet F, Demissie M, Assefa N. et al. Delay in diagnosis of pulmonary tuberculosis in low-and middle-income settings: systematic review and meta-analysis. BMC Pulm Med 2017; 17: 202 Im Internet: https://bmcpulmmed.biomedcentral.com/articles/10.1186/s12890-017-0551-y
• 32 Purohit M, Mustafa T. Laboratory Diagnosis of Extra-pulmonary Tuberculosis (EPTB) in Resource-constrained Setting: State of the Art, Challenges and the Need. J Clin Diagn Res 2015; 9: EE01-EE06 Im Internet: http://www.ncbi.nlm.nih.gov/pubmed/26023563
• 33 Pagán AJ, Ramakrishnan L. Immunity and Immunopathology in the Tuberculous Granuloma. Cold Spring Harb Perspect Med 2014; 5: 9 . Im Internet: http://www.ncbi.nlm.nih.gov/pubmed/25377142
• 34 Santosham R, Deslauriers J. Tuberculosis and Other Granulomatous Diseases of the Airway. Thorac Surg Clin 2018; 28: 155-161 Im Internet: http://www.ncbi.nlm.nih.gov/pubmed/29627049
• 35 Tussupbekova M, Bakenova R, Stabayeva L. et al. Clinic – Morphologic and Morphometric Criteria for Differential Diagnosis of Sarcoidosis and Pulmonary Tuberculosis. Open Access Maced J Med Sci 2019; 7: 1480 Im Internet: http://www.ncbi.nlm.nih.gov/pubmed/31198459
• 36 DIN 58943-32–2015-05 Medizinische Mikrobiologie – Tuberkulosediagnostik – Teil 32: Mikroskopische Methoden zum Nachweis von Mykobakterien. Im Internet: https://www.beuth.de/de/norm/din-58943-32/232046133
• 37 Tostmann A, Boeree MJ, Aarnoutse RE. et al. Antituberculosis drug-induced hepatotoxicity: Concise up-to-date review. J Gastroenterol Hepatol 2008; 23: 192-202 Im Internet: http://doi.wiley.com/10.1111/j.1440-1746.2007.05207.x
• 38 Ramappa V, Aithal GP. Hepatotoxicity Related to Anti-tuberculosis Drugs: Mechanisms and Management. J Clin Exp Hepatol 2013; 3: 37-49 Im Internet: http://www.ncbi.nlm.nih.gov/pubmed/25755470