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Tuberculosis and Microscopic Polyangiitis. A Rare Combination
Tuberculosis y poliangitis microscópica. Una asociación muy poco frecuente
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Una asociación muy poco frecuente" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "635" "paginaFinal" => "637" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Tuberculosis and Microscopic Polyangiitis. A Rare Combination" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3684 "Ancho" => 3000 "Tamanyo" => 1894464 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A. Tomografía computarizada (TC) de tórax de alta resolución. No hay evidencia de enfermedad ni derrame pleural en campos medios e inferiores. B. Biopsia pulmonar. Inflamación granulomatosa con extensas áreas de necrosis y células gigantes multinucleadas tipo Langhans. C. TC de tórax de alta resolución. Aumento difuso de la radiodensidad pulmonar con predominio de vidrio deslustrado con moderado derrame pleural izquierdo loculado, con un componente cisural, que se interpretó como una hemorragia alveolar difusa. D. Biopsia renal. Glomérulo renal con área de necrosis focal con fenómenos de cariorrexis. E. Biopsia renal con necrosis fibrinoide de arteria de pequeño calibre que afecta a más del 50% de la circunferencia y que se acompaña de inflamación transmural. F. TC de tórax de alta resolución. Disminución del derrame pleural y ligera mejoría de la opacidad en vidrio deslustrado.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Vanessa Riveiro, Jorge Ricoy, María E. 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true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 459 "Ancho" => 604 "Tamanyo" => 25684 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">CT with bilateral granular opacities and ground-glass opacification.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Mª Carmen López Castillo, Estela Pérez Ruiz, Pilar Caro Aguilera, María Adela Rodríguez Vives" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Mª Carmen" "apellidos" => "López Castillo" ] 1 => array:2 [ "nombre" => "Estela" "apellidos" => "Pérez Ruiz" ] 2 => array:2 [ "nombre" => "Pilar" "apellidos" => "Caro Aguilera" ] 3 => array:2 [ "nombre" => "María Adela" "apellidos" => "Rodríguez Vives" 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A Rare Combination" "tieneTextoCompleto" => true "saludo" => "To the Editor:" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "635" "paginaFinal" => "637" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Vanessa Riveiro, Jorge Ricoy, María E. Toubes, Luis Valdés" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Vanessa" "apellidos" => "Riveiro" "email" => array:1 [ 0 => "vanessa.riveiro.blanco@sergas.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Jorge" "apellidos" => "Ricoy" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "María E." "apellidos" => "Toubes" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Luis" "apellidos" => "Valdés" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Neumología, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, La Coruña, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, La Coruña, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tuberculosis y poliangitis microscópica. Una asociación muy poco frecuente" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3684 "Ancho" => 3000 "Tamanyo" => 1894464 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Chest high-resolution computed tomography (HRCT). No evidence of disease or pleural effusion observed in middle and lower fields. (B) Lung biopsy. Granulomatous inflammation with extensive areas of necrosis and multinucleated Langhans giant cells. (C) Chest HRCT. Diffuse increase of pulmonary radiodensity, mainly ground glass opacities with moderate left loculated pleural effusion, and a fissural component, interpreted as diffuse alveolar hemorrhage. (D) Renal biopsy. Renal glomerulus with area of focal necrosis and karyorrhexis. (E) Renal biopsy with fibrinoid necrosis of the small arteries affecting more than 50% of the circumference, associated with transmural inflammation. (F) Chest HRCT. Reduction of pleural effusion and slight improvement of the ground glass opacities.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Tuberculosis (TB) is one of the most common causes worldwide of morbidity and mortality due to infection, with a recorded incidence in Spain in 2015 of 21.5 cases/100<span class="elsevierStyleHsp" style=""></span>000 inhabitants.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Vasculitis is a general term for a heterogeneous group of diseases characterized by inflammation and destruction of blood vessel walls.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a> Most cases are primary, but vasculitis can also be secondary to other diseases, including infections.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a> At times the difference between TB and vasculitis can be difficult to determine, because they share similar characteristics, and moreover, both entities can coexist in the same patient.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">4</span></a> The definitions of vasculitis and its different forms are well established.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> We report the case of a patient that who presented simultaneous TB and microscopic polyangitis (MPA).</p><p id="par0015" class="elsevierStylePara elsevierViewall">This was a 68-year-old man with a history of TB, who attended the emergency room with a 1-month history of fever, bloody sputum, asthenia, weight loss, and dyspnea. His temperature was 38.4<span class="elsevierStyleHsp" style=""></span>°C, with no other significant findings. Blood tests were normal, and chest X-ray revealed scarring in the upper right lobe and a solid, spiculated parenchymal lesion. Chest computed tomography (CT) showed no changes in the middle and lower fields (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). No upper respiratory tract involvement was observed. Polymerase chain reaction was positive for <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> in bronchial aspirate and bronchoalveolar lavage. Core needle biopsy of the spiculated lesion revealed necrotizing granulomatous inflammation with multinucleated Langhans giant cells (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B), and positive Ziehl–Neelsen staining and polymerase chain reaction for <span class="elsevierStyleItalic">M. tuberculosis</span>. The patient developed sudden onset hemoptysis with anemia (hemoglobin>6.8<span class="elsevierStyleHsp" style=""></span>g/dL, hematocrit 20.8%), acute renal failure (urea 123<span class="elsevierStyleHsp" style=""></span>mg/dL, creatinine 8.3<span class="elsevierStyleHsp" style=""></span>mg/dL), oligoanuria and elevated transaminases (values 5 times the upper limit of normal). Intubation, mechanical ventilation, and hemodialysis were required. In view of the patient's hepatic and renal insufficiency, antituberculosis treatment began with ethambutol, levofloxacin, and streptomycin. Chest CT showed diffusely increased pulmonary radiodensity, mainly ground glass opacities and areas of consolidation in the peribroncovascular region, with moderate left loculated pleural effusion, with a fissural component, that was interpreted as diffuse alveolar hemorrhage (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C). Renal biopsy revealed vasculitis with fibrinoid necrosis of the small arteries associated with focal and segmental necrotizing glomerulonephritis with an absence of immunoglobulin, complement and light chain deposits, suggestive of MPA (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>D and E). Pleural fluid was a lymphocytic exudate; ADA 45<span class="elsevierStyleHsp" style=""></span>U/L, with no other significant changes. Anti-neutrophil cytoplasmic antibodies (ANCA) (dilution 1/320; p-ANCA pattern) with anti-myeloperoxidase antibodies>300<span class="elsevierStyleHsp" style=""></span>IU/mL were detected. Anti-glomerular basement membrane antibodies were negative. Treatment was administered with corticosteroids (3 initial boluses of methylprednisolone 500<span class="elsevierStyleHsp" style=""></span>mg/day, tapered to 15<span class="elsevierStyleHsp" style=""></span>mg/day of prednisone), plasmapheresis (7 sessions), and rituximab (700<span class="elsevierStyleHsp" style=""></span>mg/week for 4 weeks). Rifampicin and isoniazid could subsequently be reintroduced. Progress was slow but favorable, with stabilization of respiratory symptoms and radiological improvement (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>F).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The association between TB and vasculitis has been described, but generally always in association with granulomatosis with polyangitis.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">4,6,7</span></a> As far as we know, this is the second case in which TB has been associated with MPA.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a> Both diagnoses appear to be confirmed: positive polymerase chain reaction in 2 different samples in the case of TB; and for MPA, granulomatous inflammation with necrosis and multinucleated giant cells in lung tissue with positive Ziehl–Neelsen staining, and confirmed diagnostic criteria with rapidly progressing diffuse alveolar hemorrhage and necrotizing glomerulonephritis.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The question here is, is this association incidental or does one disease (TB) lead to another (MPA)? The inverse association is possible, and the administration of an immunosuppressive treatment for a diagnosis of vasculitis as a trigger for TB has been documented,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a> but this could be ruled out in our patient by the order of events. Flores-Suárez et al. observed high odds ratios for positive p-ANCA by indirect immunofluorescence in TB patients, compared with asthma patients (odds ratio 2.96 [1.19–7.38]; <span class="elsevierStyleItalic">P</span><0.027) and healthy subjects (odds ratio 18 [3.88–83.4]; <span class="elsevierStyleItalic">P</span><0.0001).<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">9</span></a> It is difficult to establish an association between TB and MPA, although the coexistence of TB and positive ANCA may be a causative factor. Some drugs, especially isoniazid and rifampicin, can be transformed into active metabolites that develop cytotoxic products that destroy the neutrophils with subsequent synthesis of ANCA, a phenomenon which might explain the presence of anti-myeloperoxidase antibodies in patients receiving these drugs.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">10,11</span></a> However, this is unlikely in our patient, because he had not yet received these products when the diffuse alveolar hemorrhage and necrotizing glomerulonephritis occurred. On the other hand, <span class="elsevierStyleItalic">M. tuberculosis</span> can stimulate the release of oxygen metabolites from the neutrophils. When these cells are activated in the initial stages of mycobacterial infection, lysosomal enzymes are released that could lead to the development of autoantibodies (ANCA) against the granular components of these cells.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">9</span></a> These IgG antibodies that act against neutrophilic and monocytic cytoplasmic antigens (proteinase-3 and myeloperoxidase) induce neutrophil migration and degranulation in the vessel wall, and release proteases and other toxic metabolites that cause vascular damage,<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">12</span></a> which could give rise to this or any other vasculitis.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In summary, TB is more common in our setting than vasculitis, so diagnosis must be established promptly and treatment must be initiated in case of objective evidence. The characteristics of vasculitis and TB can overlap, and vasculitis should be considered in the differential diagnosis, particularly if azotemia is observed. Sometimes the possibility of a simultaneous presentation must be considered, and while no association between the 2 entities has been demonstrated, the mechanisms we describe may provide a physiopathological explanation. A high index of suspicion and clinical experience in the management of this presentation is necessary, since diagnostic errors and delays in treatments can lead to life-threatening situations.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Riveiro V, Ricoy J, Toubes ME, Valdés L. Tuberculosis y poliangitis microscópica. Una asociación muy poco frecuentex. Arch Bronconeumol. 2018;54:635–637.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3684 "Ancho" => 3000 "Tamanyo" => 1894464 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Chest high-resolution computed tomography (HRCT). No evidence of disease or pleural effusion observed in middle and lower fields. (B) Lung biopsy. Granulomatous inflammation with extensive areas of necrosis and multinucleated Langhans giant cells. (C) Chest HRCT. Diffuse increase of pulmonary radiodensity, mainly ground glass opacities with moderate left loculated pleural effusion, and a fissural component, interpreted as diffuse alveolar hemorrhage. (D) Renal biopsy. Renal glomerulus with area of focal necrosis and karyorrhexis. (E) Renal biopsy with fibrinoid necrosis of the small arteries affecting more than 50% of the circumference, associated with transmural inflammation. (F) Chest HRCT. Reduction of pleural effusion and slight improvement of the ground glass opacities.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0065" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Dirección Xeral de Saúde Pública. Informe da tuberculose en Galicia. Características dos casos de tuberculose de Galicia no ano 2015. Evolución do período 1996–2015 [monografía en Internet]. Santiago de Compostela: Xunta de Galicia, Consellería de Sanidade; 2016. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 5 | 10 |
| 2024 October | 58 | 34 | 92 |
| 2024 September | 59 | 15 | 74 |
| 2024 August | 77 | 49 | 126 |
| 2024 July | 68 | 29 | 97 |
| 2024 June | 72 | 55 | 127 |
| 2024 May | 91 | 36 | 127 |
| 2024 April | 51 | 37 | 88 |
| 2024 March | 41 | 30 | 71 |
| 2024 February | 24 | 12 | 36 |
| 2023 March | 17 | 5 | 22 |
| 2023 February | 69 | 27 | 96 |
| 2023 January | 46 | 49 | 95 |
| 2022 December | 65 | 42 | 107 |
| 2022 November | 70 | 30 | 100 |
| 2022 October | 72 | 46 | 118 |
| 2022 September | 43 | 33 | 76 |
| 2022 August | 57 | 51 | 108 |
| 2022 July | 38 | 40 | 78 |
| 2022 June | 47 | 41 | 88 |
| 2022 May | 48 | 43 | 91 |
| 2022 April | 61 | 29 | 90 |
| 2022 March | 69 | 44 | 113 |
| 2022 February | 52 | 50 | 102 |
| 2022 January | 55 | 37 | 92 |
| 2021 December | 47 | 51 | 98 |
| 2021 November | 60 | 50 | 110 |
| 2021 October | 58 | 54 | 112 |
| 2021 September | 51 | 54 | 105 |
| 2021 August | 44 | 31 | 75 |
| 2021 July | 40 | 27 | 67 |
| 2021 June | 46 | 39 | 85 |
| 2021 May | 50 | 29 | 79 |
| 2021 April | 113 | 89 | 202 |
| 2021 March | 54 | 25 | 79 |
| 2021 February | 28 | 21 | 49 |
| 2021 January | 33 | 17 | 50 |
| 2020 December | 30 | 24 | 54 |
| 2020 March | 17 | 4 | 21 |
| 2020 February | 37 | 10 | 47 |
| 2020 January | 42 | 22 | 64 |
| 2019 December | 33 | 22 | 55 |
| 2019 November | 25 | 27 | 52 |
| 2019 October | 10 | 19 | 29 |
| 2019 September | 37 | 4 | 41 |
| 2019 August | 24 | 16 | 40 |
| 2019 July | 17 | 20 | 37 |
| 2019 June | 18 | 8 | 26 |
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