Tuberculosis

Nearly on a daily basis, we have a patient with an entirely new presentation form of tuberculosis.  This is mostly due to the fact that patients with immunosuppression from HIV have a different set of characteristics of a TB infection- basically it can cause pathology anywhere in the body, not just caseating granulomas in the upper lobes of the lungs.  Yesterday a woman presented with left flank pain (HIV+).  Once a urinary tract infection was ruled out and physical exam showed hip flexor weakness, it was diagnosed as psoas abscess caused by TB and a four drug regimen was initiated of INH+ethambutol+PZA+rifampin.  Extrapulmonary lesions in HIV patients increase as their CD4+ cell counts drop below 50.  The xray below demonstrates miliary tuberculosis in the lungs- a peppering of the middle and lower lobes.  A third example: an HIV+ woman presented with persistant diarrhea, night sweats and anemia, her chest xray was normal.  Other causes of anemia were ruled out and thus "unexplained anemia in an HIV patient" was attributed to TB.  Unfortunately, HIV increases the risk of reactivation of tuberculosis by 100x, as illustrated repeatedly here.

Miliary Tuberculosis (sorry very poor detail)

Tuberous xanthomas: on elbows, knees and extensor surface of wrists...

caused by hypertriglyceridemia (lipids/fats), a side effect of one of his HIV medications.

A Kenyan clinical officer, or physician's assistant, performing a lumbar puncture on a patient with suspected cryptococcal meningitis.  After ten pokes we were still unable to get any cerebrospinal fluid and let the 26 yr old rest... maybe because it was a needle half the length we needed?