Qasim Z A, Sarwari A R, Jilani S M.
Treatment failure of Tuberculosis due to Concomitant Pathology.
J Pak Med Assoc Jan ;53(8):367-9.

A 19-year-old male was referred to the Infectious Diseases clinic for the evaluation of a progressively increasing neck swelling associated with persistent fever and pain. He was given anti-tuberculous therapy (ATT) at another hospital for tuberculous cervical lymphadenitis and Pott`s disease of the lumbar vertebrae, which had caused a compression fracture with spinal cord impingement. Examination revealed a 15-centimeter firm, tender right cervical lymph node. Fine needle aspiration biopsy (FNAB) confirmed a chronic granulomatous process. A nine-month course of ATT (an initial 4-drug regimen consisting of isoniazid, rifampicin, ethambutol and pyrazinamide in doses appropriate for weight) was completed with good compliance and symptomatic improvement, although he had several isolated recurrences of bacterial superinfection. Three months after ompleting his ATT, the patient returned with symptoms of fever, weight loss, and recurrence of his neck swellings. A chest CT showed mediastinal and axillary adenopathy. Diagnosed as having a relapse of his TB, he was restarted on the same regimen of ATT. The patient`s condition worsened on subsequent follow-ups, and MRI revealed progressive adenopathy and the development of cord compression. The patient underwent surgical decompression of the spinal cord with concurrent vertebral bone biopsy and an excisional lymph node biopsy. Bone histopathology revealed a chronic granulomatous process while the lymph node biopsy showed an effaced architecture, infiltrative inflammatory cells with predominant lymphocytes, as well as atypical cells. Immunophenotyping confirmed a T-cell rich B-cell non-Hodgkin`s lymphoma. The final diagnosis was a stage IIB non-Hodgkin`s lymphoma with concomitant disseminated TB.

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