Abid Mehmood, ZU Rehman, M Alam, M Siddiq, A Mubarik, Karamat Ahmed Karamat.
Dignosis of disseminated tuberculosis by bone marrow trephine biopsy and culture.
Pak J Pathol Jan ;9(2):44-5.

A young lady of 38 years presented atKarachi in last week of Dec 1995 with 10 days history of fever with chills. The fever used to develop every alternate day. There was no history of cough, urinary or bowel complaints. She already had a course of tab.co-trimoxazole and chloroquine but without response. On examination she was looking toxic but conscious and well oriented. Her temperature was 103°F, pulse 116/min & BP 120/70 mmHg. The tongue was coated and sclerae were dirty yellow. Examination of abdomen revealed mild tenderness in righthypochondrium with palpable edge of liver.hypochondrium with palpable edge of liver.Examination of cardiovascular,nervous and respiratory systems didreveal any abnormality. She was admitted with provisional diagnoses of malaria/liver abscess/enteric fever and was put on parenteral ampicillin and antipyretics. She was found to have a total leukocyte count of 29x109/L with 54% polymorphs and 41% lymphocytes. Her ESR was 42 mm at the end of first hour by Westergren method. Mantoux test carried out with 5 TU showed an induration of 14 mm after 72 hours. Blood slides for malarial parasite were repeatedly negative. X-ray chest, urine routine examination, serum urea, electrolytes, LFTs and cardiac enzymes were unremarkable. HBsAg, Brucella antibodies and anti-DNA antibodies were negative. Blood for culture did not yield any growth after incubation at 37C for seven days. Ultrasound examination of abdomen showed no abnormality splenomegaly. The patient did not respond to except ampicillin and remained febrile. She was put on tab quinine 600 mg 8 hourly and tab pefloxacin 400 mg 12 hourly for two weeks without improvement. During this period her bone marrow trephine biopsy was carried out which showed large areas of caseation necrosis replacing haemopoietic tissue. A few epitheleoid granulomata were also seen. Ziehl Neelsen stain was negative for AFB. Bone marrow aspirate was also sent for routine and AFB culture. It was inoculated on two Lowenstein Jensen (LJ) slopes, one plain and one containing para nitro benzoic acid (PNB). Keeping in view the biopsy findings, she was started with anti tuberculosis treatment. She responded well to this treatment and became afebrile in about a week. About two weeks later, acid fast bacill were grown on plain LJ central slope while the one with PNB remained growth free. This was identified as Mycobacterium tuberculosis because of its sensitivity and inabililty to grow in the presence of PNB. The isolate was sent to Armed Forces Institute of Pathology Rawalpindi for antibiotic sensitivity testing. It was confirmed as Mycobacterium uberculosis and was sensitive to rifampicin, isoniazid and pyrazinamide but resistant to ethambutol. The patient is still on anti-tuberculosis treatment, is afebrile and symptom free.

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