Ethambutol is a first-line chemotherapeutic agent, which is commonly used in combination with other drugs for the treatment of tuberculosis. Ethambutol-induced optic neuritis is a serious and rare side effect that is either dose or duration-related and causes progressive painless vision loss, and cecocentral scotomas in the visual field. A rare case of ethambutol-induced optic neuritis was reported in a 52-year-old female who was taking anti-tubercular treatment for pulmonary tuberculosis for five months. She presented with painless diminished vision in both eyes. The patient was diagnosed with a rare case of optic neuritis through various examination methods. Ethambutol was stopped and therapy was continued with oral prednisone, zinc, and vitamin B complex being started along with anti-TB treatment. She showed no marked improvement in visual parameters until the last follow-up. The patient died due to cardiopulmonary arrest as a consequence of pulmonary tuberculosis.

BACKGROUND: Mycobacterium marinum infection rarely occurs and has atypical symptoms. It is challenging to distinguish disseminated M. marinum infection from multifocal dermatosis caused by other factors clinically.
METHODS: Herein, we reported a 68-year-old male patient with Human Immunodeficiency Virus (HIV) who presented redness and swelling in his left hand after being stabbed by marine fish for over 2 months. Mycobacterium tuberculosis infection was considered according to biochemical and pathological examinations, while empirical anti-infection treatment was ineffective.
RESULTS: The metagenomic next-generation sequencing (mNGS) detected a large amount of M. marinum sequences, and the patient was finally diagnosed with M. marinum infection. After one month of combination therapy with ethambutol, rifabutin, moxifloxacin, and linezolid, the swelling disappeared significantly. In this case, the successful application of mNGS in diagnosing and treating M. marinum infection has improved the understanding of the microbe both in the laboratory and clinically, especially in patients with HIV.
CONCLUSIONS: For diseases with atypical symptoms or difficulty in determining the pathogens, mNGS is suggested in clinical procedures for rapid and accurate diagnosis and treatment.

We herein report a case of Mycobacterium interjectum pulmonary disease (M. interjectum-PD) that improved considerably after azithromycin (AZM), rifampicin (RFP), and ethambutol (EB) therapy. A 69-year-old woman, managed locally for suspected NTM-PD based on chest computed tomography (CT) findings was referred to our hospital for worsening productive cough six years after the initial diagnosis. High-resolution chest CT showed right middle and left lower lobe bronchiectasis with middle and centrilobular nodules. Bronchial washing and sputum culture yielded M. interjectum. Treatment with AZM, RFP, and EB resulted in sputum culture conversion, and the chest CT findings subsequently improved. This is the first reported case of M. interjectum-PD in Japan.

BACKGROUND: Esophageal cancer is the seventh most common malignancy worldwide and the sixth leading cause of cancer mortality with an overall survival rate of <20%. Esophageal cancer frequently metastasizes to distant lymph nodes, lungs, liver, and bones. Cerebral metastases originating from esophageal cancer are rare and often carry a poor prognosis as do most all metastatic lesions in esophageal cancer.
METHODS: In this report, we describe a 55-year-old patient with past history of esophageal carcinoma who presented with blurred vision after taking ethambutol for tuberculosis. Ethambutol-induced optic neuropathy was the lead diagnosis. Initial vision testing was normal so additional testing with visual field examination was warranted. The visual field examination revealed homonymous hemianopsia. Subsequent magnetic resonance imaging of his brain, demonstrated a focal lesion, consistent with but not diagnostic of a brain metastasis likely from his primary esophageal malignancy.
CONCLUSIONS: We conclude that a careful review of the medical history and comprehensive assessment are essential in establishing an obscure clinical diagnosis especially in the event that an uncommon metastatic lesion is encountered.

Mycobacterium xenopi is a non-tuberculous mycobacterium (NTM) that sporadically causes infections in humans and can cause rare bone and joint infections in immunocompromised hosts with history of spinal surgery. This slow-growing mycobacterium takes 8-12 weeks to grow on culture. Metagenomic next-generation sequencing (MNGS) is a highly sensitive and specific plasma-based microbial cell-free DNA test that can detect M. xenopi weeks prior to culture growth. We present a case of M. xenopi lumbosacral discitis with presacral abscess in an immunocompromised woman without history of spinal surgery which was detected by MNGS 8 weeks prior to culture growth. The patient\'s discitis resolved with an M. xenopi-directed regimen of ethambutol, rifampin and azithromycin. This case illustrates the utility of next-generation sequencing tests in rapid diagnosis of rare and opportunistic infections, as compared with traditional diagnostic tests, with supporting contextual clinical and diagnostic findings.

UNASSIGNED: Tuberculosis (TB) is the second leading cause of death due to an infectious disease worldwide (World Health Organization, 2022 [1]). The first line treatment of TB involves the concurrent use of four drugs: rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE). Given the rising threat of multidrug resistant TB, it is crucial to understand how TB can be treated when first line treatment is not an option.
UNASSIGNED: We report a rare case of multi-drug hypersensitivity to RIPE therapy in an immunocompetent patient with an unusual presentation of CNS tuberculoma. The patient presented to an outside hospital four months prior with weakness, numbness, imbalance, and speech difficulties. A CT of the head revealed a mass in the left parietal lobe that demonstrated chronic necrotizing granulomatous inflammation with positive cultures for M. tuberculosis. The patient was started on a regimen of rifampin 600 mg daily, isoniazid 300 mg daily, pyrazinamide 2000 mg daily, ethambutol 1200 mg daily, and pyridoxine 50 mg daily. However, the patient developed drug hypersensitivity reactions to both rifampin and ethambutol with subsequent failed desensitization to rifabutin. She was ultimately discharged from the hospital on a regimen of isoniazid, pyridoxine, pyrazinamide, and moxifloxacin with plans for outpatient follow-up.
UNASSIGNED: This case highlights a rare clinical presentation of multiple drug hypersensitivity in the setting of a CNS tuberculoma and the importance of identifying the offending agents early in the course of treatment and adjusting the drug regimen accordingly. Desensitization should be attempted, but if ineffective, then alternative drug regimens should be formulated on a case-by-case basis.

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a severe, potentially life-threatening condition precipitated by reaction of therapeutic drugs. The prevalence of potential antitubercular therapy (ATT)-induced DRESS is 1.2%.
UNASSIGNED: A 71-year-old female patient after 5 weeks of starting ATT complaints of fever, vomiting, dizziness, and generalized itchy maculopapular rash over the body. It was associated with marked eosinophilia (absolute eosinophil count 3094 cell/mm3, 36% in peripheral blood smear).
UNASSIGNED: Fever, rash, lymphadenopathy, and internal organ involvement with marked eosinophilia constitute the major clinical manifestations of DRESS. RegiSCAR scoring system is usually used to diagnose DRESS. Identification of the culprit drug is based on the temporal correlation of symptoms with drug exposure and rechallenge test, patch test and lymphocytic transformation tests may be valuable adjunctive tools. Treatment includes withdrawal of offending agent and use of topical or systemic corticosteroids, antihistamines, cyclosporin or JAK inhibitor with clinical judgement.
UNASSIGNED: Clinicians from the tuberculosis burden region must be aware of DRESS associated with ATT and they must counsel the patient properly before prescription and manage them without delay if DRESS ensues.

BACKGROUND: Tuberculosis remains a complicated problem. A lack of awareness accompanied by difficulty in diagnosis hinders the management of tuberculosis. Delayed management, particularly in osteoarticular regions, results in unnecessary procedures, including joint-sacrificing surgery.
METHODS: Three cases of subclinical ankle joint tuberculosis without clear signs of tuberculosis were presented. The efficacy of technetium-99m-ethambutol scintigraphy in diagnosing early-stage tuberculous arthritis is reported.
CONCLUSIONS: The reports suggested that scintigraphy is recommended to diagnose subclinical tuberculous arthritis, especially in tuberculosis endemic regions.

Cutaneous tuberculosis is a rare extrapulmonary pre-sentation of tuberculosis, caused by mycobacterial species of the Mycobacterium tuberculosis complex. We describe a case of cutaneous tuberculosis in a 57-year-old technician from the microbiology laboratory in our hospital. She accidentally experienced a needlestick injury with a hollow needle while at work. Skin lesion developed shortly after on the punctured finger. A biopsy was performed, revealing necrotizing (caseating) granulomatous inflammation. Pharmacological treatment was initiated with four standard drugs: isoniazid, rifampicin, pyrazinamide, and ethambutol hydrochloride. Improvement was observed, but the initial treatment had to be suspended due to intolerance to some of the drugs and changed to a treatment with isoniazid, rifampicin, and levofloxacin. The long duration of the treatment may increase the risk of toxic effects, making it necessary to discard the drug causing these effects and change the treatment regimen.

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