Epididymal tuberculosis is rare and often presents diagnostic difficulties. It may be indicative of a disseminated form of the infection, which is the case of our patient. A 19-year-old man, with no past medical history, was admitted for a swollen painful left scrotum that had been evolving for 8 months. He had undergone an orchiectomy and the anatomopathological examination was consistent with epididymal tuberculosis. The radiological investigations had revealed other localizations of the infection: lymphatic, pulmonary, parietal and osteoarticular tuberculosis. Anti-tuberculosis therapy was introduced. However, in the 4th month of treatment, the patient developed seizures. A cerebral magnetic resonance imaging was practiced, concluding to cerebral tuberculomas. Anti-tuberculosis treatment was continued associated to an anticonvulsant with a favourable outcome. The originality of our observation resides in the mode of revelation of a disseminated paucisymptomatic tuberculosis, by an epididymal localization, in an immunocompetent patient.

Tuberculosis is usually seen in the lungs. However, the involvement of various extrapulmonary sites is due to the spread of the bacteria via blood, lymphatic, or direct inoculation. The present case is a rare presentation of tuberculosis in an Indian female who came with complaints of swelling in her right elbow joint, headache, and cough with expectoration. A diagnostic evaluation resulted in the isolation of Mycobacterium tuberculosis from the sputum samples and elbow joints, which was further supported by an exudative picture on the cerebrospinal fluid examination. The findings were supported by advanced radiometric techniques. She was commenced on an antituberculous treatment per her weight. Disseminated tuberculosis is a challenging diagnosis as there is often a delay in clinical presentation, a lack of awareness about the possibility of multiple sites with tuberculous infection in clinicians, and a time lag in the availability of the culture results.

BACKGROUND: HIV-associated tuberculosis (TB) contributes disproportionately to global tuberculosis mortality. Patients hospitalised at the time of the diagnosis of HIV-associated disseminated TB are typically severely ill and have a high mortality risk despite initiation of tuberculosis treatment. The objective of the study is to assess the safety and efficacy of both intensified TB treatment (high dose rifampicin plus levofloxacin) and immunomodulation with corticosteroids as interventions to reduce early mortality in hospitalised patients with HIV-associated disseminated TB.
METHODS: This is a phase III randomised controlled superiority trial, evaluating two interventions in a 2 × 2 factorial design: (1) high dose rifampicin (35 mg/kg/day) plus levofloxacin added to standard TB treatment for the first 14 days versus standard tuberculosis treatment and (2) adjunctive corticosteroids (prednisone 1.5 mg/kg/day) versus identical placebo for the first 14 days of TB treatment. The study population is HIV-positive patients diagnosed with disseminated TB (defined as being positive by at least one of the following assays: urine Alere LAM, urine Xpert MTB/RIF Ultra or blood Xpert MTB/RIF Ultra) during a hospital admission. The primary endpoint is all-cause mortality at 12 weeks comparing, first, patients receiving intensified TB treatment to standard of care and, second, patients receiving corticosteroids to those receiving placebo. Analysis of the primary endpoint will be by intention to treat. Secondary endpoints include all-cause mortality at 2 and 24 weeks. Safety and tolerability endpoints include hepatoxicity evaluations and corticosteroid-related adverse events.
CONCLUSIONS: Disseminated TB is characterised by a high mycobacterial load and patients are often critically ill at presentation, with features of sepsis, which carries a high mortality risk. Interventions that reduce this high mycobacterial load or modulate associated immune activation could potentially reduce mortality. If found to be safe and effective, the interventions being evaluated in this trial could be easily implemented in clinical practice.
BACKGROUND: ClinicalTrials.gov NCT04951986. Registered on 7 July 2021 https://clinicaltrials.gov/study/NCT04951986.

OBJECTIVE: This systematic review aimed to evaluate the published cases with miliary brain lesions and their etiological factors, clinical manifestations, diagnostic procedures, and outcomes.
METHODS: A comprehensive search of PubMed, Scopus, Embase, and Google Scholar was conducted using the specified search strategy. Eligibility criteria included cases with miliary lesions in the brain confirmed through neuroimaging and various diagnostic procedures. The PRISMA guidelines were followed, and the PROSPERO registration number for the protocol is CRD42023445849.
RESULTS: Data from 130 records provided details of 140 patients. Tuberculosis was the primary cause in 93 cases (66.4%), malignancies in 36 cases (25.7%), and other causes accounted for the remaining 11% cases. Tuberculosis patients averaged 35.7 years old, while those with malignancies averaged 55.44 years. Tuberculosis symptoms primarily included fever, headache, and altered sensorium, whereas malignant cases often exhibited progressive encephalopathy, headache, and specific neurological deficits. Distinctive indicators for CNS tuberculosis were choroidal tubercles and paradoxical reactions. Additionally, 63 tuberculosis patients showed miliary lung shadows and 49 had abnormal CSF findings. For the malignancy group, 13 exhibited miliary lung lesions, and 8 had CSF abnormalities. Regarding outcomes, a significant mortality disparity was observed, with 58.3% in the malignancy group, compared to 10.8% in the tuberculosis group and 27.3% in other cases.
CONCLUSIONS: Miliary brain lesions are a crucial imaging abnormality that necessitates prompt work up. In an immunocompromised state, diagnostic possibilities of miliary brain lesions are more varied and often pose a bigger challenge.

Tuberculosis (TB), a Mycobacterium tuberculosis (Mtb) infection, remains a significant global health concern despite a declining incidence. This report highlights a complex case involving a 24-year-old patient from Angola who presented with a constellation of symptoms, including fever, weight loss, and neurological deficits. The patient had been on chronic corticosteroid therapy, a known risk factor for the reactivation of latent TB infection (LTBI). Her clinical course was marked by diagnostic challenges, such as a previous diagnosis of Kikuchi\'s disease and paradoxical progression despite appropriate tuberculostatic chemotherapy. Miliary TB, characterized by widespread dissemination of Mtb from the primary site of infection, can manifest in various extrapulmonary locations. Central nervous system (CNS) involvement, particularly TB meningitis, is the most severe form of TB, associated with significant morbidity and mortality. The diagnosis of miliary and CNS TB can be elusive due to nonspecific clinical presentations and imaging findings. This case underscores the importance of a high index of suspicion, especially in immunocompromised individuals, and the need for comprehensive microbiological analysis, including cerebrospinal fluid (CSF) examination, to confirm CNS involvement. Furthermore, this case illustrates the challenges associated with TB treatment, including the risk of drug toxicity, medication adherence, and the potential for drug resistance. Treatment duration for miliary TB is extended, typically lasting nine months to a year, and may require adaptation based on the patient\'s clinical response and drug penetration into the CNS. Corticosteroids play a critical role as adjuvant therapy, particularly in cases with perilesional edema or paradoxical reactions during treatment. This case underscores the complexity of diagnosing and managing miliary and CNS TB, emphasizing the importance of considering TB as a diagnostic possibility in patients with nonspecific symptoms and risk factors. Early identification, multidisciplinary collaboration, and tailored therapeutic strategies are essential for achieving optimal outcomes in such challenging cases. Additionally, screening for latent TB infection should be a priority for patients requiring immunosuppressive therapy to mitigate the risk of reactivation.

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In tuberculous patient, abnormal extrarenal production of 1.25-dihydroxyvitamin D3 by activated macrophages results in hypercalcemia. High calcium level associated with tuberculosis is frequent in adults with active pulmonary tuberculosis even though most patients are asymptomatic, while hypercalcemia in children due to disseminated tuberculosis is rare. Here, we described a case of a 5-year-old who presented with cough and right anterior chest swelling of two-month duration with an Erythrocyte Sedimentation Rate of 144mm/hour, and a high serum ionized calcium level of 1.46millimol/L. With the epidemiologically prevalence, clinical and radiological imaging findings the diagnosis of disseminated tuberculosis to lung, pleura, lymph node, liver and bone was made, and the child was started with the anti-tuberculosis treatment, hypercalcemia was attributed to the disseminated tuberculosis precipitated by high calcium meal intake and excessive sun exposure. Tuberculosis can be complicated with hypercalcemia; care must be taken in supplementing vitamin D and high calcium meals especially in high sun exposure geographic areas.

In India, tuberculosis (TB) has the second highest disease burden following diabetes mellitus. During the COVID-19 pandemic, there was a surge of several opportunistic infections. In this case series, we report five patients, including three adults and two adolescents, who have developed various forms of TB disease after symptomatic COVID-19 pneumonia. The average time for development of post-COVID TB was 48 days. Adolescent patients have developed disseminated TB, which can be due to COVID-19-induced immunological injury or its treatment-related immune suppression. All the adult patients had high CT severity scores (CTSS) and required the administration of intravenous steroids during their COVID-19 pneumonia. Various presentations of TB were secondary spontaneous pneumothorax, miliary TB, consolidation, and nodular infiltrates. One patient had a drug-induced liver injury, which complicated the treatment of that patient. Factors that may contribute to the development of post-COVID TB are diabetes mellitus, increased severity of COVID-19 pneumonia manifested by CTSS, and administration of intravenous steroids. Bidirectional screening of TB had to be done when patients present with symptoms of COVID-19 pneumonia.

BACKGROUND: Severe combined immunodeficiency disease (SCID) is a rare primary immunodeficiency disease, usually manifest in the first six months of life with failure to thrive, oral thrush, recurrent respiratory infection, and chronic diarrhea.
METHODS: In three male patients, we describe an unusual presentation of SCID. They are an outcome of consanguineous marriage; all received the BCG vaccine at birth. All three cases presented with regional lymphadenopathy at three months, progressing to generalized lymphadenopathy treated with anti-tuberculous. The first and second cases were twins. The first had an uneventful history until 33 months when he developed multiple Suppurative Tuberculous lymphadenitis confirmed by biopsy. The second and the third cases were diagnosed with Disseminated Tuberculosis at 24 months as they developed fever, anemia, weight loss, tuberculous peritonitis, and lymphadenopathy confirmed by biopsy. After investigations, the first case was diagnosed as CD4, CD16 lymphopenic SCID, the second one as CD4, CD8, CD19, CD16 lymphopenic SCID with hypogammaglobulinemia and the third case as CD3, CD4, CD8 lymphopenic SCID with hypogammaglobulinemia. They received anti-Tuberculous medications, prophylactic Trimethoprim/Sulfamethoxazole, and Immunoglobulin infusion. When writing this abstract, the patients were alive and had no other bacterial, viral, or fungal infections. The twins are three years old, and the third case is 30 months old.
CONCLUSIONS: SCID may not exhibit the classical manifestation of recurrent infections. It may present only as a complication of the BCG vaccine, alarming to maintain high susceptibility in such patients, especially in a developing country, specifically in Sudan, where the BCG vaccine is usually given at birth.

Tuberculosis is mainly known to affect the lungs, but it can manifest at various extrapulmonary sites. Disseminated tuberculosis is a relatively rare clinical condition, and cases with no history of the disease are sparse. A case of an 18-year-old Indian male is presented. He came with complaints of chest pain, coughing with expectoration, and loss of appetite. The diagnostic workup led to a definite diagnosis of disseminated tuberculosis with involvement of the lungs, pleura, mediastinal lymph nodes, and pericardium. He was initiated on a fixed-dose anti-tubercular treatment per the national guidelines.