Patients with end-stage renal disease undergoing chronic hemodialysis (HD) are at high risk to develop tuberculosis (TB) associated with a high mortality rate. TB diagnosis is often delayed due to non-specific symptoms, frequent extra-pulmonary manifestations, and rare microbiological confirmation. This case report illustrates the clear added value of combined interferon-γ -release assays (IGRA) in response to different mycobacterial antigens for an early diagnosis of TB in HD patients. We report the case of an Egyptian patient under chronic HD treatment, who presented with recurrent episodes of fever and myalgia of unknown origin, associated with an important inflammatory syndrome. These episodes resolved partially or completely within less than 1 month without any treatment but recurred 10 times within 3 years. Chest Computed Tomography and 18F-fluorodeoxyglucose Positron Emission Tomography/Computed Tomography (18FDG PET-CT) demonstrated several active mediastinal lymphadenopathies. TB was the first suspected diagnosis but cultures and polymerase chain reaction (PCR) remained negative on a mediastinal lymph node aspiration. In contrast, the results from two different IGRA performed on blood were highly suggestive of TB disease. Several granulomas, some of them with central non-caseating necrosis, were demonstrated on a pulmonary nodule obtained by thoracoscopic resection, but PCR and culture remained negative for M. tuberculosis. Three years after the initial symptoms, a new PET-CT revealed a retro-clavicular lymphadenopathy in addition to the mediastinal lymphadenopathies, and the M. tuberculosis culture performed on the resected lymphadenopathy was positive. Antibiotic treatment for TB was started and resulted in a clear improvement of the patient’s clinical condition, allowing him to successfully receive a renal graft. In view of the high frequency of TB in patients undergoing chronic HD and of the limitations of the classical diagnosis procedures, nephrologists have to diagnose TB mostly on clinical suspicion. We demonstrate here that the use of a combined IGRA to two different mycobacterial antigens may significantly raise the index of suspicion and help clinicians to decide starting anti-TB treatment in HD patients.

中文翻译：

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通过结合两种干扰素-γ-释放测定对血液透析患者粟粒性结核进行早期诊断：病例报告。

接受慢性血液透析（HD）的终末期肾病患者患结核病（TB）的风险很高，且死亡率很高。由于非特异性症状、频繁的肺外表现和罕见的微生物学确诊，结核病的诊断常常被延迟。该病例报告说明了针对不同分枝杆菌抗原的联合干扰素-γ释放测定（IGRA）对于 HD 患者结核病早期诊断的明显附加价值。我们报告了一名接受慢性 HD 治疗的埃及患者的病例，该患者出现反复发作的发热和不明原因的肌痛，与一种重要的炎症综合征相关。这些发作在不到 1 个月的时间内部分或完全缓解，无需任何治疗，但在 3 年内复发了 10 次。胸部计算机断层扫描和 18F-氟脱氧葡萄糖正电子发射断层扫描/计算机断层扫描 (18FDG PET-CT) 显示数种活动性纵隔淋巴结病。结核病是第一个疑似诊断，但纵隔淋巴结抽吸培养和聚合酶链反应 (PCR) 仍呈阴性。相比之下，对血液进行的两次不同 IGRA 的结果高度提示结核病。胸腔镜切除肺结节上发现数个肉芽肿，其中一些具有中央非干酪样坏死，但 PCR 和培养结核分枝杆菌仍呈阴性。出现初始症状三年后，新的 PET-CT 显示除纵隔淋巴结肿大外还有锁骨后淋巴结肿大，对切除的淋巴结肿大进行的结核分枝杆菌培养呈阳性。结核病的抗生素治疗开始后，患者的临床状况明显改善，使他能够成功接受肾移植。鉴于慢性 HD 患者中结核病的发病率较高以及经典诊断程序的局限性，肾脏科医生只能根据临床怀疑来诊断结核病。我们在此证明，对两种不同的分枝杆菌抗原联合使用 IGRA 可能会显着提高怀疑指数，并帮助临床医生决定对 HD 患者开始抗结核治疗。