Journal of Yeungnam Medical Science

Original article

Performance of the BD MAX MDR-TB assay in a clinical setting and its impact on the clinical course of patients with pulmonary tuberculosis: a retrospective before-after study: Sung Jun Ko, Kui Hyun Yoon, Sang Hee Lee; J Yeungnam Med Sci. 2024;41(2):113-119. Published online April 5, 2024; DOI: https://doi.org/10.12701/jyms.2024.00024

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Abstract PDF: Background
Missing isoniazid (INH) resistance during tuberculosis (TB) diagnosis can worsen the outcomes of INH-resistant TB. The BD MAX MDR-TB assay (BD MAX) facilitates the rapid detection of TB and INH and rifampin (RIF) resistance; however, data related to its performance in clinical setting remain limited. Moreover, its effect on treatment outcomes has not yet been studied.
Methods
We compared the performance of BD MAX for the detection of INH/RIF resistances to that of the line probe assay (LPA) in patients with pulmonary TB (PTB), using the results of a phenotypic drug sensitivity test as a reference standard. The treatment outcomes of patients who used BD MAX were compared with those of patients who did not.
Results
Of the 83 patients included in the study, the BD MAX was used for an initial PTB diagnosis in 39 patients. The sensitivity of BD MAX for detecting PTB was 79.5%. The sensitivity and specificity of BD MAX for INH resistance were both 100%, whereas these were 50.0% and 95.8%, respectively, for RIF resistance. The sensitivity and specificity of BD MAX were comparable to those of LPA. The BD MAX group had a shorter time interval from specimen request to the initiation of anti-TB drugs (2.0 days vs. 5.5 days, p=0.001).
Conclusion
BD MAX showed comparable performance to conventional tests for detecting PTB and INH/RIF resistances. The implementation of BD MAX as a diagnostic tool for PTB resulted in a shorter turnaround time for the initiation of PTB treatment.

Case report

Successful treatment with vedolizumab in an adolescent with Crohn disease who had developed active pulmonary tuberculosis while receiving infliximab: Sujin Choi, Bong Seok Choi, Byung-Ho Choe, Ben Kang; Yeungnam Univ J Med. 2021;38(3):251-257. Published online February 19, 2021; DOI: https://doi.org/10.12701/yujm.2020.00878

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Vedolizumab (VDZ) has been approved for the treatment of inflammatory bowel diseases (IBDs) in patients aged ≥18 years. We report a case of a pediatric patient with Crohn disease (CD) who was successfully treated with VDZ. A 16-year-old female developed severe active pulmonary tuberculosis (TB) during treatment with infliximab (IFX). IFX was stopped, and TB treatment was started. After a 6-month regimen of standard TB medication, her pulmonary TB was cured; however, gastrointestinal symptoms developed. Due to the concern of the patient and parents regarding TB reactivation on restarting treatment with IFX, VDZ was started off-label. After the second dose of VDZ, the patient was in clinical remission and her remission was continuously sustained. Ileocolonoscopy at 1-year after VDZ initiation revealed endoscopic healing. Therapeutic drug monitoring conducted during VDZ treatment showed negative antibodies to VDZ. No serious adverse events occurred during the VDZ treatment. This is the first case report in Korea demonstrating the safe and effective use of VDZ treatment in a pediatric CD patient. In cases that require recommencement of treatment with biologics after recovery of active pulmonary TB caused by anti-tumor necrosis factor agents, VDZ may be a good option even in pediatric IBD.

Citations

Citations to this article as recorded by

The safety of vedolizumab in a patient with Crohn’s disease who developed anti-TNF-alpha agent associated latent tuberculosis infection reactivation: A case report
Yuya Sugiyama, Nobuhiro Ueno, Shion Tachibana, Yu Kobayashi, Yuki Murakami, Takahiro Sasaki, Aki Sakatani, Keitaro Takahashi, Katsuyoshi Ando, Shin Kashima, Kentaro Moriichi, Hiroki Tanabe, Toshikatsu Okumura, Mikihiro Fujiya
Medicine.2023; 102(28): e34331. CrossRef
Vedolizumab Is Safe and Efficacious for the Treatment of Pediatric-Onset Inflammatory Bowel Disease Patients Who Fail a Primary Biologic Agent
Sujin Choi, Eun Sil Kim, Yiyoung Kwon, Mi Jin Kim, Yon Ho Choe, Byung-Ho Choe, Ben Kang
Journal of Korean Medical Science.2022;[Epub] CrossRef

Review article

Diagnosis and treatment of multidrug-resistant tuberculosis: Jong Geol Jang, Jin Hong Chung; Yeungnam Univ J Med. 2020;37(4):277-285. Published online September 4, 2020; DOI: https://doi.org/10.12701/yujm.2020.00626

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Abstract PDF

Tuberculosis (TB) is still a major health problem worldwide. Especially, multidrug-resistant TB (MDR-TB), which is defined as TB that shows resistance to both isoniazid and rifampicin, is a barrier in the treatment of TB. Globally, approximately 3.4% of new TB patients and 20% of the patients with a history of previous treatment for TB were diagnosed with MDR-TB. The treatment of MDR-TB requires medications for a long duration (up to 20–24 months) with less effective and toxic second-line drugs and has unfavorable outcomes. However, treatment outcomes are expected to improve due to the introduction of a new agent (bedaquiline), repurposed drugs (linezolid, clofazimine, and cycloserine), and technological advancement in rapid drug sensitivity testing. The World Health Organization (WHO) released a rapid communication in 2018, followed by consolidated guidelines for the treatment of MDR-TB in 2019 based on clinical trials and an individual patient data meta-analysis. In these guidelines, the WHO suggested reclassification of second-line anti-TB drugs and recommended oral treatment regimens that included the new and repurposed agents. The aims of this article are to review the treatment strategies of MDR-TB based on the 2019 WHO guidelines regarding the management of MDR-TB and the diagnostic techniques for detecting resistance, including phenotypic and molecular drug sensitivity tests.

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Original article

Comparison of small bowel findings using capsule endoscopy between Crohn’s disease and intestinal tuberculosis in Korea: Yong Gil Kim, Kyung-Jo Kim, Young-Ki Min; Yeungnam Univ J Med. 2020;37(2):98-105. Published online November 22, 2019; DOI: https://doi.org/10.12701/yujm.2019.00374

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Abstract PDF

Background
Little is known about capsule endoscopy (CE) findings in patients with intestinal tuberculosis who exhibit small bowel lesions. The aim of the present study was to distinguish between Crohn’s disease (CD) and intestinal tuberculosis based on CE findings.
Methods
Findings from 55 patients, who underwent CE using PillCam SB CE (Given Imaging, Yoqneam, Israel) between February 2003 and June 2015, were retrospectively analyzed.
Results
CE revealed small bowel lesions in 35 of the 55 patients: 19 with CD and 16 with intestinal tuberculosis. The median age at diagnosis for patients with CD was 26 years and 36 years for those with intestinal tuberculosis. On CE, three parameters, ≥10 ulcers, >3 involved segments and aphthous ulcers, were more common in patients with CD than in those intestinal tuberculosis. Cobblestoning was observed in five patients with CD and in none with intestinal tuberculosis. The authors hypothesized that a diagnosis of small bowel CD could be made when the number of parameters in CD patients was higher than that for intestinal tuberculosis. The authors calculated that the diagnosis of either CD or intestinal tuberculosis would have been made in 34 of the 35 patients (97%).
Conclusion
The number of ulcers and involved segments, and the presence of aphthous ulcers, were significantly higher and more common, respectively, in patients with CD than in those with intestinal tuberculosis. Cobblestoning in the small bowel may highly favor a diagnosis of CD on CE.

Citations

Citations to this article as recorded by

Deep Learning Radiomics Analysis of CT Imaging for Differentiating Between Crohn’s Disease and Intestinal Tuberculosis
Ming Cheng, Hanyue Zhang, Wenpeng Huang, Fei Li, Jianbo Gao
Journal of Imaging Informatics in Medicine.2024;[Epub] CrossRef
Differentiating gastrointestinal tuberculosis and Crohn's disease- a comprehensive review
Arup Choudhury, Jasdeep Dhillon, Aravind Sekar, Pankaj Gupta, Harjeet Singh, Vishal Sharma
BMC Gastroenterology.2023;[Epub] CrossRef
Difficulties in the differential diagnosis of intestinal tuberculosis and Crohn‘s disease
M. N. Reshetnikov, D. V. Plotkin, Yu. R. Zyuzya, A. A. Volkov, O. N. Zuban, E. M. Bogorodskaya
Acta Biomedica Scientifica.2021; 6(5): 196. CrossRef
Differentiating intestinal tuberculosis and Crohn disease: Quo Vadis
Vishal Sharma
Expert Review of Gastroenterology & Hepatology.2020; 14(8): 647. CrossRef

Case Reports

Tracheal pleomorphic adenoma with coexisting pulmonary tuberculoma: Jehun Kim, Chul-Ho Oak, Tae-Won Jang, Mann-Hong Jung; Yeungnam Univ J Med. 2018;35(1):114-120. Published online June 30, 2018; DOI: https://doi.org/10.12701/yujm.2018.35.1.114

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Abstract PDF

Tracheal tumors are rare and difficult to diagnose. Moreover, delays in diagnosis are very common because the symptoms are nonspecific. As a result, tracheal tumors are commonly mistreated as chronic obstructive pulmonary disease or bronchial asthma. We report a case of a 49-year-old male who presented with a 3-month history of dyspnea and cough. Chest computed tomography scan showed a 1.5×1.3 cm homogenous tumor originating from the right lateral wall of the tracheobronchial angle into the tracheal lumen as well as a 0.5×0.4 cm round nodular lesion at the right upper lobe with multiple mediastinal lymph nodes enlargement. Bronchoscopic findings revealed a broad-based, polypoid lesion nearly obstructing the airway of the right main bronchus. The patient was diagnosed with pleomorphic adenoma which is the most common benign tumor of the salivary glands, but rarely appears in the trachea. Upon surgery, tracheal pleomorphic adenoma and co-existing active pulmonary tuberculoma that had been mistreated as bronchial asthma over 3 months was revealed. Following surgery, the patient underwent anti-tuberculosis treatment. No recurrence has been detected in the 3 years since treatment and the patient is now asymptomatic.

Citations

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Pleomorphic adenoma of the trachea: A case report
Mayu Inomata, Shoei Kuroki, Nobuyuki Oguri, Yuichiro Sato, Fumiya Kawano, Ryo Maeda
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Pleomorphic adenoma of the trachea: A case report and review of the literature
Qian-Nuan Liao, Ze-Kui Fang, Shu-Bing Chen, Hui-Zhen Fan, Li-Chang Chen, Xi-Ping Wu, Xi He, Hua-Peng Yu
World Journal of Clinical Cases.2020; 8(23): 6021. CrossRef
Pleomorphic adenoma of the trachea: A case report and review of the literature
Qian-Nuan Liao, Ze-Kui Fang, Shu-Bing Chen, Hui-Zhen Fan, Li-Chang Chen, Xi-Ping Wu, Xi He, Hua-Peng Yu
World Journal of Clinical Cases.2020; 8(23): 6026. CrossRef
Obstructive tracheal neoplasm
Badreeddine Alami, Saïd Boujraf, Mohamed Smahi, Mounia Serraj, Moulay Youssef Alaoui Lamrani, Meryem Boubbou, Mustapha Maaroufi
Formosan Journal of Surgery.2019; 52(3): 92. CrossRef

Malignant mesothelioma mistaken for tuberculous pleurisy.: Ji Young Yang, Min Joo Song, So Jung Park, Jaekyung Cheon, Jung Wan Yoo, Chang Min Choi, Yong Hee Kim; Yeungnam Univ J Med. 2015;32(1):50-54. Published online June 30, 2015; DOI: https://doi.org/10.12701/yujm.2015.32.1.50

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Abstract PDF: Malignant mesothelioma is a common, primary tumor that can invade pleura, and is associated with previous exposure to asbestos. However, it poses considerable difficulties regarding its diagnosis and treatment, and thus, accurate history taking with respect to exposure to asbestos, and radiologic and pathologic examinations are essential. In addition, the involvement of a multidisciplinary team is recommended in order to ensure prompt and appropriate management using a framework based on radiotherapy, chemotherapy, surgery, and symptom palliation with end-of-life care. Because lymphocyte-dominant, exudative pleural effusion can occur in malignant mesothelioma, adenosine deaminase values may be elevated, which could be mistaken for tuberculous pleurisy, and lead to an incorrect diagnosis and suboptimal treatment. The authors describe a case of malignant mesothelioma initially misdiagnosed as tuberculous pleurisy. As evidenced by the described case, malignant mesothelioma should be considered during the differential diagnosis of patients with lymphocyte-dominant, exudative pleural effusion with a pleural lung lesion.

Surgical treatment of recurrent pseudochylothorax occurring after therapy of tuberculous pleurisy.: Jae Ryung Yi, Woo Sik Kim, Eun Jung Jeong, Yu Na Jung, Hee Sook Lee, Gi Ho Jo, Ji Yeon Lee; Yeungnam Univ J Med. 2014;31(1):65-68. Published online June 30, 2014; DOI: https://doi.org/10.12701/yujm.2014.31.1.65

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Abstract PDF: Pseudochylothorax is an uncommon pleural effusion disease characterized by the presence of cholesterol crystals or high lipid content not resulting from a disrupted thoracic duct. Most of the cases reported so far had been found in patients with long-standing pleural effusion due to a chronic inflammatory disease such as old tuberculous pleurisy or chronic rheumatoid pleurisy. Authors encountered a case of pseudochylothorax in a 45-year-old man who had been treated for tuberculous pleurisy 6 years before his visit to authors' hospital. After that, he had visited the emergency department many times for removal of pleural effusion. The patient's chest X-ray revealed dyspnea and large left-sided pleural effusion. Although a large amount of pleural fluid was removed with a drainage catheter, massive pleural effusion was likely to recur, and the underlying lung was able to fully re-expand. Accordingly, decortication was done, and the patient's symptom was improved without postoperative complications.

Original Article

Usefulness of the BACTEC MGIT 960 System for Mycobacterial Culture and TB Ag MPT64 Immunochromatographic Assay to Identify Mycobacterium tuberculosis.: Seung Hun Lee, Min Jeong Lee, Jeong Mi Lee, Su Jin Yim, Seung Jun Lee, You Eun Kim, Yu Ji Cho, Yi Yeong Jeong, Ho Cheol Kim, Jong Deog Lee, Sun Joo Kim, Young Sil Hwang; Yeungnam Univ J Med. 2012;29(2):83-88. Published online December 31, 2012; DOI: https://doi.org/10.12701/yujm.2012.29.2.83

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Abstract PDF

BACKGROUND
This study was conducted to evaluate the usefulness of the BACTEC MGIT (Mycobacterium Growth Indicator Tube) 960 system for mycobacteria culture and immunochromatographic assay to identify Mycobacterium tuberculosis (MTB) in positive MGIT culture. METHODS: Mycobacteria-culture-positive cases were retrospectively analyzed from December 2010 to July 2011. The detection rates and the recovery times of the mycobacteria between the Ogawa media and the MGIT were compared. An immunochromatographic assay (ICA) (SD BIO-LINE) was also performed in the positive MGIT culture for identification, and the results were compared with those of the Ogawa media in the Korea National Tuberculosis Association. RESULTS: Among the 261 patients (M:F, 168:93; mean age, 61.6+/-17.16 yrs), 450 specimens (sputa, 365; bronchial washing, 61; and pleural effusion, 24) were found positive with mycobacteria. Mycobacteria were grown both on the MGIT and Ogawa media in 310 cases (68.9%); only on the MGIT in 115 cases (22.6%); and only on the Ogawa media in 25 cases (5.5%) (p<0.05).The recovery time was 28.2+/-8.9 days in the Ogawa media and 11.1+/-5.8 days in the MGIT (p<0.05). Among the 127 cases from the positive MGIT culture, all 92 cases that were confirmed as MTB cases bythe Korea National Tuberculosis Association were identified as MTB by ICA, with 100% sensitivity. CONCLUSION: MGIT increases the detection rate and shortens the recovery time of mycobacteria in clinical respiratory specimens, and the TB Ag MPT64 kit using ICA is useful in identifying MTB in a positive MGIT culture.

Citations

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A Low Cost/Low Power Open Source Sensor System for Automated Tuberculosis Drug Susceptibility Testing
Kyukwang Kim, Hyeong Kim, Hwijoon Lim, Hyun Myung
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Case Reports

A Case of Sacral Tuberculosis Mimicking Metastatic Bone Tumor with Elevated CA 19-9.: Kyung Yoon Chang, Kyung Sun Ha, Kyung Seon Park, Eun Hui Sim, Jae Ho Byun; Yeungnam Univ J Med. 2011;28(2):196-201. Published online December 31, 2011; DOI: https://doi.org/10.12701/yujm.2011.28.2.196

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Abstract PDF

A 73-year-old male presented a six-month history of buttock pain radiating into his thigh. The MRI revealed a large enhancing mass lesion involving the sacrum, with extension into the sacral canal. The tumor markers were measured to distinguish skeletal metastasis of carcinoma from primary bone tumor. The CA 19-9 was elevated. Despite the investigation, the primary site of cancer could not be found. Sacral bone biopsy was done. The pathologic examination revealed necrosis, chronic granulomatous inflammation, and multinucleated giant cells, consistent with tuberculosis. Sacral tuberculosis is rare in patients with no history of tuberculosis. Such solitary osteolytic lesions involving the subarticular region of large joints may mimic bone neoplasms and may be called "tuberculous pseudotumors." This case report intends to emphasize that bone tuberculosis should be a differential diagnosis in the presence of atypical clinical and radiological features. As tuberculous lesions may be mistaken for neoplasms, a small amount of fresh tissue should be sent for culture even if clinical diagnosis of a tumor seems likely. Described herein is a case of sacral tuberculosis mimicking metastatic bone tumor with elevated CA 19-9.

Citations

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Isolated Sacral Tuberculosis: A Case Report and Review of Literature of this Rare Sacral Pathology
Harshit Arora, Vasudha Sharma, Waryaam Singh, Lavanya Arora, Sumer Singh Nanda, Rajesh Pasricha
EMJ Neurology.2023;[Epub] CrossRef

Eosinophilic Myositis Induced by Anti-tuberculosis Medication.: Hyun Jung Kim, Jung Eun Park, Yeong Ha Ryu, Dae Hyung Woo, Kyeong Cheol Shin, Jin Hong Chung, Kwan Ho Lee; Yeungnam Univ J Med. 2010;27(1):42-46. Published online June 30, 2010; DOI: https://doi.org/10.12701/yujm.2010.27.1.42

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Abstract PDF: Eosinophilic myositis is a rare idiopathic inflammatory muscle disease, and the patients with this malady present with diverse signs and symptoms such as muscle swelling, tenderness, pain, weakness, cutaneous lesions and eosinophilia. The etiology and pathogenesis of eosinophilic myositis remain elusive. Several drugs may occasionally initiate an immune mediated inflammatory myopathy, including eosinophilic myositis. We report here on a case a 17-year-old female patient who had taken anti-tuberculosis medicine for tuberculosis pleurisy. She presented with many clinical manifestations, including fever, skin rash, proximal muscle weakness, dyspnea, dysphagia and hypereosinophilia. She was diagnosed with eosinophilic myositis by the pathologic study. The muscle weakness progressed despite of stopping the anti-tuberculosis medicine, but the myositis promptly improved following the administration of glucocorticoid. Although drug induced myopathies may be uncommon, if a patient presents with muscular symptoms, then physicians have to consider the possibility of drug induced myopathies.

A Case of Polyarteritis Nodosa Associated with Pulmonary Tuberculosis.: Chang Woo Son, Jeong Hwan Cho, In Wook Song, Jung Eun Park, Kyeong Cheol Shin, Jin Hong Chung, Kwan Ho Lee; Yeungnam Univ J Med. 2009;26(2):130-136. Published online December 31, 2009; DOI: https://doi.org/10.12701/yujm.2009.26.2.130

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Abstract PDF: Polyarteritis nodosa (PAN) is a systemic necrotizing vasculitis that typically affects the medium-sized muscular arteries, with occasional involvement of the small muscular arteries. As with other vasculitides, PAN can affect any organ system, including the cardiovascular, gastrointestinal and central nervous systems. The prognosis for patients with untreated PAN is relatively poor, with five-year survival rates of approximately 13 percent. The outcome has improved with proper therapy to approximately 80 percent survival at five years. We report here on a case of a 46 year old man with polyarteritis nodosa and who suffered from pulmonary tuberculosis.

A Case of Tarsal Bone Tuberculosis in a Patient with Polycythemia Vera.: Sung Ae Koh, Se Hun Shon, Dong Gun Kim, Sung Woo Park, Choong Ki Lee, Kyung Hee Lee, Min Kyoung Kim, Myung Soo Hyun; Yeungnam Univ J Med. 2009;26(1):44-48. Published online June 30, 2009; DOI: https://doi.org/10.12701/yujm.2009.26.1.44

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Abstract PDF: Talus tuberculosis is a rare disease, even in an endemic tuberculosis area. In reviews of the worldwide literature, only 18 cases of talus tuberculosis have been reported. Recently, we experienced a case of a 70-year-old polycythemia vera patient with right metatarsopharyngeal joint pain for 2 months duration who was diagnosed with talus tuberculosis with prostate involvement. Tuberculosis should be considered as one of the causes of monoarticulitis, especially in countries, where the disease is endemic. Additionally, we highly recommend taking a biopsy of the site of suspected infection because an early diagnosis is the key to successful treatment.

Original Article

Comparison of REP13E12 PCR with Amplicor MTB for the Detection of Mycobacterium tuberculosis in Respiratory Specimens: Tae-Yoon Lee; Yeungnam Univ J Med. 2007;24(2 Suppl):S456-462. Published online December 31, 2007; DOI: https://doi.org/10.12701/yujm.2007.24.2S.S456

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Abstract PDF: Background
s：In recent years, the incidence of tuberculosis has increased mainly in high-risk populations. Classical laboratory diagnostic methods for tuberculosis have low sensitivity and time consuming procedures. Thus, it is important to identify the presence of Mycobacterium tuberculosis in the clinical specimens earlier than the culture results for the decision to initiate anti-tuberculosis therapy. Lee et al. reported a species-specific repeated sequence from a Korean M. tuberculosis isolate, which was later proved to be a part of REP13E12 repetitive sequence. Materials and Methods：In this study, we compared the acid-fast staining, culture, Amplicor MTB (Roche), and REP13E12 PCR for detection of M. tuberculosis using 88 clinical samples. The sensitivity, specificity, positive and negative predictive values were compared.
Results
：REP13E12 PCR showed equivalent score to Amplicor MTB. Both PCR-based methods showed better score than conventional stain and culture methods.
Conclusion
：This result suggested that REP13E12 PCR is helpful for the rapid detection of the M. tuberculosis from clinical specimens.

Case Reports

A Case of Lichenoid Drug Eruption Caused by Antituberculosis Drug.: Soo Keoung Lee, Jong Soo Choi, Ki Hong Kim; Yeungnam Univ J Med. 1995;12(2):405-411. Published online December 31, 1995; DOI: https://doi.org/10.12701/yujm.1995.12.2.405

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Abstract PDF: Lichenoid drug eruption is lichenoid skin eruptions caused by certain drugs and compounds, and can be identical or similiar to lichen planus. A 75-year-old woman who had taken antituberculosis medication(INH, ethambutol, rifampin) for 4 months developed pruritic generalized erythematous papular eruptions on the trunk and extremities, alopecia and nail dystropy. Histopathologic findings were hyperkeratosis, hypergranulosis, hyc rophic degenaration of basal layer, band like lymphohistiocytic infiltration in the upper dermis and perivascular lymphohistiocytic infiltration in the deep dermis. She was treated with systemic corticosteroid, and then skin lesion were slightly improved. After termination of antituberculosis medication, skin lesions were markedly improved with residual hyperpigmentation. Alopecia and nail dystrophy were also improved.

Four cases of cutaneous tuberculosis.: Moo Woong Lee, Tae Hun Kwak, Jong Soo Choi, Ki Hong Kim, Mi Jin Kim; Yeungnam Univ J Med. 1992;9(1):181-188. Published online June 30, 1992; DOI: https://doi.org/10.12701/yujm.1992.9.1.181

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Abstract PDF: The incidence of the cutaneous tuberculosis has shown a steady decline over the past decades. This parallels the decreasing incidence of pulmonary tuberculosis. We experienced 5 cases of cutaneous tuberculosis from January 1990 to February 1991. We present herein 4 cases of cutaneous tuberculosis. They were 3 cases of vulgaris and 1 case of tuberculosis verrucosa cutis. Mantoux tests were done except one case and were reactive in all cases. Culture for Mycobacterium tuberculosis were done but Mycobacterium tuberculosis were not cultivated in the all cases. Histopathological findings showed tuberculoid granulomas in the dermis except one case and no acid fast bacilli were demonstrated on AFB stains.

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