Otic tuberculosis. Case report

Carlos, Roman; Porras, Lorena; Sánchez Sánchez, Rafael

doi:10.1016/j.medcle.2020.04.061

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Descripción de un caso" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1422 "Ancho" => 1500 "Tamanyo" => 125098 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Granulomas on the tympanic membrane." ] ] ] "textoCompleto" => "Although tuberculosis is a disease that has traditionally been linked to poverty and overcrowding, it is also found in susceptible individuals such as immunocompromised patients. Despite the scientific advances made in both the diagnosis and treatment of this disease, it continues to be a cause of high morbidity and mortality rates.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> In Spain, it is still registered as a notifiable disease (ND) despite the fact that its incidence has decreased progressively for the past 20 years.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> Middle ear tuberculosis is a rare disease that accounts for 0.04%–0.9% of all cases of chronic, suppurative otitis media. This disease must be suspected when making a differential diagnosis in conditions that fail to improve with the standard of care.<a class="elsevierStyleCrossRefs" href="#bib0015">3,4</a>We hereby present the case of a 38-year-old man with a history of chronic sinusitis, bronchial hyperreactivity, seborrheic dermatitis, lumbar spine osteopenia, a heterozygous prothrombin gene mutation, and a right single lung transplantation with a simultaneous lingulectomy four years ago due to bronchiectasis syndrome. He reported a pre-transplantation colonization by Pseudomonas sp., S. aureus, and Alcaligenes xylosoxydans, as well as some post-transplantation complications, including an episode of acute transplant rejection, a mixed respiratory tract infection, anemia, arterial hypertension, and sternal osteomyelitis caused by Candida albicans.The patient consulted with the on-call Emergency Care otorhinolaryngologist due to experiencing chronic ear discharge of several week’s evolution that responded poorly to topical treatment, together with profound bilateral hearing loss. An otoscopic examination revealed multiple granulomatous lesions in his tympanic membrane, associated with the presence of whitish discharge and inflammation of the external auditory canal of both ears (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Because several sample cultures were performed without detecting a clear underlying cause of his condition, and given the suspected diagnosis of complicated otitis media, a biopsy and a computerized axial tomography (CAT) scan with an intravenous (IV) contrast agent were performed on both ears. The CAT scan images revealed tympanic cavities with soft-tissue occupation resulting in bone alterations, as well as thinning and irregularities in the ear bones. A loss of bilateral pneumatization was also observed, together with predominantly right-sided sclerotic phenomena at the level of the mastoid cells.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>The diagnostic studies were completed with a single-photon emission computed tomography (SPECT) scan that revealed pathological contrast uptake levels in both petrous temporal lobes, with the left focus spreading up to the mastoid antrum, as well as a cavitated infiltrate in the right upper lung lobe. Given that the otic exudate culture was negative, a fibrobronchoscopy and bronchoalveolar lavage (BAL) were performed on the anterior segment of the right upper lung lobe, and the collected samples were sent to the Pathology and Microbiology laboratories for testing. Although the BAL cytology study was negative for malignancy, Mycobacterium tuberculosis complex of the bovine variant was isolated.The left ear biopsy performed applying the Ziehl-Neelsen technique was positive for acid-alcohol-fast bacilli (AAFB) compatible with tuberculosis. Based on these findings, treatment with rifampicin + isoniazid + pyrazinamide + ethambutol was started following the patient’s assessment in the Pulmonology Department. He was finally diagnosed with pulmonary tuberculosis in the context of a right single lung transplantation and secondary otomastoiditis (necrotizing granulomatous otitis), owing to which he was prescribed a weekly follow-up with ear cleanses for the following two months, observing a lower amount of ear discharge and fewer tympanic granulations. Four months later, persistent central perforations were detected in the posteroinferior quadrants of both ears, without active ear discharge. However, subsequent follow-up audiometry tests revealed that he had developed total anacusis in his right ear and severe sensorineural hearing loss in his left ear. Unfortunately, during his follow-up he developed a complicated pneumococcal lung infection that eventually resulted in his death.Middle ear tuberculosis is an uncommon disease with non-specific symptoms whose diagnosis is hard to reach.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> Its prognosis depends on the time until diagnosis and the time of treatment onset, and its diagnosis is reached based on the results of pathology tests and, complementarily, the levels of C-reactive protein (CRP) in a blood biochemistry analysis and the findings of microbiology tests. Its treatment is fundamentally based on the use of anti-tuberculosis drugs for six to 12 months, with surgery being limited exceptionally to cases with complications such as facial paralysis, abscesses, or meningitis." "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Carlos R, Porras L, Sánchez Sánchez R. Tuberculosis ótica. Descripción de un caso. Med Clin (Barc). 2021;157:50–51." ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1422 "Ancho" => 1500 "Tamanyo" => 125098 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Granulomas on the tympanic membrane." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Neuro-otologic manifestations of tuberculosis. “The great imitator”" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.M. Diplan Rubio" 1 => "A.V. Alarcón" 2 => "M.P. Díaz" 3 => "O. Vales" 4 => "R. Hinojosa" 5 => "J.M. Del Angel" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.amjoto.2015.01.018" "Revista" => array:6 [ "tituloSerie" => "Am J Otolaryngol" "fecha" => "2015" "volumen" => "36" "paginaInicial" => "467" "paginaFinal" => "471" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25697088" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The changing epidemiology of tuberculosis in a Spanish tertiary hospital (1995–2013)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. González-García" 1 => "J. Fortún" 2 => "E. Elorza Navas" 3 => "P. Martín-Dávila" 4 => "M. Tato" 5 => "E. Gómez-Mampaso" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Medicine (Baltimore)" "fecha" => "2017" "volumen" => "96" "paginaInicial" => "e7219" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Primary tuberculosis of the eustachian tube causing otitis media with effusion" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S.J. Oh" 1 => "K.I. Yi" 2 => "C.H. Lee" 3 => "K.S. Cho" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.amjoto.2015.04.004" "Revista" => array:6 [ "tituloSerie" => "Am J Otolaryngol" "fecha" => "2015" "volumen" => "36" "paginaInicial" => "575" "paginaFinal" => "577" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25935077" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tuberculosis del oído medio" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "B. Aupy" 1 => "A. Jahidi" 2 => "F. Benariba" 3 => "A. Akre" 4 => "D. Ettien" 5 => "P. Saint-Blancard" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "EMC - Otorrinolaringología" "fecha" => "2009" "volumen" => "38" "paginaInicial" => "1" "paginaFinal" => "6" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015700000003/v3_202201060717/S2387020621003351/v3_202201060717/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015700000003/v3_202201060717/S2387020621003351/v3_202201060717/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020621003351?idApp=UINPBA00004N"]

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Vol. 157. Issue 3.

Pages 148-149 (August 2021)

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