Журнал «Актуальная инфектология» Том 9, №4, 2021

Tuberculosis in patients with systemic lupus erythematosus (SLE) may be present not as in immunocompetent patients. Risk of the incidence of miliary tuberculosis with multiple locations due to late diagnosis and non-specific clinical symptoms imitating lupus higher. Therefore, early diagnosis of pulmonary tuberculosis is important for proper treatment. High dose of steroid therapy is an important risk factor for tuberculosis.

We present an observation of the case for steroid tuberculosis in a patient on a systemic lupus erythematosus. A patient of 52 years, which for 4 years took every day 12 mg methylprednisolone about the systemic lupus, turned to the polyclinic for the pain in the lower abdomen and periodically raise the body temperature to 37,5 °C, and sometimes to 39,0 °C. The general condition of the patient was relatively satisfactory. The patient was a sufficient food. At palpation noted diffuse increase in thyroid gland 1 degree. Skin was pale, dry with erythematous rashes on the upper and lower extremities. Heart tones are muted, rhythmic. Arterial pressure 130/90 mm/mercury. Pulse 72 strikes on Min. Over the lungs were listened to weakened breathing with a stiff tinge and the noise friction of the pleura below the blades on the right. Liver is 2 cm protrude from the edge of the rib arc. There was no peripheral swelling. The patient was examined by a gynecologist and, due to suspected oncological pathology, is directed for further examination in the oncological dispensary. In the oncological dispensary, the patient was carried out laparoscopic stage, during which there was found a focal seeding of peritoneum. After a biopsy of the peritoneum during histological examination a large number of productive epithelioid cell granulomas with giant multi-nuclei Langhan’s cells were found. Ultrasonic investigation and computer of multi-detector tomography with contrast revealed signs of soft-tissue components of left-tube area of 33 × 20 mm, fallopian tube of the habitual cystic structure up to 6 mm, the minimum ascites, a local area of visceral peritoneum lesion, which was estimated as TB-specific changes in left fallopian tube, peritoneum. To refine the diagnosis, the patient was sent to TB dispensary. In X-ray studies of the thoracic organs, there is a miliary dissemination in the lungs and signs of right-sided pleurisy in the form of inflammation of the sinus and interpleural adhesion. Since the patient did not excrete sputum for microbiological research, bronchial washings were taken, where seven acid-fast bacilli were found by microscopy with Ziehl-Nielsen technique on 100 of visual fields. A molecular-genetic study of the material (GeneXpertMTB/RIF) was also found to have DNA TB Mycobacterium (MTB) sensitive to rifampicin. In the clinical analysis of blood marked mild leukocytosis (9.8 g/L) and ESR reduction (32 mm/hour). Urine is found in protein (0.084 g/L) and hyaline cylinders. In biochemical analysis of blood was noted a decrease in total protein up to 59.4 G/L in another without pathological changes. The disease was established by a diagnosis of miliary tuberculosis with multiple localization: in lungs; pleura; peritoneum; seal left Fallopian tube, confirmed microbiologically and histologically. Systemic lupus erythematosus. Diffuse hyperplasia of the thyroid gland 1grade, euthyroidism. In view of the generalized process, treatment is initiated according to the individual scheme with six drugs: isoniazid, rifampicin, pyrazinamide, ethambutol, kanamycin, and ofloxacin up to obtaining the data of the MTB sensitivity to anti-tuberculosis drugs by culture results. This case draws the attention of rheumatologists, gynecologists, oncologists, endocrinologists and doctors of other specialties at an increased risk of disease on tuberculosis of patients who have long-term steroid hormones. The case is a typical example of “steroid” TB prone to generalizing and multiple localization. This version of the disease with late diagnosis and progression is often leads to fatal outcomes. Patients who take long time steroids require suspicion regarding Critical in the staging diagnosis of tuberculosis is the X-ray and CT scan study of the thoracic cavity and microbiological examination of sputum or bronchial washings, using a microscopy of sputum smear, stained by Ziehl-Nielsen, amplification methods and culture methods for Mycobacterium tuberculosis. In case of suspicion of extrapulmonary localization, consultation of the relevant specialists, ultrasound and tomography investigations and histological examination of the biopsy material is advisable. The peculiarity of tuberculosis is the absence of clinical, strictly pathognomic only for this pathology of symptoms; tuberculosis remains a great change that constantly tries to mask other diseases.