The patient is a 34 year-old woman from Central America, who presented to the hospital with mental
The clinical history was collected from her husband who accompanied her to the hospital. He says that
the patient had recently immigrated to New York City area and was previously in good health. Two weeks
before, the patient complained of mild headaches. The husband noted that the patient was becoming
increasingly forgetful and that she started to sleep more than usual. The day he decided to bring her to
the hospital she could not be easily awakened. He denies fever or convulsions. He says the patient has
been losing weight slowly but does not know how much. He also says that he is not aware of any
significant family history for carcinoma or other diseases. He denies alcohol and tobacco abuse.
Laboratories tests were non-contributory. She had normochromic-normocytic anemia and slight
leukocytosis. A computerized tomography (CT) scan of the head showed intracranial masses suggestive of
metastasis. Subsequent CT scan of the abdomen and pelvis showed a 12 cm cystic septate mass in the
pelvis, posterolateral to the uterus, suggestive of a cystic adnexal neoplasm. There was no associated
lymphadenopathy and intra-abdominal organs were within normal limits. A chest X-ray showed two nodules
in the lung.
A transvaginal aspiration biopsy of the pelvic mass was performed.
The aspirated biopsy material was composed of necrotic debris and neutrophils, in the absence of
epithelioid histiocytes and giant cells. Ziehl-Neelsen stains revealed acid-fast bacilli.
Diagnosis: Tuberculosis (confirmed by microbial culture)
Tuberculosis is the worldwide leading cause of death as the result of a single infectious agent, with an
estimated 10 million new cases and 2 million deaths each year.1 Although commonly regarded as an
ongoing health problem in developing countries and in immunosuppressed individuals, tuberculosis can
affect all sections of the population. Several factors have been attributed to an increase in the number
of cases reported in the United States in the last two decades, namely concomitant HIV infection and
increased immigration from countries where tuberculosis is endemic.
Tuberculosis continues to be an important public health problem worldwide despite efforts at
eradication and control. In the US, the downward trend in the incidence of new tuberculosis cases was
reversed in 1985, with an increase in reported cases. The increases have been significant in racial and
ethnic minorities, in immigrants, and in children younger than 15 years old. In 1993, 29.6% of people
infected with M. tuberculosis were born outside of the US, compared with 22%
In addition, changes have occurred not only in the demographic distribution of tuberculosis cases, but
also in the anatomic distribution of disease. The number of pulmonary cases had decreased from 1963 to
1986 by an annual average of 5%; the number of extra-pulmonary cases of tuberculosis had declined only by
0.9% annually.12 In analysis of reported cases of tuberculosis in 1986, 17.5% of all tuberculosis
cases were extrapulmonary. Of those, 71.2% occurred in racial/ethnic minorities and people who were not
born in the US. In a different study,13 where cases were analyzed according to HIV status, 60% of HIV
positive patients with pulmonary tuberculosis, also had extrapulmonary disease; 26% of HIV positive
patients had extrapulmonary disease only. In HIV negative patients with pulmonary tuberculosis, 28% also
had extrapulmonary disease, and 28% had only extrapulmonary disease.
One of the key components in eradication of tuberculosis is timely diagnosis. This facilitates early
treatment, as well as prophylaxis for exposed social and household contacts. The diagnosis of pulmonary
lesions is relatively uncomplicated, regardless of HIV status. When a biopsy is recommended, the finding
of pulmonary necrotizing granulomatous inflammation with acid-fast bacilli confirms the diagnosis. In
cases of extra-pulmonary tuberculosis, the diagnosis can be difficult since tuberculosis may have not
been considered in the differential diagnosis. But if necrotizing granulomas are identified in a biopsy
specimen, the search for acid-fast bacilli will be initiated.
Diagnostic difficulty is encountered when extrapulmonary tuberculosis mimics neoplastic processes
clinically and radiographically,2-5 and a biopsy of the mass does not show the classical findings of
M. tuberculosis infection, such as necrotizing granulomas. The combination
of atypical presentation and atypical findings on biopsy of an immunocompetent patient may lead to
misdiagnosis and delay in treatment, such as exemplified in the case presented here.
The aspirated biopsy material represented a diagnostic challenge in this case because necrotic debris
and neutrophils, in the absence of epithelioid histiocytes and giant cells, mislead the cytopathologist
into making the diagnosis of an abscess or necrosis of tumor. Although cases of tuberculosis presenting
as suppurative inflammation have been described, these are favored to occur in the setting of severe
immunodeficiency 6,7 or in the course of tuberculous lymphadenitis.8,9
A careful search of the medical literature showed that a few cases of atypical presentations of
extra-pulmonary tuberculosis have been described but only in one case 3 the disease manifested as
suppurative inflammation in a solid organ (liver).
Another pitfall in these cases is the presence of atypical cells on the smears. These atypical cells
are large cells with vacuolated cytoplasm, enlarged irregular nuclei and prominent nucleoli. Some
resembled signet-ring cells with a distended cytoplasmic vacuole, which causes indentation of the
nucleus. Immunostains on sections of cells block demonstrates reactivity to CD68, a monocytic marker in
these atypical cells. Reactive macrophages have been described in cytological and histological
preparation to mimic neoplastic cells.9-11
The case presented herein underscore the importance of having a high index of suspicion for
tuberculosis in certain patient groups (i.e. immigrants), even in patients who are HIV negative or whose
clinical diagnosis is carcinoma. A search for acid-fast bacilli should be included in the investigation
of all masses where aspiration biopsy yields necrotic debris with neutrophils to avoid unnecessary and
inappropriate diagnostic and therapeutic procedures.
- Huebner RE and Castro K. The changing face of tuberculosis. Annu Rev
Med 1995; 46:47-55.
- Demir K, Kaymakoglu S, Besisik F, Durakoglu Z, Ozdil S, Kaplan Y, Boztas G, Cakaloglu Y, and Okten A.
Solitary pancreatic tuberculosis in immunocompetent patients mimicking pancreatic carcinoma. J of Gastroenterol and Hepatol 2001;16:1071-1074.
- Wee A, Nilsson B, Wang T-L, Yap I, and Siew P-Y. Tuberculous pseudotumor causing biliary
obstruction. Acta Cytol 1995;39(3):559-562.
- Cacir B, Tuncbilek N, Karakas HM, Unlu E, Ozylmaz F. Granulomatous mastitis mimicking breast
carcinoma. Breast J 2002 8:251-252.
- Romand F, Gaudin JL, Bobichon R, Souquet JC. Abdominal tuberculosis of pseudotumor aspect. Presse
Med. 1997. 26:1717-1721.
- Lucas S, Nelson AM. Pathogenesis of Tuberculosis in Human Immunodeficiency virus-infected people.
In: Bloom BR ed. Tuberculosis: Pathogenesis, protection and control. Washington, D.C. 1994.pp
- Smith MB, Boyars MC, Veasey S, Woods GL. Generalized Tuberculosis in the Acquired Immune Deficiency
Syndrome. A clinicopathologic analysis based on autopsy findings. Arch Pathol Lab Med 2000.
- Ellison E, Lapuerta P, Martin SE. Fine Needle Aspiration Diagnosis of Mycobacterial Lymphadenitis.
Sensitivity and predictive value in the United States. Acta Cytologica 1999. 43:153-157.
- Tsang WY, Chan JK. Fine-needle Aspiration Cytologic diagnosis of Kikuchi's lymphadenitis. A report
of 27 cases. Am J Clin Pathol 1994. 102:454-458.
- Gould E, Perez J, Albores-Saavedra J, Legaspi A. Signet ring cell sinus histiocytosis. A previously
unrecognized histologic condition mimicking metastatic adenocarcinoma in lymph nodes. Am J Clin Pathol
- Finley AJ, Ishak KG. Atypia of hepatic histiocytes induced by Renografin-60. J Pediatr
Gastroenterol Nutr 1986. 5:472-475.
- Rieder HL, Snider DE and Cauthen GM. Extrapulmonary tuberculosis in the United States. Am Rev Respir Dis 1990;141:347-351.
- Chaisson RE, Schecter GF, Theuer CP, Rutherford GW, Echenberg DF and Hopewell PC. Tuberculosis in
patients with the acquired immunodeficiency syndrome. Am Rev Respir Dis