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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor&#44; </span></p><p class="elsevierStylePara">Haemodialysis patients are more likely to develop infections due to changes in their immune response associated with kidney failure&#46; The use of some immunosuppressor drugs and pathologies such as diabetes also make infections more likely&#46;<span class="elsevierStyleSup">1-4 In&#160;recent years we have witnessed an increase in the incidence of tuberculosis &#40;TB&#41; in the general population&#44; and as a result in the haemodialysis population as well&#46;1</span> The diagnosis of TB in these patients is hindered by its insidious and unspecific medicial symptoms&#46; Also&#44; some diagnostic tests and screening fail to identify the disease in this group of patients&#46;<span class="elsevierStyleSup">3&#44;5 </span></p><p class="elsevierStylePara">We present the case of a 67-year-old male patient in a haemodialysis program with a history of high blood pressure&#44; a positive blood test for hepatitis C virus&#44; and chronic kidney disease due to nephroangiosclerosis&#46; He began haemodialysis in 1989&#44; had a kidney transplant in 1990&#59; he has post-transplant diabetes mellitus&#59; he began dialysis again in September&#44; 2007&#46; He has been in treatment for 3 months with prednisone at 30 mg&#47;day due to an initial clinical suspicion of kidney graft rejection&#46; He was admitted with week-long fever and night sweats without apparent source&#46; The case history of the patient and physical examination were not specific&#44; only revealing asthenia and weight loss in the last few months&#46; Blood&#44; urine&#44; pleural liquid and sputum cultures were negative&#44; as were x-rays of the chest and abdomen&#46; He began broad-spectrum antibiotic therapy&#46; The study was continued to find the source of the fever&#46; The results of transthoracic and transoesophageal echocardiography were normal&#46; Staphylococcus aureus was isolated from only one of the subsequent blood cultures&#44; so the antibiotic treatment was changed and transthoracic and transoesophageal echocardiograms were performed again&#46; These ruled out endocarditis&#46; In view of the persistent fever&#44; antifungal treatment was added&#46; Tests revealed&#58; PCR 13 U&#44; total protein 5&#46;1 g&#47;dl&#44; albumin 2&#46;3 g&#47;dl&#44; leukocytes 3600 mm<span class="elsevierStyleSup">3</span> &#40;80&#37; neutrophils&#41;&#44; Hgb 12&#46;4&#44; hematocrits 37&#37;&#44; platelets 102&#160;000 x 10&#46;<span class="elsevierStyleSup">9</span>&#160;Abdominal ultrasound showed splenomegaly with multiple small&#44; well-defined hypoechoic areas of up to 1cm in diameter which could correspond to multiple splenic microabscesses&#46; The patient underwent a thoracoabdominal CT scan which showed multiple mediastinal lymphadenopathies of up to 2cm in diameter in the retrocaval-pretracheal&#44; para-aortic&#44; upper and lower right paratracheal&#44; and subcarinal spaces&#46; Bilateral pericardial and pleural effusion&#46; Mosaic attenuation of lung parenchyma&#46; CT scan showed at least 3 pseudonodular focal masses of around 1cm in diameter in a peripheral&#44; subpleural location in an anterior segment of the right upper lobe&#44; and 2 masses in the left upper lobe&#46; Irregular interstitial and acinar infiltrates at the base of the abdomen and pelvis&#44; splenomegaly with multiple undefined hypodense focal areas of less than 1cm compatible with splenic microabscesses&#59; at least 2 small hypodense punctiform masses in the liver &#40;Figure 1&#41;&#46; This suggested a differential diagnosis between microcytic pulmonary carcinoma and lymphoma&#46; A bone marrow biopsy showed hypoplasia&#44; with no evidence of neoplastic cells&#46; Gallium-67 scintigraphy revealed no source of inflammatory&#47;infectious activity&#46; PET&#47;CT scan revealed hypermetabolic adenopathies in cervical&#44; supraclavicular&#44; axillary and mediastinal regions&#44; and multiple hypermetabolic lung nodules in subpleural regions&#46; Splenomegaly showed multiple hypermetabolic nodules&#44; and hypermetabolic focal lesions in the C3&#44; C4&#44; and D8 vertebral bodies&#44; and the fourth costal arch&#46; Despite broad-spectrum antibiotic and antifungal treatment&#44; the patient still suffered fever spikes with significant constitutional syndrome and weight loss&#46; All the cultures&#44; blood tests&#44; the intradermal PPD test&#44; bacilli sputum cultures&#44; pleural fluid&#44; and urine&#44; as well as pleural fluid adenosine deaminase were repeatedly negative&#46; A mediastinoscopy was performed with biopsies of 2 adenopathies&#46; The pathologic diagnosis was described as necrotic granulomatous lymphadenitis highly indicative of mycobacterial infection&#46; No acid-alcohol-resistant bacilli or fungi were found in the histochemical stains&#46; In view of this&#44; and the patient&#39;s symptoms&#44; with a strong suspicion of tuberculosis infection&#44; we decided to begin treatment with tuberculostatic drugs &#40;rifampin&#44; isoniazid&#44; and ethambutol&#41;&#46;</p><p class="elsevierStylePara">The patient then progressed favourably&#59; the fever remitted&#44; his general condition improved and he gained weight&#44; even enabling physiotherapy and mobility&#46; A control CT scan 2 months after beginning treatment showed a significant reduction in the size and number of mediastinal adenopathies&#44; fewer paratracheal adenopathies&#44; a decrease in the size and density of the parenchymal lesions in the lungs&#44; and the disappearance of the splenic masses&#46; Only a hypodense lesion remained at the anterior pole of the spleen which was smaller than in the previous CT scan &#40;Figure 2&#41;&#46;</p><p class="elsevierStylePara">Therefore&#44; the diagnosis was disseminated TB probably due to TB reactivation in the patient in dialysis under chronic corticosteroid treatment&#46; The diagnosis was made using anatomical pathology and the patient&#8217;s clinical manifestations&#46; In this type of cases&#44; diagnosing the infection is difficult because the detection and laboratory tests are usually negative&#46; It is also difficult because patients have unspecific clinical symptoms&#44; and due to its extrapulmonary location&#59; thus&#44; the diagnosis and onset of treatment are usually delayed&#46;<span class="elsevierStyleSup">5</span>&#160;We agree with other authors that levels of suspicion need to be maintained high and early empirical treatment needs to be administered which reduces mortality&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10617&#95;108&#95;11436&#95;en&#95;10617&#95;f1&#95;en&#46;jpg" class="elsevierStyleCrossRefs"><img src="10617_108_11436_en_10617_f1_en.jpg" alt="CT scan with contrast at the level of the spleen with multiple lesions"></img></a></p><p class="elsevierStylePara">Figure 1&#46; CT scan with contrast at the level of the spleen with multiple lesions</p><p class="elsevierStylePara"><a href="grande&#47;10617&#95;108&#95;11437&#95;en&#95;10617&#95;f2&#95;en&#46;jpg" class="elsevierStyleCrossRefs"><img src="10617_108_11437_en_10617_f2_en.jpg" alt="CT scan with contrast at the level of the spleen after 2 months of treatment with tuberculostatic drugs"></img></a></p><p class="elsevierStylePara">Figure 2&#46; CT scan with contrast at the level of the spleen after 2 months of treatment with tuberculostatic drugs</p>"
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