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Delay in diagnosis of generalized miliary tuberculosis with osseo-articular involvement: a case report.

Rodrigo C, Atukorala I - J Med Case Rep (2011)

Bottom Line: A cause could not be found despite extensive investigations.The constellation of skin and skeletal symptoms and pulmonary tuberculosis is a rare occurrence in an immunocompetent individual, but cases have been reported.It also demonstrates the value of maintaining a high degree of suspicion in endemic areas, even in the absence of microbiological evidence.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Sri Lanka. chaturaka.rodrigo@gmail.com.

ABSTRACT

Introduction: Diagnosis of atypical tuberculosis is difficult. Therefore, it is important that physicians are aware of rare presentations of tuberculosis to avoid diagnostic delays.

Case presentation: We present the case of a 17-year-old Sri Lankan man who presented to our facility with an ill-defined large induration over the skin of his left buttock and thigh. A cause could not be found despite extensive investigations. He also complained of chronic knee pain, but this was not investigated further at the time due to spontaneous resolution. Three years later his knee disease flared up again, with pain, swelling and restriction of movement. A synovial biopsy was suggestive of tuberculosis. He was started on antituberculosis therapy, to which he responded well. Our patient was asymptomatic two months after completion of therapy without any subsequent flare-ups. A chest roentgenogram taken on his second presentation showed evidence of tuberculosis sequelae in his lungs. The most likely diagnosis for the buttock and thigh swelling, when considering the entire clinical picture, is a tuberculous abscess. The constellation of skin and skeletal symptoms and pulmonary tuberculosis is a rare occurrence in an immunocompetent individual, but cases have been reported.

Conclusions: This case demonstrates the different presentations and the diagnostic difficulties posed by atypical manifestations of tuberculosis. It also demonstrates the value of maintaining a high degree of suspicion in endemic areas, even in the absence of microbiological evidence.

No MeSH data available.


Related in: MedlinePlus

Roentgenogram of the left hip and thigh of our patient. Calcifications that might be the sequelae of a healed tuberculous abscess can be seen.
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Figure 2: Roentgenogram of the left hip and thigh of our patient. Calcifications that might be the sequelae of a healed tuberculous abscess can be seen.

Mentions: His basic biochemical investigations and the hematological parameters were within reference ranges apart from the ESR, which was was 55 mm in the first hour. A chest roentgenogram showed bilateral lower zone pulmonary fibrosis. There was honeycombing of the right middle lobe with traction broncheictasis plus a few calcified lymph nodes suggestive of tuberculosis sequelae (Figure 1). A roentgenogram of the left hip and thigh showed multiple calcifications, which it was hypothesized could be the remnants of a tuberculous abscess (Figure 2). The effusion of the knee joint was aspirated but it kept recurring. The appearance of the aspirate was yellow and cloudy. Biochemical analysis of the aspirate showed a protein level of 50 mg/dL, glucose level of 83.5 mg/dL and lactate dehydrogenase concentration of 2893 IU/L. Acid-fast bacilli (AFB) were not seen on direct smear. Cytological analysis revealed a leukocyte count of 6.1 × 109 cells/L (lymphocytes 70%, neutrophils 30%). Histology of the synovial biopsy showed several granuloma composed of epithelioid histiocytes located below the synovial membrane. Additionally, there were several lymphoid follicles and scattered collections of lymphocytes, plus plasma cells below the synovial membrane. This was suggestive of TB.


Delay in diagnosis of generalized miliary tuberculosis with osseo-articular involvement: a case report.

Rodrigo C, Atukorala I - J Med Case Rep (2011)

Roentgenogram of the left hip and thigh of our patient. Calcifications that might be the sequelae of a healed tuberculous abscess can be seen.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3198717&req=5

Figure 2: Roentgenogram of the left hip and thigh of our patient. Calcifications that might be the sequelae of a healed tuberculous abscess can be seen.
Mentions: His basic biochemical investigations and the hematological parameters were within reference ranges apart from the ESR, which was was 55 mm in the first hour. A chest roentgenogram showed bilateral lower zone pulmonary fibrosis. There was honeycombing of the right middle lobe with traction broncheictasis plus a few calcified lymph nodes suggestive of tuberculosis sequelae (Figure 1). A roentgenogram of the left hip and thigh showed multiple calcifications, which it was hypothesized could be the remnants of a tuberculous abscess (Figure 2). The effusion of the knee joint was aspirated but it kept recurring. The appearance of the aspirate was yellow and cloudy. Biochemical analysis of the aspirate showed a protein level of 50 mg/dL, glucose level of 83.5 mg/dL and lactate dehydrogenase concentration of 2893 IU/L. Acid-fast bacilli (AFB) were not seen on direct smear. Cytological analysis revealed a leukocyte count of 6.1 × 109 cells/L (lymphocytes 70%, neutrophils 30%). Histology of the synovial biopsy showed several granuloma composed of epithelioid histiocytes located below the synovial membrane. Additionally, there were several lymphoid follicles and scattered collections of lymphocytes, plus plasma cells below the synovial membrane. This was suggestive of TB.

Bottom Line: A cause could not be found despite extensive investigations.The constellation of skin and skeletal symptoms and pulmonary tuberculosis is a rare occurrence in an immunocompetent individual, but cases have been reported.It also demonstrates the value of maintaining a high degree of suspicion in endemic areas, even in the absence of microbiological evidence.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Sri Lanka. chaturaka.rodrigo@gmail.com.

ABSTRACT

Introduction: Diagnosis of atypical tuberculosis is difficult. Therefore, it is important that physicians are aware of rare presentations of tuberculosis to avoid diagnostic delays.

Case presentation: We present the case of a 17-year-old Sri Lankan man who presented to our facility with an ill-defined large induration over the skin of his left buttock and thigh. A cause could not be found despite extensive investigations. He also complained of chronic knee pain, but this was not investigated further at the time due to spontaneous resolution. Three years later his knee disease flared up again, with pain, swelling and restriction of movement. A synovial biopsy was suggestive of tuberculosis. He was started on antituberculosis therapy, to which he responded well. Our patient was asymptomatic two months after completion of therapy without any subsequent flare-ups. A chest roentgenogram taken on his second presentation showed evidence of tuberculosis sequelae in his lungs. The most likely diagnosis for the buttock and thigh swelling, when considering the entire clinical picture, is a tuberculous abscess. The constellation of skin and skeletal symptoms and pulmonary tuberculosis is a rare occurrence in an immunocompetent individual, but cases have been reported.

Conclusions: This case demonstrates the different presentations and the diagnostic difficulties posed by atypical manifestations of tuberculosis. It also demonstrates the value of maintaining a high degree of suspicion in endemic areas, even in the absence of microbiological evidence.

No MeSH data available.


Related in: MedlinePlus