The skeletal system is the most common extrapulmonary site for tuberculous infection with an incidence ranging from 1% to 10%.4 Spine is the most common involved site (50%) followed by hip or knee (30%), and less commonly, the pubis, wrist, shoulder, and sacroiliac joint.5 As in the present case, the thoracolumbar junction is the most commonly involved site, but many levels may be involved at presentation.6 As in our case also, features of spinal tuberculosis that can be seen on CT scans include anterior vertebral body destruction, vertebral body collapse, disk space narrowing, and large paraspinal soft-tissue masses representing abscess formation (Figs. 5-7).7
Paraspinal abscess formation is seen in as many as 71% to 75% cases of spinal tuberculosis.4,8 Paraspinal abscess develops secondary to destruction of the cortical bone and elevation of the periosteum.9 Paraspinal abscess formation may be detected on plain radiographs as areas of fusiform soft-tissue swelling around the spine (Fig. 3).10
Focal rib destruction in pulmonary tuberculosis is uncommon, and in the literature, the incidence varies from 0% to 5%.11-13 Involvement of ribs in tuberculous may occur either by direct extension from a pleuropulmonary tuberculous lesion or from hematogenous spread from a distant focus.11 Clinically, these patients present with subcutaneous swelling in the chest wall.13 On CT scan, rib lesions are seen as juxtacostal soft-tissue mass with central low attenuation and peripheral rim enhancement with or without bone destruction.12 Tubercular rib lesions can heal with antituberculosis drug therapy11; however, rib resection may be needed in recurrent cases.13
Due to the proximity of the iliopsoas compartment to the dorsolumbar spine, tubercular infection of the spine can spread into the iliopsoas compartment, pelvis, and thigh, leading to abscess formation.9 The inflammatory masscan penetrate the periosteum leading to a psoas abscess.1 Treatment of psoas abscess can be either conservative (drug therapy, immobilization, external brace application) or surgical intervention (in conjunction with drug therapy)4,14 including percutaneous drainage under radiological guidance.15
Tuberculous involvement of the metacarpals and phalanges is a rare presentation of extrapulmonary tuberculosis and can be difficult to diagnose during the early stages.16 Overlying finger swelling, although rare, can be the manifestation of metacarpal tuberculosis.17 In our case, in addition to the swelling, the patient later on developed the sinus in the palm over the affected metacarpal (Figs. 1, 4). In isolated lesions of metacarpals, an unusual destructive bony lesion should warrant early biopsy and appropriate microbiologic testing to avoid diagnostic delay and followed by appropriate treatment.16,17
The differential diagnoses of osteolytic lesions of tuberculosis at multiple sites include multiple myeloma, secondary metastasis, bacterial osteomyelitis, and less commonly gout, actinomycosis, coccidioidomycosis, maduromycosis, cryptococcosis, and syphilis.18 In musculoskeletal tuberculosis, active lung infection is present in less than 50% of cases.19 In our case, the chest radiograph did not show abnormalities. Although a positive Mantoux test and elevated erythrocyte sedimentation rate give important diagnostic clue but may be negative in 10% of patients.20 Histopathologic examination yields a high percentage of positive results, and the use of histopathology, culture, and guinea pig inoculation together may confirm the diagnosis in all of the cases of skeletal tuberculosis and help to differentiate skeletal tuberculosis from other infections or neoplasm.18,19 Computerized tomography is a useful adjunct in demonstrating the skeletal lesion and delineating the extent of disease, and also, it may be used in the assessment of response to treatment.11 Multiplanar imaging, especially magnetic resonance imaging with gadolinium enhancement, has become the standard modality for defining subtle discovertebral lesions and in detecting unsuspected paravertebral soft-tissue extension, especially in patients with epidural and intradural infections and neurological symptoms.9 Because of financial constraints, however, it may not always be possible to perform these tests in developing countries, and we used the clinical response of the patient as the guideline for response to treatment.
There can be considerable delay between presentation and diagnosis, mainly due to its insidious onset, nonspecific clinical picture, and low index of clinical suspicion even in areas where the disease is endemic. This case report probably represents a missed diagnosis. If Mantoux test had been performed initially, when the patient developed a sinus after initial drainage of the swelling over the back, probably the diagnosis would have been suspected at a much earlier stage, and early treatment with antituberculous therapy would have avoided the need for surgery.
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