Muscular tuberculosis can involve any muscle. Muscular tuberculosis is mostly present as muscle mass, myositis, or deep abscess. According to the literature, thigh muscle, calf muscle, chest wall muscle, the psoas muscle is the most common muscle involved in muscular tuberculosis. Gluteal muscle and forehead muscles are rarely reported in the literature. Our case presented with multiple discharging sinuses in the gluteal region.
A 45-year-old female patient presented with a complaint of pain and swelling over the right gluteal region for a 1-month duration. There was no history of chronic cough with expectoration. There was no history of loss of appetite or loss of weight. The patient denied a previous history of tuberculosis or a history of exposure to tuberculosis. On examination, the patient was well built and nourished. The systemic examination was normal. Local examination showed a single abscess cavity with local features of inflammation. The patient underwent incision and drainage of the abscess cavity and the patient did not respond well.
Blood investigations such as complete blood count, renal function test, and liver function were normal. Ultrasound examination showed a few small hypoechoic lesions present in the right gluteal region. Fine-needle aspiration of lesions was inconclusive. Chest X-ray showed a normal study. Mantoux test revealed no induration after 72 h. Computed tomography of the chest and abdomen showed a normal study.
She was treated initially for a pyogenic gluteal abscess due to the presence of a single abscess cavity. The patient did not respond to treatment and in due course, the patient developed multiple gluteal sinuses [Figure 1]. Later, the patient underwent abscess draining with excision biopsy of the sinus tract [Figures 2 and 3]. Postoperative histopathology examination showed features of muscular tuberculosis such as giant cells and granuloma [Figure 4]. The patient was started on antituberculous treatment (isoniazid, rifampicin, ethambutol, and pyrazinamide). The patient showed a good response following antituberculous treatment. Postexcision biopsy, the patient recovered well and has been on follow-up for more than 2 years without any recurrence.
Muscular tuberculosis is one of the rare types of tuberculosis, with an incidence of around 1%. Primary muscular tuberculosis is rare compared to secondary muscular tuberculosis. The location of muscular tuberculosis varies from the lower limb to the upper limb. Most of the studies show muscular tuberculosis more commonly affect the lower limb compared to other locations. Muscular tuberculosis is mostly present as local muscle mass, myositis, muscular abscess, nodule, and painful mass. Most muscular tuberculosis does not have systemic manifestations such as fever, malaise, loss of appetite, and loss of weight.[2,3]
Zeng etal. showed muscular tuberculosis sometimes misdiagnosed as sarcoma. According to his case report, magnetic resonance image and histopathological examination confirmed the diagnosis of muscular tuberculosis. The following are the reasons for the rare involvement of skeletal muscle in tuberculosis, (1) Muscle contain a high level of lactic acid which inhibit mycobacterium growth, (2) High blood flow of muscle, (3) Absence of reticuloendothelial cells which never allow bacilli to inoculate, and proliferate, (4) Skeletal muscle are well differentiated.
In muscular tuberculosis, inflammatory markers such as lymphocytes, erythrocyte and sedimentation rate is not always elevated. Imaging studies such as ultrasound, computed tomography, and magnetic resonance imaging are used to locate the muscle lesions. Fine-needle aspiration cytology or postoperative biopsy with granuloma is the confirmatory investigations for muscular tuberculosis [Table 1].[5–7] The treatment of muscular tuberculosis includes local surgical resection along with anti-tuberculous treatment. However in a minority of cases, do not need surgical resection, they do respond well with anti-tuberculous treatment.
Isolated intramuscular tuberculosis is a rare type of tuberculosis. Muscular tuberculosis must be considered one of the differential diagnoses for the patient with multiple gluteal discharging sinuses. The best investigation to confirm muscular tuberculosis is histopathological confirmation of granuloma. Surgical resection with anti-tuberculous treatment is the standard of care for muscular tuberculosis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
1. Dhakal AK, Shah SC, Shrestha D, Banepali N, Geetika KC. Tuberculosis presenting as multiple intramuscular nodules in a child:A case report. J Med Case Rep 2015;9:72.
2. Derkash RS, Makley JT. Isolated tuberculosis of the triceps muscle. Case report. J Bone Joint Surg Am 1979;61:948.
3. Lombardi R, Pelusi S, Airaghi L, Fargion S. Extrapulmonary tuberculosis:An unusual presentation in an immunocompetent patient. BMJ Case Rep 2015;2015:bcr2014207146.
4. Zeng Y, Liu Y, Xie Y, Liang J, Kuang J, Lu Z, et al. Muscular tuberculosis:A new case and a review of the literature. Front Neurol 2019;10:1031.
5. Meena M, Dixit R, Samaria JK, Vijayakandeepan Kumaresan SH. Tuberculosis of the triceps muscle. BMJ Case Rep 2015;2015:bcr2014207032.
6. Djaja YP, Phedy P, Silitonga J, Librianto D, Saleh I. Submuscular gluteal abcess:An unusual presentation of rare sacral tuberculosis. Int J Surg Case Rep 2019;54:55–9.
7. Neogi DS, Bandekar SM, Chawla L. Skeletal muscle tuberculosis simultaneously involving multiple sites. J Pediatr Orthop B 2013;22:167–9.
8. Gou LJ, Su JM, Zhao Y, Zhang FC. Clinical analysis of 20 cases of muscular tuberculosis. Zhonghua Yi Xue Za Zhi 2012;92:206–8.