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Volume 21 |
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Volume 21 |
October December 2005 |
Number 4 |
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An unusual presentation of
Tuberculosis of Iliac BoneIshtiaq Ahmed Chaudhary1, Samiullah2 & Ashraf Ali Mallhi3
Summary:
Tuberculous osteomyelitis is not uncommon but isolated involvement of bone other than spine or joints is a rare entity. An unusual presentation of tuberculous osteomyelitis of iliac bone seen as a buttock abscess and abscess in right iliac fossa simultaneously having communication through a defect in the iliac crest is presented.
KEY WORDS: Tuberculosis, Osteomyelitis, Iliac bone, Abscess
Pak J Med Sci October-December 2005 Vol. 21 No. 4 489-490
1. Dr Ishtiaq Ahmed Chaudhary FCPS
Assistant Professor of Surgery,
Fauji Foundation Hospital, Rawalpindi.2. Dr Samiullah FCPS
Assistant Professor Surgery,
Fauji Foundation Hospital, Rawalpindi.3. Prof. Major General (Retr) Ashraf Ali Mallhi FRCS, FCPS
Head of Department Surgery
Foundation University Medical College,
Rawalpindi.Correspondence
Dr Ishtiaq Ahmed Chaudhary
E-mail: surgish2000@yahoo.comReceived for publication: December 3, 2004
Accepted: June 15, 2005
INTRODUCTION
Tuberculosis is an ancient disease. Its evidence has been found in Egyptian Mummies and in the Grico-Roman civilization in various forms
1. Tuberculosis is common in tropical region including Pakistan and developing countries2. In spite of major advances in medicine, diagnosis of this disease some times becomes a dilemma. So delay in diagnosis is very common which leads to increase in number of cases of abdominal tuberculosis and other forms of extra-pulmonary tuberculosis. Tuberculous osteomyelitis is rare and occurs following the haematogenous spread from the primary focus in the lungs or gut. Majority of cases presented late in our set up which causes delay in management, increases number of complications and atypical presentations. Tuberculosis is on increase in developed world due to drug resistance, poor compliance among patients especially drug addicts and in immuno-compromised patients.Case Report
A 35 years old female was admitted in surgical ward with history of low grade fever off and on, dull, low intensity pain in right iliac fossa and gradually increasing mass right buttock for last two months. There was no history of anorexia, weight loss, urinary or bowel complaints. She had no complaints of backache. On examination she was afebrile (98.6°F). There was no pallor. There was immobile, non-tender, soft to firm mass, about 15x15cm size in right iliac fossa. Patient had also non-tender, soft fluctuant swelling in right gluteal region. On investigations her Hemoglobin was 10.2gm%, ESR 62 mm fall at the end of first hour , X-rays chest was normal. X-ray lumbo-sacral spine revealed no abnormality. X-ray pelvis shows a well-defined, radiolucent defect in the right iliac crest about 1x1 cm in size (Fig-1). Ultrasound abdomen and CT scan shows cystic mass about 15x12 cm in right iliac fossa. Needle aspiration of buttock swelling showed thick greenish pus. Incision and drainage of buttock abscess was done in general anesthesia. During drainage it was found that buttock abscess has got communication with the abscess in the right iliac fossa through defect in ala of right ilium. Histopathology of curetted piece of bone showed tuberculous osteomyelitis. With repeated dressings and antituberculous chemotherapy patient recovered within two months.
Fig-1: X-rays right hip bone showing a well defined
radiolucent defect in iliac boneDISCUSSION
Tuberculosis is emerging as one of the major killers worldwide. It is responsible for 8 million new cases and three million deaths annually
3,4. It is still considered a major health problem worldwide. WHO in 1993 declared tuberculosis as a global emergency5. Pulmonary tuberculosis is the commonest form but extrapulmonary tuberculosis can affect any organ system of the body. It is estimated that 10% to 15% of tuberculosis is extrapulmonary and that 10% of extrapulmonary tuberculosis is skeletal6. Almost half of the patients with skeletal tuberculosis have spinal involvement. The hips and knees are next most frequently affected but the other sites are rare. Diagnosis of extra-pulmonary tuberculosis is often difficult because of different spectrum of clinical presentation and non-availability of sensitive or specific diagnostic tests7. Tuberculous osteomyelitis is almost always osteoarticular in 2-3% of cases and 7% of these may have involvement of more then one site8. Isolated involvement of the bone in tuberculosis is rare entity. The bony involvement sparing the joint occurs in ribs, metacarpal, metatarsals, calcaneum, femur, tibia, fibula, radius, humerus, sternum, facial bones, pelvis and skull8,9. Tuberculous bony lesion can start anywhere in the bone with bony necrosis, caseation and formation of cold abscesses, which may or may not form a sinus. Diagnosis at an early stage is by far the most important of the management, which is often missed because of the rarity of bony involvement, atypical clinical presentation as in this case. Histology is mandatory for the confirmation of the diagnosis. Excision biopsy is preferred method, which not only confirms the diagnosis but also helps in the removal of osseous necrotic material and early healing10. Osseous lesions are relatively more resistant to treat then the synovial lesions. In the typical tubercle the epitheloid cells become less compact and soon the tubercle gets unrecognizable because the epitheloid cells and lymphocytes gets widely scattered. The central caseous area gets smaller or even gets absorbed with prevalence of fibrosis8. Tuberculous osteomyelitis of rare sites is difficult to diagnose. Recurrence is not uncommon in tuberculous osteomyelitis. These patients should be followed up routinely during and after chemotherapy.REFERENCES
1. Ravinglione ML. Global epidemiology of tuberculosis: morbidity and mortality of a worldwide epidemic. JAMA 1995;273:220-6.
2. Hameed F, Malik MA. Abdominal tuberculosis – profile of 50 cases. J Coll Physicians Surg Pak 2000;10(4):1256-7.
3. Almani SA, Memon NM, Qureshi AF. Drug resistant tuberculosis in sindh. J Coll Physicians Surg Pak 2002;12(30):136-9.
4. Mehmood A. Multi-drug resistance tuberculosis. J Pak Med Assoc 2001;51:204-5.
5. Mirza M, Sarwar M. Tuberculous injection abscess. J Surg Pak.2003;8(4):37-8.
6. Carensale PG. Tuberculosis in, A H Crenshaw’s (editors) Campbell’s Operative Orthopedics 7th edit. The CV Mosby Company Toronto 1987;699-709.
7. Channa GA, Khan MA. Abdominal tuberculosis "surgeons" perspective. J of Surg Pak 2003;8(4):18-22.
8. Bast A, Zubari AH, Rehman AZ. Tuberculous osteomylitis. J Surg Pak 2003;8(4):13-7.
9. Grifith et al. Imaging of musculoskeletal tuberculosis: a new look at an old disease. Clin Orth. 2002;398:32-9.
10. Vohra R, Kang EIG, Dogra S, Saggar RR, Sharma R. Tuberculous osteomylitis. J Br Jt Surg 1997; 79(4):467-8.
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