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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 10  |  Issue : 1  |  Page : 98-100

Pubic symphysis tuberculosis: A diagnostic dilemma


1 Department of Internal Medicine, Aster Medcity, Kochi, Kerala, India
2 Department of Infectious Diseases, Aster Medcity, Kochi, Kerala, India

Date of Submission01-Feb-2021
Date of Acceptance17-Feb-2021
Date of Web Publication28-Feb-2021

Correspondence Address:
Balram Rathish
Department of Infectious Diseases, Aster Medcity, Kochi, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmy.ijmy_16_21

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  Abstract 


Symphysis pubis tuberculosis (TB) is extremely rare in the reported literature. The diagnosis of pelvic TB is confounded by close differentials such as osteomyelitis as well as the low yield of TB bacilli in microbiological sampling in the initial stages of the disease. Pelvic TB should be suspected early on in areas with high TB burden, and prompt treatment with antitubercular treatment may help prevent disability associated with the disease. Here, we present a 49-year-old diabetic man with pubic symphysis TB which was diagnosed on the basis of clinical and radiological aspects, with near-total resolution following 9 months of anti-tubercular treatment.

Keywords: Extrapulmonary tuberculosis, pelvic tuberculosis, pubic symphisis, tuberculosis


How to cite this article:
Ahammadunny R, Rathish B, Wilson A, Warrier A. Pubic symphysis tuberculosis: A diagnostic dilemma. Int J Mycobacteriol 2021;10:98-100

How to cite this URL:
Ahammadunny R, Rathish B, Wilson A, Warrier A. Pubic symphysis tuberculosis: A diagnostic dilemma. Int J Mycobacteriol [serial online] 2021 [cited 2021 Apr 20];10:98-100. Available from: https://www.ijmyco.org/text.asp?2021/10/1/98/310499




  Introduction Top


Osteoarticular tuberculosis (TB) is a relatively rare presentation of TB, constituting around 10%–15% of all cases of extrapulmonary TB.[1],[2] In osteoarticular TB, the spine and the long bones are most commonly affected. With respect to joints, the knee or hip arthritis is relatively common.[2] Pelvic TB is very rarely encountered and very few cases are reported in the literature.[1] In these cases, pelvic girdle TB is primarily limited to the sacroiliac joints. Less frequently, it may be associated with involvement of ilium or ischium. Symphysis pubis TB is extremely rare.[1]

Here, we present a 49-year-old diabetic man with pubic symphysis TB which was diagnosed on the basis of clinical and radiological aspects, with near-total resolution following 12 months of anti-tubercular treatment.


  Case Report Top


A 49-year-old man came with weight loss and debilitating pain in the right hip since 3 months. His medical history was significant for poorly controlled diabetes mellitus. The right hip pain gradually progressed to the right knee joint, incapacitating him from getting up and walking. He also lost about 15 kg during this period of 3 months.

On examination, he appeared to have cachexia and had weakness of the right lower limb with difficulty in standing or walking. Workup showed a raised C-reactive protein of 72 (<10 mg/dL) and erythrocyte sedimentation rate of 116 (0–10 mm/h) with neutrophilic leukocytosis. Urine and blood cultures were sterile. A chest X-ray was normal. Serology for human immunodeficiency virus and venereal disease research laboratory was negative. A magnetic resonance imaging (MRI) of the hip revealed features suggestive of septic arthritis of pubic symphysis with osteomyelitis involving bilateral pubic rami [Figure 1]. Brucella IgM was negative. Rheumatoid factor , anti-cyclic citrullinated peptide, and anti-nuclear antibody were negative. A positron emission tomography – Computed tomography revealed fluorodeoxyglucose an avid lesion involving the pubic symphysis [Figure 2]. Ultrasonography-guided aspiration from lesion drained frank pus. The pus bacterial culture was sterile, as was acid-fast staining, GeneXpert Ultra® (Cepheid. California, United States), and Mycobacterial culture.
Figure 1: Magnetic resonance Coronal SPAIR image showing a bright signal intensity involving the pubic symphysis (red arrow)

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Figure 2: Positron emission tomography showing a fluorodeoxyglucose avid lesion involving the pubic symphysis (red arrow)

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He was empirically started on antitubercular treatment (ATT) with isoniazid, rifampicin, ethambutol, and pyrazinamide. At the end of completion of 6 months of ATT, he showed significant clinical improvement with a weight gain of 10 kg. He was able to walk without support and his pain had subsided. A repeat MRI revealed significant radiological improvement [Figure 3]. He was continued on treatment with isoniazid, rifampicin, and ethambutol for 6 more months, following which he has near-total resolution of symptoms on follow-up.
Figure 3: Magnetic resonance Coronal SPAIR image showing the resolution of previous lesson

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  Discussion Top


The differential diagnosis in similar cases should include bacterial or fungal osteomyelitis, osteitis pubis, and adolescent osteochondritis of the symphysis pubis.[3] Clinical presentation may be similar in all these conditions, making the diagnosis difficult at the outset. It is important to differentiate between other infectious osteomyelitis and TB because a delay in diagnosis can result in significant disability and morbidity.[4]

The INDEX-TB guidelines assert that in areas endemic for TB, it may be reasonable to start patient with suspected osteoarticular TB on ATT based on strong clinical and radiological evidence. Tissue specimens are recommended only in the case of ambiguity or uncertain diagnosis.[5] The resolution of osteoarticular TB is determined by the completion of ATT and no evidence of relapse at 2 years of follow-up, resolution of symptoms including fever, night sweats, and weight loss, and radiological evidence of bone healing.[5] In our patient, at the follow-up after 1 year of ATT, there was a significant clinical improvement with repeat magnetic resonance showing features of the resolution of the bony lesions.

Hence, we wish to highlight the possibility of incidence of pelvic TB and the need for early recognition, especially in areas with high endemicity for TB. It is important to rule out other common causes such as osteomyelitis. The diagnosis may be made based on strong clinical and radiological suspicion and not always necessarily on microbiological sampling. Early diagnosis and prompt appropriate treatment may help in the reduction of morbidity and disability.

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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ansari S, Amanullah MF, Ahmad K, Rauniyar RK. Pott's spine: Diagnostic imaging modalities and technology advancements. N Am J Med Sci 2013;5:404-11.  Back to cited text no. 1
    
2.
Pigrau-Serrallach C, Rodríguez-Pardo D. Bone and joint tuberculosis. Eur Spine J 2013;22 Suppl 4:556-66.  Back to cited text no. 2
    
3.
Singh S, Arora S, Sural S, Dhal A. Tuberculosis of the pubic symphysis masquerading as osteitis pubis: A case report. Acta Orthop Traumatol Turc 2012;46:223-7.  Back to cited text no. 3
    
4.
Meena S, Gangary SK. Tuberculosis of symphysis pubis: A case report. J Res Med Sci 2015;20:100-2.  Back to cited text no. 4
    
5.
Index TB Guidelines. Available from: http://www.tbonline.info/media/uploads/documents/index-tb_guidelines_-_green_colour_2594164.pdf. [Last accessed 2020 Dec 15].  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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