Multicentric tuberculosis is usually seen in immunocompromised patients; other predisposing factors are intravenous drug use, diabetes mellitus, alcohol abuse, and hepatic cirrhosis [3
]. Sternal osteomyelitis caused by Mycobacterium tuberculosis
is a rare entity, accounting for less than 1% of all cases of osteoarticular tuberculosis, and coccygeal tuberculosis is an even rarer entity, with only one reported case in the English literature [2
]. Tuberculosis at both of these sites at the same time has also not been reported in the English literature previously.
A painful coccyx is a common complaint in women due to the posterior prominence of the coccyx anatomically in the female pelvis, meaning that it is exposed to multiple traumas. However, physicians should also consider atypical conditions such as tuberculosis in patients presenting with coccygodynia, especially those who are refractory to treatment with conservative measures, and in association with HIV. Most sacral and sacrococcygeal lesions heal with adequate local support and antitubercular therapy, but coccygectomy may be essential in refractory cases.
Sternal tuberculosis usually presents as tuberculous osteomyelitis or rarely as a tuberculous granuloma, or remotely as metastatic disease [4
]. There have also been reports of tuberculosis of the sternum after open heart surgery. Plain radiographs are usually insufficient, and further imaging in the form of CT or MRI is usually required [1
]. Most of these lesions heal with oral antitubercular therapy. However, surgical intervention in the form of resection may be required on rare occasions, followed by local rotation flaps.
Although no primary focus of infection could be located in our patient, the mode of involvement is most likely hematogenous, as suggested by its multicentric nature. Other routes of tuberculous involvement are direct inoculation, extension from adjacent bones or joints, and lymphogenous spread.
To conclude, tuberculosis can present in any form or organ of the human body. In spite of the great strides made in its management, tuberculosis continues to baffle clinicians with its varied presentations. Therefore, it is essential for all physicians to keep tuberculosis in the differential diagnosis of patients with atypical presentations in atypical locations, thus enabling its early diagnosis and better treatment.