Defecation pain is a common problem with many etiologies implicated. Elucidating a cause requires a thorough medical history, examination and appropriate investigations, which may include endoscopy, barium enema, examination under anesthesia and magnetic resonance imaging or computed tomography. Coccydynia is a term used to describe pain in the region of the coccyx, often due to abnormal mobility of the coccyx. Non-surgical management options remain the gold-standard for coccydynia with surgery being reserved for complicated cases.
This is a case of a 67-year-old Caucasian man who presented with a two-and-a-half-year history of worsening rectal pain.
To the best of our knowledge, we describe the first case in the literature of an abnormally mobile anteverted coccyx causing predominantly defecation pain and coccydynia, successfully treated by coccygectomy. When first-line investigations fail to elucidate a cause of defecation pain one must, in the presence of unusual symptoms, consider musculoskeletal pathologies emanating from the coccyx and an orthopedic consultation must then be sought for diagnostic purposes.
The authors present the case of a sacral chordoma in which the diagnosis was delayed as the patient was diagnosed and treated as coccydynia. Persistent, severe coccydynia following minor trauma is common1 but the symptom can also be caused by significant underlying disease. The correct diagnosis was made in this patient but after significant delay. The presentation of this case involved multiple specialties and provides several learning points regarding the importance of thorough history taking and clinical examination. It highlights the importance of ‘red flag’ symptoms of low back pain2 which need to be fully investigated.
Granulomas caused by Mycobacterium Tuberculosis have been observed at autopsy in the heart, pre-dominantly in the myocardium and endocardium, but rarely involving the coronary vessels and valvular structures. Mycobacterium tuberculosis valvular endocarditis is extremely rare, with most reports coming from autopsy series.
We report the case of a 17 year old immunocompetent girl who presented with history of fever, malaise, foot gangrene and a left sided hemiparesis. On investigation she was found to have infective endocarditis involving the aortic, mitral and tricuspid valves. She had developed a right middle cerebral artery stroke. She underwent dual valve replacement and tricuspid repair. The vegetations showed granulomatous inflammation but blood cultures and other biological specimen cultures were negative for any organisms. She was started on antituberculous treatment and anticoagulation.
This is the first reported case of triple valve endocarditis by Mycobacterium Tuberculosis in an immunocompetent host. Especially important is the fact that the right heart is involved which has been historically described in the setting of intravenous drug abuse.
This implies that Tuberculosis should be considered in cases of culture negative endocarditis in endemic areas like Pakistan even in immunocompetent hosts.
Immunocompetent; Endocarditis; Mycobacterium tuberculosis
Coccydynia is a term that refers to pain in the region of the coccyx. Most cases are associated with abnormal mobility of the coccyx which may trigger a chronic inflammatory process leading to degeneration of this structure. In some patients this instability may be detected on dynamic radiographs. Nonsurgical management remains the gold standard treatment for coccydynia, consisting of decreased sitting, seat cushioning, coccygeal massage, stretching, manipulation, local injection of steroids or anesthetics, and postural adjustments. Those patients who fail these conservative modalities may potentially benefit from coccygectomy. However, surgical intervention is typically reserved for patients with evidence of advanced coccygeal instability (e.g., subluxation or hypermobility) or spicule formation, as this population appears to exhibit the greatest improvement postoperatively.
Coccydynia; Coccygodynia; Coccygectomy; Coccyx; Management
Isolated tuberculosis of the coccyx is extremely rare. A 35-year-old man presented with a 3-month history of coccygeal and gluteal pain. Computed tomography and magnetic resonance imaging revealed osseous destruction and a large enhancing mass involving the coccyx with anterior and posterior extension. Pathologic examination of the surgical specimen revealed necrosis, chronic granulomatous inflammation, and multinucleated giant cells consistent with tuberculosis. This case highlights the importance of considering tuberculosis as a diagnosis even though unusual sites are involved.
Splenic lesions due to tuberculosis are extremely rare in immunocompetent indi-viduals and delays in diagnosis are frequent. Here, we describe a 49-year-woman presenting with pyrexia-of-unknown origin with no evidence of any immunodefi-ciency. Computed tomography of the abdomen showed an enlarged spleen having multiple small focal hypodense lesions; the later were confirmed to be of tubercu-lous etiology on histopathological examination. She had favorable response with anti-tubercular chemotherapy. We report this case of tuberculosis spleen in an im-munocompetent individual for its rarity and to highlight the fact that these patients can be managed by medical treatment effectively.
Splenic tuberculosis; CT guided splenic biopsy; Non-immunocompromised patient
A 54 year old Asian woman developed fulminant hepatic failure followed by renal failure. Because of a past history of possible tuberculosis, she was given antituberculous drugs. The chest x ray was normal. A transjugular liver biopsy showed caseating necrosis, granulomas, and acid fast bacilli indicative of miliary tuberculosis. Despite full supportive therapy, her condition deteriorated and she died. Postmortem examination showed widespread miliary tuberculosis; culture confirmed the presence of Mycobacterium tuberculosis. Tuberculosis causes fulminant hepatic failure rarely and only three cases have been described. In this, as with the other cases, hyponatraemia and hepatomegaly were features at presentation. This is the first report of treatment being given before death.
Aspergilloma and invasive aspergillosis coexisting with multidrug resistant Mycobacterium tuberculosis (MDR-TB) in the same patient is a rare entity. We report a 50 year old South Indian woman, a diabetic, who presented to us with complaints of productive cough and hemoptysis for the past 2 months. She was diagnosed to have pulmonary tuberculosis 2 years ago for which she took irregular treatment. Lung imaging showed features of a thick walled cavity in the right upper lobe with an indwelling aspergilloma. She underwent a right lung upper lobe resection. Biopsy and culture of the resected specimen showed the coexistence of Aspergillus fumigatus and multi-drug resistant Mycobacterium tuberculosis. 2 blood cultures grew Aspergillus fumigatus. She was successfully treated with Voriconazole and anti tuberculous therapy against MDR-TB.
A pseudotumour is a rare presentation of bronchopulmonary tuberculosis which occurs in immunocompetent patients, which can simulate malignancy, both clinically and radiologically, and may cause delay in its diagnosis and treatment. The incidence of bronchopulmonary pseudotumours was found to vary from 2-4%, as was seen in various studies. A mycobacterial pseudotumour of the pleura is a rare entity. We are reporting a case of a pleura based tubercular pseudotumour in a 59 years old patient who presented with a four month history of the nonspecific symptoms of cough and chest pain. The radiological investigations showed that a pleural based mass lesion was occupying the right lower hemithorax. The initial biopsy was suggestive of a hyalinizing variant of an inflammatory pseudotumour. The follow-up surgical resected mass was consistent with the features of a tubercular granuloma. The clinical presentation and the histopathological findings have been presented, with a brief review of the literature. Due to its varied and unusual presentation, bronchopulmonary tuberculosis should always be kept in mind when a patient with a similar clinical and a radiological picture is being evaluated.
Tuberculosis; Malignancy; Pseudotumour; Pleura
Tuberculosis is a major health problem worldwide. In India, it is highly endemic. The most common manifestation is a pulmonary disease, but involvement of the gastrointestinal tract is not uncommon with the ileocecal region being the commonest site. Gastric tuberculosis is rare and usually associated with pulmonary tuberculosis or an immunodeficient state. Here, we report a case of gastric tuberculosis presenting as gastric outlet obstruction in an immunocompetent patient without evidence of pulmonary tuberculosis. Biopsy and PCR confirmed the diagnosis, and the patient responded well to standard antitubercular treatment. Though, gastric tuberculosis is rare, it should be considered as a possibility when patients present with gastric outlet obstruction, particularly in endemic areas with tuberculosis.
A 65-year-old female had a history of tuberculosis of the left greater trochanter 30 years ago. She underwent 6 months of chemotherapy after which the disease healed completely. Currently she presented to us with pain and swelling on the lateral aspect of left hip of 2-month duration. Clinical and radiological findings were suggestive of a recurrence. Biopsy was conclusive for tuberculosis. She was successfully treated with debridement and curettage with chemotherapy for 1 year. Recurrent tuberculosis of the greater trochanter is rare and should be aggressively treated.
Prosthetic joint infection due to Mycobacterium tuberculosis is occasionally encountered in clinical practice. To the best of our knowledge, this is the first report of a prosthetic joint infection due to Mycobacterium tuberculosis complicated by psoas abscesses and secondary Addison disease.
A 67-year-old immunocompetent Caucasian woman underwent total left hip arthroplasty because of osteoarthritis. After 18 months, she underwent arthroplasty revision for a possible prosthetic infection. Periprosthetic tissue specimens for bacteria were negative, and empirical antibiotic therapy was unsuccessful. She was then admitted to our department because of complications arising 22 months after arthroplasty. A physical examination revealed a sinus tract overlying her left hip and skin and mucosal pigmentation. Her levels of C-reactive protein, basal cortisol, adrenocorticotropic hormone, and sodium were out of normal range. Results of the tuberculin skin test and QuantiFERON-TB Gold test were positive. Computed tomography revealed a periprosthetic abscess and the inclusion of the left psoas muscle. Results of microbiological tests were negative, but polymerase chain reaction of a specimen taken from the hip fistula was positive for Mycobacterium tuberculosis. Our patient's condition was diagnosed as prosthetic joint infection and muscle psoas abscess due to Mycobacterium tuberculosis and secondary Addison disease. She underwent standard treatment with rifampicin, ethambutol, isoniazid, and pyrazinamide associated with hydrocortisone and fludrocortisone. At 15 months from the beginning of therapy, she was in good clinical condition and free of symptoms.
Prosthetic joint infection with Mycobacterium tuberculosis is uncommon. A differential diagnosis of tuberculosis should be considered when dealing with prosthetic joint infection, especially when repeated smears and histology examination from infected joints are negative. Clinical outcomes of prosthetic joint infection by Mycobacterium tuberculosis are unpredictable, especially given the limited literature in this field and the uncertainty of whether medical treatment alone can eradicate the infection without prosthesis removal. Furthermore, this case report raises interesting issues such as the necessity of a follow-up evaluation after treatment based on clinical conditions, the utility of a more standardized length of treatment for periprosthetic tuberculous infection, and the importance of a high diffusion capacity of anti-mycobacterial agents in order to eradicate the infection.
Extrapulmonary tuberculosis (TB) account for approximately 15–20% of TB cases in immunocompetent patients. The genitourinary system is the third most commonly affected site. We report the case of a 20-year-old man admitted with fever, chills, dry cough, right flank pain, and oliguria who developed renal function loss. The pyelogram evidenced silence of the right kidney, and the abdominal and pelvic magnetic resonance showed significant dilation of the right pyelocaliceal system and proximal ureter. Biopsies of renal cortex and retroperitoneal lymph nodes showed caseous granuloma consistent with TB. Treatment was started with rifampicin, isoniazid, pyrazinamide, and ethambutol, and the patient presented a favorable outcome but with non-dialytic chronic kidney disease. This case illustrates a case of chronic kidney disease secondary to TB in a young, otherwise healthy man.
Although tuberculosis is a major health problem globally, concomitant cryptococcosis has rarely been reported, especially in immunocompetent individuals. This report describes a case involving an otherwise healthy young woman who was diagnosed with a concomitant infection and emphasizes the importance of considering more than one infection occurring simultaneously in patients with significant comorbidities or immunodeficiency.
A case of Cryptococcus gattii (pulmonary and central nervous system) and Mycobacterium tuberculosis (pulmonary) coinfection in an otherwise healthy young woman is reported. The patient presented with a two-month history of dry cough. She had an unremarkable medical history. Both tuberculosis and cryptococcosis were diagnosed following bronchoscopy, and a subsequent lumbar puncture revealed C gattii in the cerebrospinal fluid. There is evidence that both M tuberculosis and C gattii may have suppressive effects on the host immune system. This suggests a mechanism by which an otherwise healthy individual developed these two infections.
Coinfection; Cryptococcosis; Cryptococcus gattii; Immunocompetent; Tuberculosis
Cervical tuberculosis is a rare form of genital tuberculosis. The manifestations of genitourinary tuberculosis are protean in nature. A high index of suspicion is required for making prompt diagnosis.
The definitive diagnosis is based on the demonstration of the characteristic lesion on histopathology or on bacterial isolation. We are reporting a rare case of isolated cervical tuberculosis which mimicked carcinoma of the cervix. A 24 years old para 1, live 1, woman presented with secondary amenorrhoea and post coital bleeding which were there for one year. The speculum examination revealed a friable cervix which bled on touch. Though the clinical history and the examination findings were suggestive of a cervical malignancy, the histopathological examination revealed a granulomatous inflammation which was suggestive of tuberculosis. The patient responded well to the antituberculous therapy.
Cervix; Cervical tuberculosis; Genital Tuberculosis
Dermatomyositis is a rare rheumatic disease which predominantly affects the muscles and skin requiring a protracted course of immunosuppressants which may predispose the patients to opportunistic infections. A 49-year-old lady was diagnosed to have dermatomyositis in August 2010 based on history, significantly raised creatine kinase level and muscle biopsy findings. She had recurrent admissions due to fever, myalgia and muscle weakness. She had spiking temperature despite high dose steroids, broad-spectrum antibiotics and antifungal agents. This prompted extensive investigation which leads us to the additional diagnosis of disseminated tuberculosis involving the lungs, muscles and bones. This case demonstrates the challenge in controlling the disease activity of dermatomyositis with immunosuppressants in the setting of disseminated tuberculosis.
Peritoneal tuberculosis is rare with increased incidence rates in recent years. The absence of characteristic clinical features of the disease often makes its diagnosis difficult and elusive. We present the case of 61-year-old female with peritoneal tuberculosis. The patient suffered from abdominal pain for a period of 5 months prior to admission. The diagnosis was established on the basis of findings from an abdominal computed tomography scan, a chest radiograph and histopathological analysis of the laparoscopic resection of the two masses. The patient was discharged from hospital receiving a fourfold antituberculous treatment with isoniazid, rifampicin, pyrazinamide and ethambutol. A high index of suspicion and a combination of radiologic, endoscopic, microbiologic and histopathological examination achieves diagnostic accuracy and prevents clinical mismanagement.
Abdominal; Tumor; Ascites; Laparoscopy
The occurrence of a solitary sternal metastasis from breast cancer is relatively uncommon, and its treatment is controversial. Most case reports on the role of sternal resection in what is termed a “solitary sternal metastasis” tend to present a rather optimistic outcome.
Here, we report the case of a premenopausal woman with axillary lymph node–positive, triple-negative breast cancer treated with mastectomy followed by adjuvant chemotherapy and radiation therapy. She developed a radiologically isolated sternal recurrence 3 years later, which was treated with partial sternectomy. The present case report reviews the use of sternectomy for breast cancer recurrence and highlights the need for thorough clinical and radiologic evaluation to ensure the absence of other systemic disease before extensive surgery is undertaken.
Breast cancer; sternal metastasis; sternectomy
Primary tubercular osteomyelitis of the sternum with dissemination to bone marrow is a rarely described entity even in countries where tuberculosis is endemic. Delayed presentations can be in the form of sinus formation, spontaneous fracture of the sternum, extrasternal spread, and sepsis. Diagnosis can be made by CT of the chest wall and Ziehl–Neelsen staining of aspirate from the lesion or by tissue biopsy. We present a case of tuberculous osteomyelitis of the sternum with sinus formation along with widespread involvement of bone marrow, which was successfully treated with antituberculous therapy. Sternal osteomyelitis is difficult to diagnose on chest radiography and ultrasonography, but we were able to make the probable diagnosis of sternal tuberculous osteomyelitis. CT showed erosion of part of the sternal bone. Diagnosis was confirmed on histopathology and by bone marrow trephine biopsy. During the follow-up period of 3 months, the patient showed a satisfactory response to treatment.
Tuberculous infection of the thoracic cage is rare and is difficult to discern clinically or on radiographs. This study aims to describe the common sites and the imaging appearances of chest wall tuberculosis.
Materials and Methods:
A retrospective review of the clinical and imaging records of 12 confirmed cases of thoracic cage tuberculosis (excluding that of the spine), seen over the last 7 years, was performed. Imaging studies available included radiographs, ultrasonographies (USGs), and computed tomography (CT) scans. Pathological confirmation was obtained in all cases.
All patients had clinical signs and symptoms localized to the site of involvement, whether it was the sternum, sternoclavicular joints, or ribs. CT scan revealed sternal destruction in three patients and osteolytic lesions with sclerosis of the articular surfaces of the sternoclavicular joints in two patients. In five patients with rib lesions, USG elegantly demonstrated the bone destruction underlying the cold abscess. All cases were confirmed to be of tuberculous origin by pathology studies of the aspirated/curetted material, obtained by CT / USG guidance.
Tuberculous etiology should be considered for patients presenting with atypical sites of skeletal inflammation. CT scan plays an important role in the evaluation of these patients. However, the use of USG for demonstrating rib destruction in a chest wall cold abscess has so far been under-emphasized, as has been the role of CT and USG guided aspiration in confirming the aetiology.
Intracranial tuberculomas are a rare complication of tuberculosis occurring through hematogenous spread from an extracranial source, most often of pulmonary origin. Testicular tuberculosis with only intracranial spread is an even rarer finding and to the best of our knowledge, has not been reported in the literature. Clinical suspicion or recognition and prompt diagnosis are important because early treatment can prevent patient deterioration and lead to clinical improvement.
We present the case of a 51-year-old African man with testicular tuberculosis and multiple intracranial tuberculomas who was initially managed for testicular cancer with intracranial metastasis. He had undergone left radical orchidectomy, but subsequently developed hemiparesis and lost consciousness. Following histopathological confirmation of the postoperative sample as chronic granulomatous infection due to tuberculosis, he sustained significant clinical improvement with antituberculous therapy, recovered fully and was discharged at two weeks post-treatment.
The clinical presentation of intracranial tuberculomas from an extracranial source is protean, and delayed diagnosis could have devastating consequences. The need to have a high index of suspicion is important, since neuroimaging features may not be pathognomonic.
A case of a middle-aged African-American woman with weight loss, ascites, a bilateral pleural effusion with no infiltrate, and a clinical diagnosis of a metastatic gynecological tumor is presented. Her carcinoembryonic antigen (CEA) and CA-125 levels were elevated (400 micrograms/L and 331 micrograms/L, respectively). She underwent an exploratory laparotomy and a dilation & curettage for biopsies and cultures. Pathological examination showed Langhans' type giant cells on peritoneal biopsy. An endometrial curette biopsy showed granulomatous endometritis and acid-fast bacilli. Cultures grew Mycobacterium tuberculosis. The patient presented with a fibroid tumor that could have contributed to her elevated CA-125 level, but after antituberculous treatment was started and tumor markers were repeated after 1 year, the CEA level decreased to 1.2 micrograms/L and CA-125 to 9 micrograms/L without surgical resection of the tumor. A review of the literature revealed only three cases in which patients had elevated CA-125 in multivisceral tuberculosis. No cases were reported in which both CEA and CA-125 levels were elevated in multivisceral tuberculosis. Possible causes of elevated CEA and CA-125 levels are discussed.
Cutaneous lymphangiectasia, also called as acquired lymphangioma, is a benign cutaneous disorder involving the dermal and subcutaneous lymphatic channels. It can rarely occur on the vulva. We describe a 35-year-old woman who came with multiple raised lesions over the vulva and left upper thigh of 1 year duration. She gave history of getting treated for multiple swellings that developed over right side of the neck and inguinal regions on both sides three decades ago. On local genital examination, the patient had a large polypoidal growth involving both sides of the vulva, left upper thigh, and over pubic area. Multiple linear scars were present over the upper thighs and groin bilaterally. The patient underwent simple vulvectomy and left thigh growth excision. Histopathological examination of the vulvectomy specimen confirmed our diagnosis.
Acquired lymphangioma; lymphangiectasia; lymphangioma circumscriptum
Gastric tuberculosis is rare, and usually associated with pulmonary tuberculosis or an immunodeficient state. Here, we report five cases of gastric tuberculosis in immunocompetent patients without evidence of pulmonary involvement.
Three patients presented with gastric outlet obstruction that required surgery to relieve the obstruction as well as to confirm the diagnosis. The remaining two had involvement of gastroesophageal junction. All of them responded well to standard antitubercular treatment.
Though gastric tuberculosis is rare, it should be considered a possibility when patients present with gastric outlet obstruction or with endoscopic evidence of diffuse chronic inflammatory activity, particularly in areas endemic for tuberculosis.
Breast tuberculosis is an uncommon form of entity especially in the infra-mammary area. A 25- year-old female, presented with a lump in the breast and infra-mammary area. She was having off and on fever without any other complaints. There was no positive family history. Primary breast tuberculosis was diagnosed on fine needle aspiration cytology wherein ZN stain for acid fast bacilli was positive. The patient received antitubercular drugs and at 3 month follow up the swelling had resolved and the patient was asymptomatic. Breast tuberculosis is a rare disease with non-specific clinical, radiological, and histological findings. Misdiagnosis is common as biopsy specimens are pauci-bacillary and investigations such as microscopy and culture are frequently negative.
Abscess; Breast; Extra–pulmonary; Infra-mammary; Lump; Tuberculosis