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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 12  |  Issue : 2  |  Page : 159-161

Pubic Ramus Tuberculosis Masquerading as Pseudomonas Infection!


Department of Trauma, Sancheti Institute for Orthopaedics and Rehabilitation, Pune, Maharashtra, India

Date of Submission22-Jul-2020
Date of Acceptance02-Sep-2020
Date of Web Publication28-Dec-2020

Correspondence Address:
Dr. Dheeraj Attarde
Department of Trauma, Sancheti Institute for Orthopaedics and Rehabilitation, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_55_20

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  Abstract 


Diagnosing tuberculosis in the new era remains a challenge. Atypical presentation of tuberculosis is not very uncommon. The musculoskeletal system remains one of the common sites for extrapulmonary tuberculosis, but pubic ramus involvement is very rare. No case is reported in literature where tuberculosis was masked by Pseudomonas infection. A high index of suspicion is necessary to correctly and timely diagnose tuberculosis. Here, we present the case of a health-care worker who was misdiagnosed as Pseudomonas. The patient had an excellent outcome following a complete course of antituberculous chemotherapy for tuberculosis.

Keywords: Atypical tuberculosis, Pseudomonas, tuberculosis


How to cite this article:
Attarde D, Patil A, Sancheti P, Shyam A. Pubic Ramus Tuberculosis Masquerading as Pseudomonas Infection!. J Orthop Traumatol Rehabil 2020;12:159-61

How to cite this URL:
Attarde D, Patil A, Sancheti P, Shyam A. Pubic Ramus Tuberculosis Masquerading as Pseudomonas Infection!. J Orthop Traumatol Rehabil [serial online] 2020 [cited 2021 Apr 11];12:159-61. Available from: https://www.jotr.in/text.asp?2020/12/2/159/305087




  Introduction Top


Osteomyelitis pubis accounts for 2% of hematogenous osteomyelitis. Among the various organisms responsible for pubic bone osteomyelitis, tuberculosis is a rarity. Only forty cases of pubic bone tuberculosis were identified by Lal et al.,[1] and its presentation as a Pseudomonas has not previously been reported. We present the case of a health worker with pubic bone osteomyelitis with sinus, misdiagnosed as bacterial infection, which proved to be tubercular infection on subsequent treatment.


  Case report Top


A young health worker was presented to us with active discharging sinus for 6 months in the left groin region. She had local abscess and a resultant swelling at the left groin 8 months back, which was treated with incision and drainage elsewhere. Culture showed Pseudomonas and further treatment was given as per culture sensitivity report. However, instead of getting better, the patient presented with discharging sinus at our hospital. Magnetic resonance imaging and computed tomography were done, and a discharging fluid was sent for culture [Figure 1]. Sinogram was also performed which was traced up to the left inferior pubic ramus [Figure 2]. We had a high index of suspicion as the patient was not relived of the symptoms. Therefore, a decision was taken to debride and send tissue biopsy and culture. Intraoperative sinogram was done with methylene blue, the sinus tract was removed and debridement was done till a healthy tissue was visible, and curettage was done for the inferior pubic ramus till a punctate bleeding bone was visible. Antibiotic was mixed with stimulant and bone void was filled with it [Figure 3].
Figure 1: Computed tomography scan showing lytic lesion at the inferior pubic ramus

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Figure 2: Sinogram done showing the sinus tract extending up to the pubic ramus

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Figure 3: Postoperative radiograph showing a well-debrided lytic lesion filled with stimulant

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The deep culture and tissue biopsy were sent. On late culture and histopathology and polymerase chain reaction (PCR), it turned out to be Mycobacterium tuberculosis complex. Antitubercular treatment was started accordingly. We followed up the patient at 3 weeks, 6 weeks, 3 months, and 6 months. At 6 months erythrocyte sedimentation rate, C- reactive protein returned to normal level and radiograph [Figure 4] showed healed lesion. Informed consent was taken from patient regarding data collection for publication.
Figure 4: Healed lesion at 6-month follow-up

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  Discussion Top


Detecting tuberculosis in the new era still remains a challenge. Tuberculosis is no longer confined to factors such as low socioeconomic status and immunodeficiency. The incidence of extrapulmonary tuberculosis is increasing, affecting the uncommon musculoskeletal region. Tuberculosis respiratory infection is airborne and transmitted via aerosols. Health-care workers that are exposed to tuberculosis have a 10- to 20-fold risk of contracting tuberculosis[2],[3] than the general population. Pubic affection of osteomyelitis is not common. The most common organism of pubic osteomyelitis is of bacterial origin.[4] Many times, tuberculosis is masqueraded by superadded bacterial infection. Tuberculosis of the symphysis pubis was first described by Thilesen in 1855. Diagnosis of tuberculosis is of paramount importance as it closely resembles osteitis pubis, juvenile osteochondrosis, and pyogenic osteomyelitis of the symphysis pubis.[5],[6],[7] The diagnostic confirmation is largely based on the isolation of microorganisms from the lesion. With the advent of new diagnostic modalities, high-risk cases should be thoroughly investigated before ruling out tuberculosis.


  Conclusion Top


A high level of suspicion is must to diagnose and treat atypical tubercular infections in health-care workers. Definitive histopathology and PCR studies can add value and guide tuberculosis treatment. Disease control can be achieved with a combination of surgery and chemotherapy.

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.
Lal H, Jain VK, Kannan S. Tuberculosis of the pubic symphysis: Four unusual cases and literature review. Clin Orthop Relat Res 2013;471:3372-80.  Back to cited text no. 1
    
2.
Dimitrova B, Hutchings A, Atun R, Drobniewski F, Marchenko G, Zakharova S, et al. Increased risk of tuberculosis among health care workers in Samara oblast, Russia: Analysis of notification data. Int J Tuberc Lung Dis 2005;9:43-8.  Back to cited text no. 2
    
3.
World Health Organization. Global tuberculosis report 2013. World Health Organization; 2013.  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.
Rajasekaran S. Tuberculosis of Bones, Joints, and Spine: Evidence-based Management Guide. Indian J Orthop. 2017;51:721.  Back to cited text no. 5
    
6.
Shende P, Gandhewar M, Gaikwad P, Nanaware S, Risbud Joshi P. Labial swelling: A rare presentation of pubic bone tuberculosis. Trop Doct 2017;47:176-8.  Back to cited text no. 6
    
7.
Nicholson OR. Tuberculosis of the pubis; report of eleven cases. J Bone Joint Surg Br 1958;40:6-15.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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