Images Dx

Pulmonary tuberculosis with Pott's disease and psoas abscess

Copyright © 2009 Society of Hospital Medicine

A 22‐year‐old man was referred from an outside hospital with 2 weeks of generalized weakness and difficulty ambulating. He also reported a 6‐month history of abdominal pain, right‐sided lumbar back pain, malaise, night sweats, cough, and weight loss of 30 kg. The patient was born in Mexico but had lived in the US for 10 years, working as a construction worker in northern California. He had had no prior medical care. On examination, the patient had a temperature of 40C, a heart rate of 109, and a respiratory rate of 20. His oxygen saturation was 97% on room air, and lung fields were clear bilaterally. Strength was slightly decreased in the right leg, with tenderness in the posterolateral aspect of the right thigh and thoracic lumbar spine.

Radiograph of the chest showed bilateral upper lobe reticulonodular infiltrates, cavitation, and pleural thickening (Figure 1). Computed tomography (CT) showed innumerable pulmonary nodules throughout the mid and lower lungs, a loss of disc space between L4 and L5, and a large multiloculated abscess of the right iliacus and psoas muscles that extended into the right thigh (Figure 2). Longitudinal relaxation time (T1)‐weighted magnetic resonance imaging (MRI) of the lumbar spine revealed vertebral destruction of L4 and L5 (Figure 3).

Figure 1

Chest x‐ray.

Figure 2

CT of the abdomen/pelvis showing large right‐sided iliopsoas abscess contiguous with L4 vertebra.

Figure 3

T1‐weighted MRI showing vertebral destruction at L4 and L5.

The patient underwent vertebrectomy of L4 and L5, anterior/posterior fixation and fusion from L4 to S1, and drainage of a large right‐sided psoas abscess. Acid‐fast bacilli were seen in abscess fluid and vertebral bone. Subsequently, the intraoperative cultures and 6 sequential sputum cultures all grew Mycobacterium tuberculosis. The patient was begun on rifampin, isoniazid, pyrazinamide, and ethambutol with a good clinical response, and subsequently transferred back to his referring hospital for continued medical care and rehabilitation.

Extrapulmonary manifestations of tuberculosis should be suspected in patients from a tuberculosis‐endemic country of origin. Bone and joint tuberculosis account for up to 35% of cases of extrapulmonary tuberculosis. Spinal tuberculosis (Pott's disease) most commonly involves the anteroinferior aspect of vertebral bodies in the thoracic spine. Tuberculosis is a disease with diverse manifestations and can elude even the most astute physician if it is not considered as a diagnosis.

   Comments ()