Q J Med 2014; 107:683–684 doi:10.1093/qjmed/hcu011 Advance Access Publication 20 January 2014
Clinical picture Tuberculous muscle abscess and pyrazinamide, in combination with repeated needle aspirations, resulted in a rapid reduction in thigh pain and swelling. Tuberculosis involvement of skeletal muscle is uncommon, occurring in 1–2% of tuberculous cases. Mycobacterium tuberculosis may spread to muscle by either direct extension from adjacent source (e.g. an infected joint, bone, tendon or lymph node) or via bacteremia. The most common site is tuberculous psoas abscess resulting from extension of vertebral osteomyelitis.1 Primary extra axial muscular tuberculosis is even rarer, with few case reports and small case series in the literature. Such cases typically present with gradual onset of pain following localized swelling. Ultrasound provides a valuable method for detection of soft tissue abscesses or adjacent bursitis, tenosynovitis and arthritis.2 Characteristic ultrasound findings include muscular fibers displaced by infiltrating fluid and focal fluid accumulation. In addition, ultrasound-guided aspiration can rapidly obtain material for microbiological examination and can be used for therapeutic drainage.3
Figure 1. CT demonstrating lobulated and septated cystic lesions involving the left rectus femoris muscle.
! The Author 2014. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: [email protected]
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A 45-year-old woman presented with subacute pain and swelling of the left thigh for 3 weeks. She reported body weight loss in the past 2 months and had no history of trauma, arthritis or back pain. Physical examination revealed a temperature of 37.88C and left thigh swelling with localized heat and tenderness. Her white blood cell count was 3100/ml and erythrocyte sedimentation rate was 78 mm/h. Serial blood cultures were negative. Chest radiograph showed no abnormal infiltration or opacity. Computed tomography (CT) revealed cystic lesions involving left rectus femoris muscle (Figure 1). High-resolution ultrasound demonstrated hypoechoic change and loss of feather texture of left rectus femoris muscle with anechoic fluid collections. The ultrasound findings were consistent with myositis with abscess formation. Ultrasound-guided needle aspiration of the muscle abscess was done and microscopic examination of the fluid sample revealed acid-fast organisms. Fluid culture for mycobacterium yielded Mycobacterium tuberculosis. Treatment with rifampin, isoniazid, ethambutol
684
Clinical picture
Photographs and text from: K.-L. Lai, Z.-Y. Shi, W.-C. Chao and P.-Y. Liu, Department of Internal Medicine, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung 40705, Taiwan; L.-H. Wu, Department of Internal Medicine, Dongyang People’s Hospital, Dongyang, Zhejiang, China. email: [email protected]
References 1. Crum-Cianflone NF. Bacterial, fungal, parasitic, and viral myositis. Clin Microbiol Rev 2008; 21:473–94. 2. Wilbur AC, Gorodetsky AA, Hibbeln JF, Aizenstein RI. Tuberculous myositis: CT and sonographic findings in two cases. J Clin Ultrasound 1995; 23:495–9. 3. De Backer AI, Mortele´ KJ, Vanhoenacker FM, Parizel PM. Imaging of extraspinal musculoskeletal tuberculosis. Eur J Radiol 2006; 57:119–30.
Conflict of interest: None declared.
Downloaded from by guest on March 22, 2016
Clinical picture Tuberculous muscle abscess and pyrazinamide, in combination with repeated needle aspirations, resulted in a rapid reduction in thigh pain and swelling. Tuberculosis involvement of skeletal muscle is uncommon, occurring in 1–2% of tuberculous cases. Mycobacterium tuberculosis may spread to muscle by either direct extension from adjacent source (e.g. an infected joint, bone, tendon or lymph node) or via bacteremia. The most common site is tuberculous psoas abscess resulting from extension of vertebral osteomyelitis.1 Primary extra axial muscular tuberculosis is even rarer, with few case reports and small case series in the literature. Such cases typically present with gradual onset of pain following localized swelling. Ultrasound provides a valuable method for detection of soft tissue abscesses or adjacent bursitis, tenosynovitis and arthritis.2 Characteristic ultrasound findings include muscular fibers displaced by infiltrating fluid and focal fluid accumulation. In addition, ultrasound-guided aspiration can rapidly obtain material for microbiological examination and can be used for therapeutic drainage.3
Figure 1. CT demonstrating lobulated and septated cystic lesions involving the left rectus femoris muscle.
! The Author 2014. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: [email protected]
Downloaded from by guest on March 22, 2016
A 45-year-old woman presented with subacute pain and swelling of the left thigh for 3 weeks. She reported body weight loss in the past 2 months and had no history of trauma, arthritis or back pain. Physical examination revealed a temperature of 37.88C and left thigh swelling with localized heat and tenderness. Her white blood cell count was 3100/ml and erythrocyte sedimentation rate was 78 mm/h. Serial blood cultures were negative. Chest radiograph showed no abnormal infiltration or opacity. Computed tomography (CT) revealed cystic lesions involving left rectus femoris muscle (Figure 1). High-resolution ultrasound demonstrated hypoechoic change and loss of feather texture of left rectus femoris muscle with anechoic fluid collections. The ultrasound findings were consistent with myositis with abscess formation. Ultrasound-guided needle aspiration of the muscle abscess was done and microscopic examination of the fluid sample revealed acid-fast organisms. Fluid culture for mycobacterium yielded Mycobacterium tuberculosis. Treatment with rifampin, isoniazid, ethambutol
684
Clinical picture
Photographs and text from: K.-L. Lai, Z.-Y. Shi, W.-C. Chao and P.-Y. Liu, Department of Internal Medicine, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung 40705, Taiwan; L.-H. Wu, Department of Internal Medicine, Dongyang People’s Hospital, Dongyang, Zhejiang, China. email: [email protected]
References 1. Crum-Cianflone NF. Bacterial, fungal, parasitic, and viral myositis. Clin Microbiol Rev 2008; 21:473–94. 2. Wilbur AC, Gorodetsky AA, Hibbeln JF, Aizenstein RI. Tuberculous myositis: CT and sonographic findings in two cases. J Clin Ultrasound 1995; 23:495–9. 3. De Backer AI, Mortele´ KJ, Vanhoenacker FM, Parizel PM. Imaging of extraspinal musculoskeletal tuberculosis. Eur J Radiol 2006; 57:119–30.
Conflict of interest: None declared.
Downloaded from by guest on March 22, 2016
